A Randomized, Double-Blind, Placebo-Controlled, Active Comparator, Multicenter Study to Validate Patient-Reported Outcome Instruments in Adult Subjects With Newly Diagnosed Nontuberculous Mycobacterial (NTM) Lung Infection Caused by Mycobacterium Avium Complex (MAC)
Phase: PHASE3
Conditions: Mycobacterium Infections, Nontuberculous
Sponsor: Insmed Incorporated

Official Title: A Randomized, Double-Blind, Placebo-Controlled, Active Comparator, 
Multicenter Study to Validate Patient-Reported Outcome Instruments 
in Adult Subjects With Newly Diagnosed Nontuberculous 
Mycobacterial (NTM) Lung Infection Caused by Mycobacterium 
avium Complex (MAC) 
NCT Number: NCT04677543 
Document Dates: Protocol Version 3: 11-July-2022 

Signature Page for INS-415 Global Protocol Amendment 2 Version 3.0
Approve
11-Jul-2022 14:32:29 GMT+0000

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CLINICAL STUDY PROTOCOL 
ARISE - A Randomized, Double-Blind, Placebo-Controlled, Active Comparator, 
Multicenter Study to Validate Patient-Reported Outcome Instruments in Adult 
Subjects with Newly Diagnosed Nontuberculous Mycobacterial (NTM) Lung 
Infection Caused by Mycobacterium avium Complex (MAC) 
Study Number: INS-415 
IND Number: 108674 
EudraCT Number: 2020-002545-42 
Insmed Incorporated 
700 US Highway 202/206 
Bridgewater, NJ 08807-1704 
Version Number 
Amendment 
Date 
Protocol Amendment 
3.0 
Global
Amendment 2 
11 JUL 2022
CONFIDENTIALITY STATEMENT 
Information contained in this document is proprietary to Insmed Incorporated. The information is 
provided to you in confidence which is requested under an agreed upon and signed 
Confidentiality and Disclosure Agreement. Do not give this document or any copy of it or reveal 
any proprietary information contained in it to any third party (other than those in your 
organization who are assisting you in this work and are bound by the Confidentiality and 
Disclosure Agreement) without the prior written permission of an authorized representative of 
Insmed Incorporated. 

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INVESTIGATOR’S AGREEMENT 
ARISE - A Randomized, Double-Blind, Placebo-Controlled, Active Comparator, Multicenter 
Study to Validate Patient-Reported Outcome Instruments in Adult Subjects with Newly 
Diagnosed Nontuberculous Mycobacterial (NTM) Lung Infection Caused by Mycobacterium 
avium Complex (MAC) 
Investigator’s Signature: 
I have fully discussed the objectives of this study and the contents of this protocol with the 
Sponsor’s representative. 
I understand that information contained in or pertaining to this protocol is confidential and 
should not be disclosed, other than to those directly involved in the execution or the ethical 
review of the study, without written authorization from the Sponsor. It is, however, permissible 
to provide information to a subject to obtain consent. 
I agree to conduct this study per this protocol and to comply with its requirements, subject to 
ethical and safety considerations and guidelines, and to conduct the study in accordance with the 
Declaration of Helsinki, the International Council for Harmonisation Guideline for Good Clinical 
Practice (ICH E6 [R2] GCP) and applicable local laws, regulations and guidelines. 
I agree to make available to Sponsor personnel, their representatives and relevant regulatory 
authorities, my subjects’ study records to verify the data that I have entered into the case report 
forms. I am aware of my responsibilities as an Investigator as provided by the Sponsor. 
I understand that the Sponsor may decide to suspend or prematurely terminate the study at any 
time for whatever reason; such a decision will be communicated to me in writing. Conversely, 
should I decide to withdraw from execution of the study, I will communicate my intention 
immediately in writing to the Sponsor. 
 
 
 
 
 
 
Print Name 
 
Signature 
 
 
 
 
 
 
 
Title 
 
Date (DD MMM YYYY) 
 
 

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PROTOCOL AMENDMENT SUMMARY OF CHANGES TABLE 
Document History 
Type of Protocol 
Amendment 
Numbering 
Date 
Global 
Version 3.0, Global Amendment 2 
11 JUL 2022 
Global  
Version 2.0, Global Amendment 1 
13 AUG 2021 
Country-Specific  
Version 1.0, Amendment 1, Denmark, Germany, Spain 
08 JAN 2021 
Original Protocol  
Version 1.0 
20 MAY 2020 
Global Amendment 2: 11 JUL 2022 
This amendment is considered to be nonsubstantial based on the criteria set forth in Article 10(a) 
of Directive 2001/20/EC of the European Parliament and the Council of the European Union. 
Overall Rationale for the Amendment:  
The primary driver for the changes in the protocol amendment is to provide a clarification of the 
planned analysis.  
The summary of major changes in this amendment, compared to the original protocol, is shown 
below:  
Revision 
Rationale 
Location of Revision 
Added text to Protocol 
Synopsis and Section 10.1 / 
Sample Size and Power 
Considerations 
Added text to clarify the 
number of subjects for the 
cross-sectional validation 
analysis 
Section 10.1  

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PROTOCOL SYNOPSIS 
EudraCT/IND 
Number: 
EudraCT Number: 2020-002545-42 
IND Number: 108674 
Protocol Number: 
INS-415 
Amendment Number: 
Global Amendment 2 
Investigational 
Product: 
Amikacin Liposome Inhalation Suspension (ALIS) 
Active 
Ingredient(s)/INN: 
Amikacin sulfate 
Study Title: 
ARISE - A Randomized, Double-Blind, Placebo-Controlled, Active 
Comparator, Multicenter Study to Validate Patient-Reported Outcome 
Instruments in Adult Subjects with Newly Diagnosed 
Nontuberculous Mycobacterial (NTM) Lung Infection Caused by 
Mycobacterium avium Complex (MAC)  
Study Phase: 
3b 
Indication Under 
Investigation: 
Adults with non-cavitary lung disease with newly diagnosed (initial or 
subsequent) MAC lung infections 
Objectives/Endpoints: 
Primary Objective 
To generate evidence demonstrating the 
domain specification (via modern 
psychometric methods [MPMs]), reliability, 
validity, and responsiveness (within-subject 
meaningful change) of the patient-reported 
outcome (PRO) endpoints  
Primary Endpoint 
Findings on psychometric validation optimized and 
reported for: 
1) Cross-sectional validation (modern psychometrics, 
internal consistency, concurrent validity, and known-
groups validity) at Baseline. 
2) Test-retest reliability between Screening and 
Baseline among subjects reporting no change on 
Patient Global Impression of Severity (PGI-S) 
between Screening and Baseline. PGI-S anchors will 
be PRO specific, with a respiratory and fatigue PGI-S 
applied to the Quality of Life – Bronchiectasis (QOL-
B) respiratory domain and Patient-Reported Outcome 
Measurement Information System – Fatigue-Short 
Form 7a (PROMIS F-SF 7a), respectively. 
3) Within-subject meaningful change estimated via 
anchor-based methods and validated via empirical 
cumulative distribution functions (eCDFs) and 
probability density functions (ePDFs) between 
Baseline and End of Study (EOS) (Month 7). 
 
 

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Secondary Objectives:  
To evaluate the effect of each treatment arm 
(amikacin liposome inhalation suspension 
[ALIS] + background regimen (azithromycin 
[AZI] + ethambutol [ETH]) and empty 
liposome control (ELC) + background regimen 
on the following: 
Secondary Endpoints 
 
1. Culture conversion by Month 6 
Proportion of subjects achieving culture conversion 
by Month 6 (negative cultures for MAC at Month 5 
and Month 6) 
2. Patient-reported respiratory symptoms 
at Month 7 
Change from Baseline to Month 7 in respiratory 
symptom score 
3. Patient-reported fatigue symptoms at 
Month 7 
Change from Baseline to Month 7 in fatigue 
symptom score 
4. Time to culture conversion 
Time to culture conversion (first of 2 consecutive 
negative cultures) of Baseline to EOT assessments 
5. Time to first negative culture 
Time to first negative culture of Baseline to EOT 
assessments 
6. MAC isolates with amikacin minimum 
inhibitory concentration (MIC) 
≥ 128 μg/mL 
Proportion of subjects who develop a MAC isolate 
with amikacin MIC ≥ 128 µg/mL at more than 1 visit 
at any timepoint during the study 
7. Recurrence of MAC (relapse) 
Proportion of subjects who achieved culture 
conversion and subsequently have at least 1 MAC 
positive culture in agar media or positive cultures in 
broth media in at least 2 consecutive visits that is the 
same species and genome as cultured at 
Screening/Baseline. 
8. Recurrence of MAC (new infection) 
Proportion of subjects who achieved culture 
conversion and subsequently have at least 1 MAC 
positive culture in agar media or positive cultures in 
broth media in at least 2 consecutive visits that is 
different than cultured at Screening/Baseline 
(different species or same species but different 
genome). 
9. Safety and tolerability of 
ALIS +background regimen 
Incidence and severity of adverse events (AEs) and 
treatment-emergent adverse events (TEAEs) and 
other safety variables (eg, vital signs, physical 
examination, clinical laboratory values) from 
Baseline through the end of study (EOS) 
 
 

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Exploratory Objective 
To evaluate the effect of each treatment arm 
(ALIS + background regimen and ELC + 
background regimen) on the following:  
Exploratory Endpoint 
1. Patient-reported non-respiratory 
symptoms at Month 7 
Change from Baseline to Month 7 in the QOL-B 
non-respiratory domains (physical, role, vitality, 
emotional, social, health perception) 
2. Within-subject meaningful change 
threshold estimated in respiratory 
symptoms from Baseline to Month 7 
Proportion of subjects meeting the within-subject 
meaningful change threshold as reflected in PRO 
changes scores computed from Baseline in patient-
reported symptoms 
3. Mean activity and sleep efficiency 
over time  
Longitudinal summary of mean activity and sleep 
efficiency as measured by Philips Actiwatch 
Spectrum PRO 
 
 

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Study Design: 
Please refer to Figure 1 for a schematic diagram of the study design and treatment duration. 
This is a randomized, double-blind, placebo-controlled, active comparator study in eligible subjects 
with a new diagnosis (initial or subsequent) of MAC lung infection who have not started treatment for 
their current infection. Subjects will be randomized at Baseline in a 1:1 ratio to receive one of the two 
treatment regimens: ALIS + background regimen or ELC + background regimen for 6 months. Note 
that background regimen in this study is defined as AZI+ETH per randomized treatment. 
Randomization will be stratified by region (North America, Europe, and Rest of World) and history of 
MAC lung infection (initial or subsequent). After Baseline, subjects will return to the study site for in-
clinic visits at Months 1, 3, 5, 6/EOT, and 7/ EOS. 
Visits at Months 2 and 4 do not require in-clinic appointments. At these non-in clinic visits, AEs and 
concomitant medications will be assessed. eDiary data will be collected continually for assessment of 
study drugs intake, and subjects will be required to provide and ship sputum samples for analysis. At 
the Month 6/EOT visit, subjects will discontinue all study drugs and will be followed for a 1 month off 
treatment period, during which medical or non-medical therapies for MAC lung infection should not be 
given. 
At Month 7/EOS, subjects will complete all protocol-specified assessments and the final EOS 
procedures.  
The procedures and assessments conducted at each study visit in the study are provided in Table 4. 
Study Duration: 
Subjects will receive ALIS + background regimen or ELC + background regimen for 6 months and 
then remain off all study drugs for 1 month. The Screening period will be up to approximately -70 days 
to -1 day (~2.5 months). 
The total duration of the study will be up to 9.5 months from the Screening visit to EOS. 
Study Sites and Locations: 
This study is planned to be conducted at approximately 150 sites globally. 
Sample Size Determination: 
Power and Sample Size Determination for the Validation Study 
Cross-sectional validation will require baseline data from a maximum of 250 subjects to adequately 
power the planned MPMs. A total of 100 subjects will be enrolled in this study and will be used for this 
analysis. Additional select baseline data from up to the first 150 subjects enrolled in a separate study will 
be used. 
Longitudinal validation will require 100 subjects to adequately power the planned within-subject 
meaningful change methods.  
The derivation of these sample sizes and the procedures used to compute power are described in 
Section 10.1. 
Subject Eligibility Criteria: 
Inclusion Criteria 
Subjects must satisfy all of the following criteria to be included in the study: 
1.
Male or female ≥ 18 years of age (19 years or older in South Korea)
2.
Current diagnosis of MAC lung infection. MAC or mixed infection with MAC as the dominant
species is allowed, with MAC as the intended organism for treatment
3.
Positive sputum culture for MAC within 6 months prior to Screening
4.
Positive sputum culture for MAC at Screening

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5. A chest computed tomography (CT) scan, read locally, within 6 months prior to Screening to 
determine presence and size of pulmonary cavities. Subjects who do not have a chest CT scan 
within 6 months prior to Screening will be required to obtain a chest CT scan, read locally, 
during Screening 
6. In the Investigator’s opinion, documented respiratory signs/symptoms at Screening that are 
attributable to the current MAC lung infection 
7. An average QOL-B respiratory domain score of ≤ 85 based on scores at Screening and on the 
day of enrollment prior to randomization 
8. In the Investigator’s opinion, underlying lung disease (eg, chronic obstructive pulmonary 
disease [COPD], bronchiectasis) have been managed according to best local standard of care, 
and on stable maintenance therapy for a minimum of 4 weeks prior to randomization 
9. Willingness and ability to adhere to prescribed study treatment during the study 
10. Ability to produce (spontaneously or with induction) approximately 2 mL of sputum for 
mycobacteriology at Screening 
11. Women of child-bearing potential [WOCBP] (ie, fertile following menarche and until 
becoming post-menopausal unless permanently sterile) and fertile men (ie, all men after 
puberty unless permanently sterile by bilateral orchidectomy) agree to practice a highly 
effective method of birth control from Day 1 to at least 90 days after the last dose. Examples of 
such birth controls are: 
• 
true abstinence (refraining from heterosexual intercourse during the entire study), 
• 
copper intrauterine device [IUD],  
• 
hormonal methods (levonorgestrel-releasing intrauterine system, progestogen implant, 
combined oral contraceptive pill [combined with barrier method]),  
• 
exclusive homosexual relationship, or  
• 
sole male partner who has undergone surgical sterilization with confirmation of 
azoospermia at least 3 months post procedure while participating in the study. 
12. Provide signed informed consent prior to administration of study drugs or performing any study 
related procedure 
13. Be able to comply with study drugs use, study visits, and study procedures as defined by the 
protocol 
14. Men with partners who are WOCBP (pregnant or non-pregnant) agree to use condoms and non-
pregnant partners should practice a highly effective method of birth control. 
 
Exclusion Criteria 
Subjects who meet any of the following criteria will be disqualified from entering the study: 
1. Diagnosis of cystic fibrosis (CF) 
2. History of more than 3 MAC lung infections 
3. Received any mycobacterial antibiotic treatment for current MAC lung infection 
4. Refractory MAC lung infection, defined as having positive MAC cultures while being treated 
with a multidrug mycobacterial antibiotic treatment regimen for a minimum of 6 consecutive 
months and no documented successful treatment, defined as negative sputum culture for MAC 
and cessation of treatment 
5. Relapse of prior MAC lung infection, defined as positive sputum culture for MAC ≤ 6 months 
of cessation of prior successful treatment 
6. MAC isolate with MIC for amikacin ≥ 128 µg/mL at Screening 
7. Evidence of any pulmonary cavity ≥ 2 cm in diameter, as determined by chest CT scan, read 
locally, within 6 months prior to Screening 
8. Radiographic finding of new lobar consolidation, atelectasis, significant pleural effusion, or 
pneumothorax during routine clinical care within 2 months prior to Screening 

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9. Active pulmonary malignancy (primary or metastatic) or any malignancy requiring 
chemotherapy or radiation therapy within 1 year prior to Screening or anticipated during the 
study 
10. Active pulmonary tuberculosis requiring treatment during Screening 
11. Hospitalization for underlying lung disease during Screening 
12. Acute pulmonary exacerbation (eg, COPD or bronchiectasis) requiring treatment with 
antibiotics, or corticosteroids (IV or oral), within 4 weeks prior to and during Screening 
13. Predicted forced expiratory volume in 1 second (FEV1) < 35%, pre-bronchodilator use 
14. Current smoker 
15. History of lung transplantation 
16. Use of inhaled or systemic aminoglycosides with activity against MAC (eg, amikacin, 
kanamycin, or streptomycin) during Screening 
17. Prior exposure to ALIS (including clinical study) 
18. Known hypersensitivity or contraindications to use to ALIS, aminoglycosides, or any of their 
excipients 
19. Disseminated MAC infection 
20. Positive pregnancy test or lactation at Screening. All WOCBP will be tested. Women not of 
child-bearing potential are defined as postmenopausal (ie, amenorrheic for 12 months without 
an alternative medical cause or confirmed by more than one follicle stimulating hormone [FSH]  
measurement), or naturally or surgically sterile through bilateral oophorectomy, hysterectomy, 
or bilateral salpingectomy. For women under the age of 45 years, confirmatory testing with 
FSH should be considered. 
21. Administration of any investigational drug within 8 weeks prior to Screening 
22. Known or suspected acquired immunodeficiency syndromes (HIV-positive, regardless of CD4 
counts). Other immunodeficiency syndromes that may interfere with study participation in the 
opinion of the Investigator. 
23. Significant (as determined by the Investigator) hearing loss, vestibular dysfunction, 
neuromuscular weakness or a diagnosis of myasthenia gravis, where the potential risk of 
aminoglycoside toxicity outweighs the potential benefit 
24. Aspartate aminotransferase or alanine aminotransferase ≥ 3 times the upper limit of normal 
(ULN) or total bilirubin ≥ 1.5 times ULN at Screening 
25. Absolute neutrophil count ≤ 500/μL at Screening 
26. Serum creatinine > 2 times ULN at Screening 
27. Current alcohol, medication, or illicit drug abuse 
28. Any condition that, in the opinion of the Investigator, interferes with ability to safely complete 
the study or adhere to study requirements 
29. Known and active COVID-19 infection  
30. MAC isolate with MIC for clarithromycin ≥ 32 µg/mL at Screening 
31. Known hypersensitivity or contraindications to use to ethambutol, azithromycin (including 
other macrolides or ketolides), or any of their excipients per local labeling guidance  
 
 

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Study Drugs:  
ALIS 590 mg or ELC will be administered once daily (QD) by inhalation via nebulization over 
approximately 6 minutes to up to 15 minutes. ALIS or ELC should be administered around the same 
time each day, any time of day, in the fasted or as-fed condition. 
The background regimen of azithromycin 250 mg tablets and ethambutol 15 mg/kg tablets will be taken 
QD by mouth, with or without food. 
Statistical Analyses:  
Statistical Analyses: 
Cross-sectional validation will be conducted at Baseline and will consist of modern psychometric 
methods (exploratory factor analysis, item response theory models and corresponding assessments of 
local dependence and differential item functioning), internal consistency, concurrent validity, and 
known groups validity. 
Test-retest reliability between Screening and Baseline among subjects reporting no change on PGI-S 
between Screening and Baseline. PGI-S anchors will be PRO specific, with a respiratory and fatigue 
PGI-S applied to the QOL-B respiratory domain and PROMIS F-SF 7a, respectively. 
Within-subject meaningful change estimated via anchor-based methods and validated via eCDFs and 
ePDFs between Baseline and EOS (Month 7). Anchors employed will include the PGI-S and culture 
conversion. 
All of the summaries pertaining to secondary endpoints will utilize and intent-to-treat (ITT) analysis set 
on available data according to Section 10.3, unless otherwise stated in Statistical Analysis Plan (SAP).  
Reporting of categorial secondary endpoints will include basic statistics, estimates derived via logistic 
regression and will include estimates of proportions, difference of proportions  together with 
corresponding 95% confidence intervals (CIs) resulting, as appropriate. 
Reporting of continuous secondary endpoints will include basic statistics, estimates derived from 
analysis of covariance (ANCOVA) model with change from Baseline as response variable and 
treatment and Baseline as independent variables regression and will include estimates with 
corresponding 95% CIs as appropriate.  
Analysis of variance and logistic regression models may not include adjustment for randomization 
strata due to expected small counts within each combination of strata.  
Reporting by visit of basic summary statistics will be provided as appropriate. 
Time to culture conversion will be plotted via Kaplan-Meier method.   
Detailed data imputation rules require for handling of missing events dates for safety data will be 
described in related data handling documents.  
The analysis of safety data will be conducted on the safety analysis set (ie, all randomly assigned 
subjects who receive at least 1 dose of ALIS, ELC, AZI, or ETH). Safety parameters for each treatment 
group will include the occurrence of AEs, the use of concomitant medications, and changes in clinical 
laboratory values (serum chemistry, hematology, and urinalysis), vital signs measurements, and 
physical examination findings (including body weight) between Baseline and EOT. Adverse events will 
be coded according to the latest version of the Medical Dictionary for Regulatory Activities (MedDRA) 
dictionary. Summaries will be presented for all AEs, AEs determined by the Investigator to be 
treatment‑related, serious adverse events (SAEs), and AEs causing withdrawal from the study. 
Hematology, chemistry, and urinalysis values will be summarized by treatment group over time and by 
visit. 
 
 

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Data Monitoring Committee:  
A Data Monitoring Committee (DMC) will periodically monitor the safety of the study. Details will be 
provided in the DMC charter. 

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TABLE OF CONTENTS 
IMPORTANT CONTACTS ............................................................................................................3 
PROTOCOL AMENDMENT SUMMARY OF CHANGES TABLE ............................................4 
PROTOCOL SYNOPSIS.................................................................................................................5 
TABLE OF CONTENTS ...............................................................................................................13 
LIST OF IN-TEXT TABLES ........................................................................................................18 
LIST OF IN-TEXT FIGURES.......................................................................................................18 
LIST OF ABBREVIATIONS ........................................................................................................19 
1. 
INTRODUCTION AND BACKGROUND INFORMATION ..................................22 
1.1. 
Nontuberculous Mycobacterial Lung Disease ............................................................22 
1.2. 
Amikacin Liposome Inhalation Suspension ...............................................................22 
1.3. 
Study Rationale ...........................................................................................................23 
1.3.1. 
Study Population .........................................................................................................23 
1.3.2. 
Treatment and Duration of Exposure .........................................................................24 
1.3.3. 
Efficacy Endpoints, Placebo Control, and Active Comparator ..................................26 
1.4. 
Risks and Benefits for Study Subjects ........................................................................26 
1.5. 
Treatment, Route, Dosage, Treatment Period ............................................................27 
1.6. 
Randomization and Blinding ......................................................................................27 
1.7. 
Compliance Statement, Ethics, and Regulatory Compliance .....................................27 
1.7.1. 
Subject Confidentiality ...............................................................................................27 
1.7.2. 
Informed Consent Procedure ......................................................................................28 
1.7.3. 
Regulatory Compliance ..............................................................................................28 
2. 
STUDY OBJECTIVES AND ENDPOINTS ..............................................................30 
2.1. 
Primary Objective and Endpoint ................................................................................30 
2.2. 
Secondary Objectives and Endpoints .........................................................................30 
2.3. 
Exploratory Objectives and Endpoints .......................................................................31 
3. 
STUDY DESIGN .......................................................................................................32 
3.1. 
Overall Plan ................................................................................................................32 
3.2. 
Data Monitoring Committee .......................................................................................33 
3.3. 
Study Duration ............................................................................................................33 
3.4. 
End of Treatment ........................................................................................................33 
3.5. 
End of Study ...............................................................................................................33 

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4. 
STUDY POPULATION .............................................................................................34 
4.1. 
Enrollment ..................................................................................................................34 
4.1.1. 
Inclusion Criteria ........................................................................................................35 
4.1.2. 
Exclusion Criteria .......................................................................................................35 
4.2. 
Discontinuation of Study Drugs and Participant Discontinuation/Withdrawal ..........37 
4.2.1. 
Discontinuation of Study Drugs .................................................................................37 
4.2.2. 
Participant Discontinuation/Withdrawal from the Study ...........................................38 
4.2.3. 
Early Discontinuation Procedures ..............................................................................38 
4.2.3.1. 
Lost-to-Follow-up .......................................................................................................38 
4.2.4. 
Subject Replacement ..................................................................................................38 
4.2.5. 
Subject Rescreening Procedures .................................................................................38 
4.3. 
Premature Termination of the Study ...........................................................................39 
5. 
STUDY DRUGS ........................................................................................................40 
5.1. 
Amikacin Liposome Inhalation Suspension ...............................................................40 
5.1.1. 
Empty Liposome Control ...........................................................................................40 
5.1.2. 
Azithromycin and Ethambutol Tablets .......................................................................41 
5.1.3. 
Methods of Assigning Subjects to Treatments ...........................................................41 
5.1.4. 
Study Drugs Administration .......................................................................................41 
5.1.4.1. 
Dose Interruption ........................................................................................................42 
5.1.5. 
Method of Assessing Treatment Compliance .............................................................42 
5.1.6. 
Emergency Unblinding ...............................................................................................42 
5.1.7. 
Labeling and Packaging ..............................................................................................43 
5.1.8. 
Storage ........................................................................................................................43 
5.1.9. 
Dispensing of Study Drugs .........................................................................................43 
5.1.10. 
Drug Accountability ...................................................................................................43 
5.2. 
Concomitant Medications ...........................................................................................43 
5.2.1. 
Bronchodilator Therapy ..............................................................................................44 
5.2.2. 
Rescue Therapy ..........................................................................................................44 
5.3. 
Prohibited Medications and Medications with Limited Use ......................................44 
5.4. 
Precautionary Medications .........................................................................................45 
6. 
STUDY PROCEDURES ............................................................................................47 
6.1. 
Schedule of Assessments ............................................................................................47 

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6.2. 
Protocol Deviations ....................................................................................................51 
6.3. 
Public Health Emergencies – COVID-19 ...................................................................51 
7. 
PSYCHOMETRIC VALIDATION ............................................................................53 
7.1. 
Variables to be Validated ............................................................................................53 
7.1.1. 
Quality of Life Questionnaire – Bronchiectasis .........................................................53 
7.1.2. 
PROMIS Fatigue Short Form 7a ................................................................................53 
7.2. 
Validating Variables ...................................................................................................54 
7.2.1. 
EXAcerbations of Chronic Pulmonary Disease Tool (EXACT) ................................54 
7.2.2. 
Exact Respiratory Symptoms (EXACT-RS) ..............................................................54 
7.2.3. 
St. George’s Respiratory Questionnaire (SGRQ) .......................................................54 
7.2.4. 
Functional Assessment of Chronic Illness Therapy (FACIT) – Fatigue Scale ..........54 
7.2.5. 
PGI-S Respiratory .......................................................................................................55 
7.2.6. 
PGI-S Fatigue .............................................................................................................55 
8. 
EFFICACY ASSESSMENTS ....................................................................................56 
8.1. 
Sputum Culture ...........................................................................................................56 
8.2. 
Actigraphy ..................................................................................................................57 
9. 
SAFETY ASSESSMENTS ........................................................................................58 
9.1. 
Vital Signs and Pulse Oximetry ..................................................................................58 
9.2. 
Physical Examination .................................................................................................58 
9.3. 
Audiology Test ...........................................................................................................58 
9.4. 
Forced Expiratory Volume in 1 Second (FEV1) .........................................................58 
9.5. 
ECG Monitoring .........................................................................................................58 
9.6. 
Ophthalmologic Test ..................................................................................................58 
9.7. 
Clinical Laboratory Evaluations .................................................................................58 
9.8. 
Chest CT Scan ............................................................................................................59 
9.9. 
Adverse Events ...........................................................................................................59 
9.9.1. 
Definition of an Adverse Event ..................................................................................60 
9.9.2. 
Definition of a Serious Adverse Event .......................................................................60 
9.9.3. 
Adverse Events of Special Interest .............................................................................61 
9.9.4. 
Assessment of Severity ...............................................................................................61 
9.9.5. 
Assessment of Causality .............................................................................................62 
9.9.6. 
Management of Adverse Events .................................................................................62 

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9.10. 
Reporting Requirements .............................................................................................62 
9.10.1. 
Adverse Events ...........................................................................................................62 
9.10.2. 
Serious Adverse Events ..............................................................................................62 
9.10.3. 
Pregnancy ...................................................................................................................63 
9.10.4. 
Overdose .....................................................................................................................63 
9.11. 
Follow-up of Adverse and Serious Adverse Events ...................................................63 
9.12. 
Regulatory Aspects .....................................................................................................63 
10. 
STATISTICAL METHODS .......................................................................................65 
10.1. 
Sample Size and Power Considerations .....................................................................65 
10.2. 
Analysis Sets ...............................................................................................................66 
10.2.1. 
Intent-to-Treat Analysis Set ........................................................................................66 
10.2.2. 
Safety Analysis Set .....................................................................................................66 
10.2.3. 
Additional Analysis Sets .............................................................................................66 
10.3. 
Data Handling Conventions ........................................................................................66 
10.4. 
Multiplicity .................................................................................................................67 
10.5. 
Study Population .........................................................................................................67 
10.5.1. 
Study Population Disposition, Demographics and Baseline Characteristics ..............67 
10.5.2. 
Primary Objective .......................................................................................................67 
10.5.3. 
Cross-sectional Validation ..........................................................................................68 
10.5.3.1. 
Modern Psychometric Methods ..................................................................................68 
10.5.3.2. 
Internal Consistency ...................................................................................................68 
10.5.3.3. 
Concurrent Validity ....................................................................................................68 
10.5.3.4. 
Known-Groups Validation ..........................................................................................68 
10.5.4. 
Longitudinal Validation ..............................................................................................68 
10.5.4.1. 
Test-retest Reliability ..................................................................................................68 
10.5.4.2. 
Within-Subject Meaningful Change ...........................................................................69 
10.5.5. 
Item-level Validation ..................................................................................................69 
10.6. 
Other Efficacy Analyses .............................................................................................69 
10.6.1. 
Secondary Efficacy Endpoint Analyses ......................................................................69 
10.6.2. 
Exploratory Efficacy Analyses ...................................................................................69 
10.7. 
Safety Analyses ..........................................................................................................70 
10.7.1. 
Extent of Exposure .....................................................................................................70 

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10.7.2. 
Concomitant Medications and Prior Therapy .............................................................70 
10.7.3. 
Adverse Event Analyses .............................................................................................71 
10.7.4. 
Clinical Laboratory Evaluation Analyses ...................................................................71 
10.7.5. 
Vital Sign Analyses ....................................................................................................71 
10.7.6. 
Physical Examination Analyses ..................................................................................71 
10.7.7. 
Audiology Analysis ....................................................................................................71 
10.7.8. 
Other Safety Analyses ................................................................................................71 
10.7.9. 
Planned Interim Analysis ............................................................................................71 
11. 
DATA INTEGRITY AND QUALITY ASSURANCE ..............................................72 
11.1. 
Source Documents ......................................................................................................72 
11.2. 
Data Collection ...........................................................................................................72 
11.3. 
Study Records Retention ............................................................................................72 
12. 
FINANCING AND INSURANCE .............................................................................73 
12.1. 
Finances ......................................................................................................................73 
12.2. 
Reimbursement, Indemnity, and Insurance ................................................................73 
13. 
STUDY ADMINISTRATIVE INFORMATION .......................................................74 
13.1. 
Financial Disclosure by the Investigator ....................................................................74 
13.2. 
Study Registration and Results Disclosure .................................................................74 
13.3. 
Study Files and Materials ...........................................................................................74 
13.4. 
Use of Stored Samples and Data ................................................................................74 
13.5. 
Disposition of Stored Samples and Data ....................................................................75 
13.6. 
Initiation of Study .......................................................................................................75 
13.7. 
Subject Reimbursement, Liability, and Insurance ......................................................75 
13.8. 
Subject Identification and Confidentiality ..................................................................76 
13.9. 
Study Monitoring ........................................................................................................76 
13.10. 
Protocol Amendments ................................................................................................76 
13.11. 
Audits and Inspections ................................................................................................77 
13.12. 
Publication Policy .......................................................................................................77 
14. 
REFERENCES ...........................................................................................................78 
APPENDIX 1. QOL-B QUALITY OF LIFE QUESTIONNAIRE ............................................82 
APPENDIX 2. PROMIS FATIGUE SHORT FORM 7A ...........................................................86 
APPENDIX 3. PGI-S INSTRUMENT .......................................................................................87 

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APPENDIX 4. EXACT & EXACT-RS INSTRUMENTS .........................................................88 
APPENDIX 5. ST. GEORGE’S RESPIRATORY QUESTIONNAIRE ....................................93 
APPENDIX 6. FACIT FATIGUE SCALE .................................................................................99 
LIST OF IN-TEXT TABLES 
Table 1: 
Composition of ALIS and ELC ..................................................................................40 
Table 2: 
List of Prohibited Medications and Medications with Limited Use ...........................45 
Table 3: 
List of Examples of Precautionary Medications for ALIS .........................................46 
Table 4: 
Schedule of Assessments ............................................................................................48 
Table 5 
Clinical Laboratory Parameters ..................................................................................59 
 
LIST OF IN-TEXT FIGURES 
Figure 1: 
Study Design ...............................................................................................................33 
Figure 2: 
Subject Eligibility Flowchart ......................................................................................34 
 
 

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LIST OF ABBREVIATIONS  
Abbreviation 
Term 
AE 
adverse event  
AESI 
adverse events of special interest 
ALIS 
amikacin liposome inhalation suspension 
ALT 
alanine aminotransferase 
ANCOVA 
analysis of covariance 
ANOVA 
analysis of variance 
ARDS 
acute respiratory distress syndrome 
AST 
aspartate aminotransferase  
ATC 
Anatomical Therapeutic Chemical 
ATS 
American Thoracic Society 
AZI 
azithromycin 250 mg 
BP 
blood pressure 
BMI 
body mass index 
CF 
cystic fibrosis  
CFR 
Code of Federal Regulation  
CI 
confidence interval 
COPD 
chronic obstructive pulmonary disease 
CRO 
Clinical Research Organization 
CRP 
C-reactive protein 
CT 
computed tomography  
DIF 
differential item function  
DMC 
Data Monitoring Committee 
DPPC 
dipalmitoylphosphatidylcholine 
EC 
Ethics Committee  
eCDF 
empirical cumulative distribution functions 
eCRF 
electronic case report form  
EDC 
electronic data capture 
EFA 
exploratory item factor 
ELC 
empty liposome control 
EMA 
European Medicines Agency 
EOS 
end of study 

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Abbreviation 
Term 
EOT 
end of treatment 
ePDF 
empirical probability density functions 
ER 
emergency room 
ETH 
ethambutol 15 mg/kg 
EXACT 
EXAcerbations of Chronic Pulmonary Disease Tool 
EXACT-RS 
EXAcerbations of Chronic Pulmonary Disease Tool – Respiratory Symptoms  
FACIT 
Functional Assessment of Chronic Illness Therapy 
FDA  
Food and Drug Administration  
FEV1 
forced expiratory volume in 1 second  
FSH 
follicle stimulating hormone 
GCP 
Good Clinical Practice  
IB 
Investigator Brochure 
HIV 
human immunodeficiency virus 
ICC 
interclass correlation 
ICFs 
Informed Consent Forms 
ICH 
International Council for Harmonisation  
ICU 
intensive care unit 
IDSA 
Infectious Disease Society of America 
IND 
Investigational New Drug 
IRB 
Institutional Review Board 
IRT 
item response theory 
ITT 
intent-to-treat 
IUD 
intrauterine device 
IV 
intravenous 
IWRS 
Interactive Web Response System 
LSMEANS 
least squares mean 
MAC 
Mycobacterium avium complex  
MAR 
missing at random 
MedDRA 
Medical Dictionary for Regulatory Activities 
MIC 
minimum inhibitory concentration 
MPM 
modern psychometric methods 
NTM 
nontuberculous Mycobacteria  

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Abbreviation 
Term 
PGI-S 
Patient Global Impression of Severity 
PI 
prescribing information 
PMR 
post-marketing requirement 
ppFEV1 
percent predicted forced expiratory volume 
PRO 
Patient-Reported Outcome 
PROMIS F-SF 7a 
Patient-Reported Outcome Measurement Information System Fatigue-Short 
Form 7a 
PV 
pharmacovigilance 
QD 
once daily 
QOL-B 
Quality of Life Questionnaire – Bronchiectasis 
RMSEA 
root mean squared error of approximation 
RR 
respiratory rate 
SAE 
serious adverse event  
SAP 
Statistical Analysis Plan 
SGRQ 
St. George Respiratory Questionnaire  
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TEAE 
Treatment-emergent adverse event 
TRTR 
test-retest reliability 
ULN 
upper limit of normal 
VAP 
Validation Analysis Plan 
WHO 
World Health Organization 
WOCBP 
women of child-bearing potential 
w:w 
weight:weight 
 

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1. 
INTRODUCTION AND BACKGROUND INFORMATION 
1.1. 
Nontuberculous Mycobacterial Lung Disease 
Nontuberculous mycobacterial lung disease caused by MAC is a potentially life-threatening and 
progressively destructive disease that is associated with symptoms of productive cough, fatigue, 
shortness of breath, fever, weight loss, lung function decline, and hemoptysis (Kim et al., 2008; 
Kobayashi et al., 2018; Park et al., 2016). It often complicates other chronic debilitating 
underlying lung diseases such as bronchiectasis or COPD. When NTM lung disease occurs in 
patients without underlying lung comorbidities, it has been implicated in progressive lung 
disease (Prince et al., 1989). If left untreated, MAC lung disease can be progressive, and has a 
5-year mortality rate of 33.3% (Ito et al., 2012). Mycobacterial lung disease carries a MAC 
related 5-year all-cause mortality rate of up to 42% (Diel et al., 2018). Prevalence has increased 
globally over the past decades (Chalmers et al., 2018; Khan et al., 2008; Khan et al., 2007; 
Marras et al., 2007). 
Signs and symptoms of NTM lung disease caused by MAC are variable and often attributable to 
an underlying disease, such as COPD, bronchiectasis, CF, HIV, and pneumoconiosis (Griffith et 
al., 2007). Evaluation is often complicated by the symptoms of other pulmonary comorbidities. 
Fatigue and loss of energy were reported as the “most common symptoms” by 80% of meeting 
attendees in an informal poll while 40% reported chronic cough and coughing up blood and 
phlegm (US FDA Patient Focused Drug Development Workshop, 2015). Less commonly, 
malaise, dyspnea, fever, and weight loss can also occur, usually with advanced MAC lung 
disease. 
The current treatment of NTM lung disease is primarily with a multidrug regimen based on the 
treatment of tuberculosis (Daley et al., 2020). The recommendation for MAC lung disease is a 
3-drug antibiotic regimen that includes a macrolide, ethambutol, and a rifamycin, however the 
optimal drugs, regimens, and duration of therapy are unknown. The recommendation of a 3-drug 
regiment over a 2-drug regimen is stated with low confidence on a conditional recommendation. 
Currently clinical trials evaluating the clinical utility of a 2-drug versus a 3-drug regimen are 
ongoing. The regimen is administered for 12 months beyond culture conversion to negative, 
although the duration of antimicrobial therapy often exceeds 18 months (Johnson and Odell, 
2014). Intravenous amikacin or intramuscular streptomycin are recommended for patients with 
fibrocavitary disease or severe nodular/bronchiectatic disease; however, the optimal treatment 
has yet to be established. Intravenous aminoglycoside use is limited by poor penetration into 
lung tissue, poor uptake by alveolar macrophages (Zhang et al., 2018), and the potential for 
ototoxicity, loss of balance, and impaired kidney function with high or prolonged systemic 
exposure (Kovacevic et al., 2016; Rybak et al., 1999). 
1.2. 
Amikacin Liposome Inhalation Suspension  
ARIKAYCE® was approved by the US FDA on 28 September 2018 under the Limited 
Population Pathway for Antibacterial and Antifungal Drugs, established by Congress under the 
21st Century Cures Act, and under the Accelerated Approval pathway, for the treatment of MAC 
lung disease as part of a combination antibacterial drug regimen in subjects who do not achieve 
negative sputum cultures after a minimum of 6 consecutive months of a multidrug background 
regimen therapy. On 27 October 2020, ARIKAYCE was granted market authorization by the 

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European Medicines Agency (EMA) for the treatment of MAC in adults with limited treatment 
options who do not have cystic fibrosis. On 23 March 2021, ARIKAYCE was approved by 
Japanese Health Authority of the Ministry of Health, Labour and Welfare (MHLW) for the 
treatment of patients with NTM lung disease caused by MAC who did not sufficiently respond to 
prior treatment with a multidrug regimen. Amikacin liposome inhalation suspension is a sterile 
aqueous liposomal formulation for inhalation via nebulization. ALIS is comprised of amikacin 
sulfate encapsulated in liposomes composed of DPPC and cholesterol; other inactive ingredients 
include sodium chloride, sodium hydroxide for pH adjustment, and water for injection. ALIS is 
supplied in a single-use 10 mL vial to deliver 590 mg amikacin to the nebulizer. ALIS is 
administered by inhalation via a nebulizer system using the
(LAMIRA) nebulizer 
system. The nebulizer system delivers medication in the form of aerosols that are inhaled into the 
lungs.  
The pivotal study on which approvals were granted, Study INS-212 (CONVERT), evaluated 
subjects with refractory NTM lung disease caused by MAC. Over 80% of the subjects in this 
study had been treated with at least 3 antibiotics prior to enrollment in the study, yet all subjects 
persistently had prior positive sputum cultures. The addition of ALIS 590 mg QD to a multidrug 
antimycobacterial regimen statistically significantly increased the proportion of subjects 
achieving culture conversion (defined as 3 consecutive monthly negative sputum cultures) by 
Month 6 as compared to a multidrug antimycobacterial regimen alone (29.0% vs 8.9%, 
respectively, P < 0.0001). Treatment with ALIS also statistically significantly increased the 
proportion of subjects achieving durable culture conversion at 3 months off treatment as 
compared to a multidrug antimycobacterial regimen alone (16.1% vs 0%, respectively, 
P < 0.0001). The safety profile of ALIS 590 mg QD was consistent with the utilization of an 
antibiotic via nebulization, and with the class of aminoglycosides, albeit with a low incidence of 
aminoglycoside related safety events. 
1.3. 
Study Rationale 
There remains an unmet medical need for patients with non-cavitary lung disease with newly 
diagnosed MAC lung infections who have not started treatment. A significant proportion of 
patients treated with currently available multidrug therapy do not achieve treatment success. A 
systematic review and meta-analysis showed in a total of 16 studies involving 1,462 subjects, the 
rate of treatment success was 60% (Kwak et al., 2017). In subjects who were macrolide 
susceptible and had previously been untreated for MAC, treatment for at least 1 year resulted in 
sputum culture conversion rate of 65.7% (Diel et al., 2018). There is currently no validated PRO 
instrument to evaluate symptoms in patients with MAC lung disease. This study aims to generate 
evidence demonstrating the domain specification (via modern psychometric methods), reliability, 
validity, and responsiveness (within-subject meaningful change) of the PRO endpoints of 
ALIS-based regimen within the MAC lung disease population. The instrument validated in this 
study will be used for the assessment of the clinical benefit in a separate study.  
1.3.1. 
Study Population 
Patients with MAC lung disease are heterogeneous in part as a consequence of the signs and 
symptoms of this infection mirroring the underlying pulmonary disease(s) that predispose 
patients to the infection. The clinical approach to MAC lung disease is to first exclude more 
common reasons for worsening respiratory disease, and the decision to treat is often based on the 

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conclusion that the MAC lung disease is progressing, evidenced by adverse changes in radiologic 
features (eg development of cavitary disease) or persistent or worsening symptoms attributed to 
MAC. Additionally, there is no standardized approach to the classification or to the severity of 
disease by CT imaging. The likelihood of a timelier diagnosis is partially related to the 
experience of a clinician managing a patient with this uncommon infection. The decision on 
which antibiotic regimen to administer is typically based upon the patient’s underlying lung 
disease. 
The proposed study will utilize eligibility criteria to decrease the heterogeneity of the study 
population. Importantly, the general approach to the clinical management of individuals of such 
a population is similar to a reasonable extent. This approach of decreasing heterogeneity will 
improve the power of the study to detect the efficacy and safety of the ALIS-based regimen. In 
particular, this is important for measurement of patient symptoms, which are inherently subject 
to random fluctuation that may obscure the treatment effects. The subject population under 
investigation for this clinical study will include adults with non-cavitary lung disease with a new 
(initial or subsequent) MAC lung infection who have not started treatment for their current 
infection. 
1.3.2. 
Treatment and Duration of Exposure 
Patients to be evaluated in this study have mild disease and have not received treatment for their 
current MAC lung infection. The design and treatment have been extensively discussed and 
agreed with a global steering committee of experts experienced in the management of NTM 
pulmonary disease and with regulatory agencies. Subjects will be randomized to ALIS + 
background regimen or ELC + background regimen. Note that background regimen in this study 
is defined as AZI+ETH per randomized treatment. Treatment will be administered continuously 
for 6 months followed by 1 month off treatment period with a final EOS evaluation at Month 7.  
It was agreed upon with the FDA that an active control that is also used in clinical practice would 
be used in the study.  
Based on extensive consultations with medical experts, in this population of newly diagnosed 
MAC patients with non-cavitary lung disease, treatment with 2 drug oral regimen, specifically 
azithromycin and ethambutol has been confirmed as acceptable. This macrolide-based regimen is 
currently prescribed in clinical practice, and keeping the background regimen simple and 
tolerable will help subjects remain in the study. The regimen excludes rifabutin or rifampin 
which are associated with well-described side effects that affect patients with MAC lung disease 
and patient tolerability for regimens that include one of these 2 drugs. In addition, the chosen 
companion drugs to ALIS can also be considered to contribute to the therapeutic success by 
virtue of their ability to prevent overgrowth of organisms that may develop resistance to 
individual agents in the regimen during the course of treatment. 
As stated in both the BTS and ATS/ERS/ESCMID/IDSA guidelines, a 2-drug regimen including 
a macrolide and ethambutol is the regimen with the fewest possible drugs for treating MAC. 
Data recently published subsequent to the release of the global guidelines show that the 2-drug 
regimen of azithromycin and ethambutol may be an option for the treatment of non-cavitary 
MAC lung disease: 76% of patients were able to achieve sputum culture conversion after 
12 months of treatment, and none of those who failed to culture convert developed macrolide 
resistance (Moon et al., 2019). Ethambutol is likely the key companion drug for preventing the 

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emergence of macrolide resistance (Haworth et al., 2017; Daley et al., 2020). Literature has 
shown that patients have a higher risk of developing macrolide resistance if they were not treated 
with ethambutol (Griffith et al., 2007; Morimoto et al., 2016) drug regimen over a 2-drug 
regimen over a 2drug regimen: 
 
“In patients with macrolide-susceptible MAC pulmonary disease, we suggest a treatment 
 
regimen with at least 3 drugs (including a macrolide and ethambutol) over a regimen with 
 
2 drugs (a macrolide and ethambutol alone) (conditional recommendation, very low certainty 
 
in estimates of effect).” 
Additionally, both sets of treatment guidelines note the uncertainty over who to treat and when to 
start treatment for newly diagnosed NTM pulmonary disease as there are no randomized 
controlled trial data. In the ATS/ERS/ESCMID/IDSA guidelines it is directly stated: 
 
“No randomized, controlled trials have been conducted to examine the impact of treatment 
 
on either survival or quality of life. Limited retrospective observational data have failed to 
 
demonstrate that treatment of NTM pulmonary disease prolongs survival over watchful 
 
waiting.”  
The BTS guidelines have a similar statement on the uncertainty “... fulfilling the criteria 
[ATS/IDSA] does not necessarily imply that treatment should be started, as patients can remain 
stable without antibiotic treatment.” 
Prevention of development of macrolide resistance is a priority in MAC treatment. As stated in 
the ATS/ERS/ESCMID/IDSA guidelines for MAC pulmonary disease: “The optimal drugs, 
regimens, and duration of therapy are not known.” (Daley et al., 2020). The guidelines do not 
state that a 2-drug regimen is inferior to 3 drugs with regards to prevention of macrolide 
resistances, only that there is currently insufficient evidence to support the 2-drug regimen. 
Miwa et al reported that no isolates in either group developed macrolide resistance, although the 
study was underpowered (Miwa et al., 2014). Ito et al also evaluated the 2-drug regimen 
compared to 3 drugs; their results suggest that 2-drug treatment with clarithromycin and 
ethambutol does not lead to a higher incidence of resistance to clarithromycin than the standard 
3-drug treatment (Ito et al., 2020). Regardless, drug susceptibility will be closely monitored and 
the unblinded data will be regularly reviewed by an independent monitoring committee which 
will continually evaluate drug susceptibility data during the study. Of note there are other active 
trials that use a 2-drug comparator arm of a macrolide and ethambutol in the treatment of 
pulmonary MAC disease, but more importantly the clinical equipoise of using a 2- versus a 
3-drug regimen is currently being investigated by a large multicenter study. The current active 
comparator is an accurate control for this study population as this is a population with milder 
disease, and a 4-drug regimen (including ALIS) is not warranted. Germane to all clinical 
research, new treatments and treatment durations are being studied.  
The optimal duration of therapy in MAC pulmonary disease is unknown. As stated in the 2020 
ATS/ERS/ESCMID/IDSA guidelines, while MAC species are the most common organisms 
causing NTM pulmonary disease, the optimal treatment duration for MAC pulmonary disease 
has not been evaluated in a prospective randomized clinical trial and the conditional 
recommendation for 12 months of therapy is given with very low certainty in estimates of the 
effect. Given the lack of data on the optimal duration of therapy, the panel voted unanimously to 
continue to follow the recommendations from the 2007 Guideline. The duration of exposure to 

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the study regimen (6 months) is less than the maximum duration of exposure of 20 months to the 
ALIS-based regimens in the subjects who participated in both Study INS-212 and Study INS-312 
that evaluated a more difficult-to-treat population of adult patients with treatment refractory 
MAC lung disease. 
1.3.3. 
Efficacy Endpoints, Placebo Control, and Active Comparator 
The primary objective of this study is to generate evidence demonstrating the domain 
specification (via modern psychometric methods), reliability, validity, and responsiveness 
(within-subject meaningful change) of the PRO endpoints. Specifically, findings on 
psychometric validation will be optimized and reported for: 
1) Cross-sectional validation (modern psychometrics, internal consistency, concurrent validity, 
and known-groups validity) at Baseline. 
2) Test-retest reliability between Screening and Baseline among subjects reporting no change on 
PGI-S between screening and baseline. PGI-S anchors will be PRO specific, with a respiratory 
and fatigue PGI-S applied to the QOL-B respiratory domain and PROMIS F-SF 7a, respectively. 
3) Within-subject meaningful change estimated via anchor-based methods and validated via 
eCDFs and ePDFs between Baseline and EOS (Month 7). 
There are no established clinical endpoints to evaluate the clinical benefit of a therapeutic 
regimen in MAC lung disease. This study aims to validate PRO endpoints that can evaluate 
benefit of a treatment in MAC lung disease. This study will utilize PRO endpoints that are being 
used uniquely to determine the clinical meaningfulness of any treatment for MAC lung disease, 
in addition to microbiological endpoints. 
This study will assess data generated from PRO instruments. Therefore, given that this endpoint 
incorporates subject symptomology and subjectivity, it is critical to conduct the study in a 
double-blinded fashion to minimize the potential for biased responses. An active comparator 
allows for the evaluation of the incremental benefit of ALIS and is an appropriate, efficient, and 
accurate control for this study population. The double-blind study design and blinding to 
microbiology results allows for an evaluation of the efficacy and safety of an ALIS-based 
regimen. 
1.4. 
Risks and Benefits for Study Subjects 
A favorable benefit/risk profile has been established for the use of ALIS in subjects with 
refractory MAC lung disease. The safety profile is acceptable given the significant risk of the 
disease, the inadequacy of current treatment approaches, and early indications of positive clinical 
outcomes from the use of ALIS.   
ALIS has not been studied in adults with non-cavitary lung disease with new (initial or 
subsequent) MAC lung infections who have not started treatment for their current infection. 
Current treatment for patients with newly diagnosed MAC lung disease is similar to that for 
patients with refractory MAC lung disease; it is based on treatment with a multidrug regimen. 
However, optimal treatment has yet to be established, and current treatment have many adverse 
effects. A significant proportion of subjects treated with currently available multidrug therapy do 
not achieve treatment success. Data from previous studies (INS-212 and INS-312) in subjects 

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with refractory MAC lung disease provide insight on the eventual benefit/risk evaluation for this 
subject population. This study will evaluate the benefit/risk profile of ALIS in subjects with 
newly diagnosed MAC lung disease.  
1.5. 
Treatment, Route, Dosage, Treatment Period 
Eligible subjects with non-cavitary lung disease with new (initial or subsequent) MAC lung 
infections who have not started treatment for their current infection (see Section 4) and who have 
signed the ICFs will be randomized and will receive treatment as follows (see Figure 1) 
• ALIS 590 mg QD + AZI 250 mg QD + ETH 15 mg/kg QD for 6 months, or 
• ELC (matching placebo for ALIS) + AZI 250 mg QD + ETH 15 mg/kg QD for 6 
months 
1.6. 
Randomization and Blinding 
Upon meeting all inclusion/exclusion criteria, subjects will be randomly assigned through IWRS 
in a 1:1 ratio to either of the treatment groups. The randomization will be stratified by region 
(North America, Europe, and Rest of World) and history of MAC lung infection (initial or 
subsequent). Subjects, Investigators, and Sponsor will be blinded to treatment group assignments 
and microbiology results throughout the study. In case of subject emergencies, unblinding of the 
assigned treatment will occur per established procedure. 
1.7. 
Compliance Statement, Ethics, and Regulatory Compliance  
This study will be conducted in compliance with the protocol, the ethical principles derived from 
international guidelines including the Declaration of Helsinki and the CIOMS International 
Ethical Guidelines, applicable ICH GCP Guidelines, and applicable local regulatory 
requirement(s) and laws. 
1.7.1. 
Subject Confidentiality 
The Investigators and the Sponsor will preserve the confidentiality of all subjects taking part in 
the study, in accordance with GCP and local regulations. 
The Sponsor will observe the rules laid down in the European Data Protection Regulation (EU) 
2016/679 of 27 April 2016 on the protection of natural persons with regard to the processing of 
personal data and the free movement of such data. 
The Investigator must ensure that the subject’s anonymity is maintained. On the eCRF or other 
documents submitted to Sponsor, subjects should be identified by a unique subject identifier as 
designated by the Sponsor. Documents that are not for submission to Sponsor (eg, signed ICFs) 
should be kept in strict confidence by the Investigator. 
In compliance with ICH GCP Guidelines, it is required that the Investigator and institution 
permit authorized representatives of the company, of the regulatory agency(s), and the EC or 
IRB direct access to review the subject’s original medical records for verification of study-
related procedures and data. The Investigator is obligated to inform the subject that his/her study-
related records will be reviewed by the above-named representatives without violating the 
confidentiality of the subject. 

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1.7.2. 
Informed Consent Procedure 
Before a subject’s participation in the study, it is the Investigator’s responsibility to obtain freely 
given consent, in writing, from the subject or legally acceptable representative after adequate 
explanation of the aims, methods, anticipated benefits, and potential hazards of the study and 
before any protocol-specific screening procedures or any study drugs are administered. A legally 
acceptable representative is an individual or other body authorized under applicable law to 
consent, on behalf of a prospective subject, to the subject’s participation in the clinical study. An 
informed consent document that includes both information about the study and the consent form 
will be prepared and given to the subject. This document will contain all the elements required 
by the ICH E6 (R2) Guideline for GCP and any additional elements required by local 
regulations. The written Informed Consent Form (ICF) should be prepared in the local 
language(s) of the potential subject population. 
In obtaining and documenting informed consent, the Investigator should comply with the 
applicable regulatory requirements, and should adhere to GCP and to the ethical principles that 
have their origin in the Declaration of Helsinki. The consent form and any revision(s) should be 
approved by the IRB/EC prior to being provided to potential subjects. 
The subject’s informed consent (written or electronic) should be obtained prior to his/her 
participation in the study, and should be documented in the subject’s medical records, as required 
by applicable regulations. Informed consent may be obtained, where applicable, via a virtual 
telemedicine visit and signed electronically. 
The ICF should be signed and personally dated by the subject or a legally acceptable 
representative, and by the person who conducted the informed consent discussion (not 
necessarily the Investigator) however, a medically qualified person must be involved during the 
consenting process. The signed ICF should be retained in accordance with institutional policy, 
and a copy of the signed consent form should be provided to the subject or legal representative. 
The date and time (if applicable) that informed consent was given should be recorded on the 
eCRF. 
1.7.3. 
Regulatory Compliance 
The study protocol, subject information and consent form, the IB, any subject diary card or 
written instructions to be given to the subject, available safety information, subject recruitment 
procedures (eg, advertisements), information about payments and compensation available to the 
subjects and documentation evidencing the Investigator’s qualifications should be submitted to 
the IRB/EC for ethical review and approval according to local regulations, prior to the study 
start. The written approval should identify all documents reviewed by name and version. 
Changes in the conduct of the study or planned analysis will be documented in a protocol 
amendment and/or the SAP. 
All protocol amendments and changes to the ICFs or changes of the investigational site, 
facilities, or personnel (when applicable) must be submitted to the IRB/EC, and where necessary, 
approval from the IRB/EC must be obtained. The Investigator should notify the IRB/EC of 
deviations from the protocol or SAEs occurring at the site and other AE reports received from 
the Sponsor, in accordance with local procedures. 

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As required by local regulations, the Sponsor’s local Regulatory Affairs group will ensure all 
legal aspects are covered, and approval of the appropriate regulatory bodies obtained, prior to 
study initiation, and that implementation of changes to the initial protocol and other relevant 
study documents happen only after the appropriate notification of or approval by the relevant 
regulatory bodies. 

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2. 
STUDY OBJECTIVES AND ENDPOINTS 
2.1. 
Primary Objective and Endpoint 
Objective 
To generate evidence demonstrating the 
domain specification (via modern 
psychometric methods), reliability, 
validity, and responsiveness (within-
subject meaningful change) of the PRO 
endpoints 
Endpoint 
Findings on psychometric validation optimized 
and reported for: 
1) Cross-sectional validation (modern 
psychometrics, internal consistency, concurrent 
validity, and known-groups validity) at Baseline. 
2) Test-retest reliability between Screening and 
Baseline among subjects reporting no change on 
PGI-S between screening and baseline. PGI-S 
anchors will be PRO specific, with a respiratory 
and fatigue PGI-S applied to the QOL-B 
respiratory domain and PROMIS F-SF 7a, 
respectively. 
3) Within-subject meaningful change estimated 
via anchor-based methods and validated via 
eCDFs and ePDFs between Baseline and EOS 
(Month 7). 
2.2. 
Secondary Objectives and Endpoints 
Objective  
Endpoint 
To evaluate the effect of each treatment arm (ALIS + background regimen and ELC + 
background regimen) on the following: 
1. Culture conversion by Month 6 
Proportion of subjects achieving culture 
conversion by Month 6 (negative cultures for 
MAC at Month 5 and Month 6) 
2. Patient-reported respiratory 
symptoms at Month 7 
Change from Baseline to Month 7 in respiratory 
symptom score 
3. Patient-reported fatigue symptoms 
at Month 7 
Change from Baseline to Month 7 in fatigue 
symptom score 
4. Time to culture conversion 
Time to culture conversion (first of 2 
consecutive negative cultures) of Baseline to 
EOT assessments 
5. Time to first negative culture 
Time to first negative culture of Baseline to EOT 
assessments 

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6. MAC isolates with amikacin MIC 
≥ 128 μg/mL 
Proportion of subjects who develop a MAC 
isolate with amikacin MIC ≥ 128 µg/mL at more 
than 1 visit at any timepoint during the study 
7. Recurrence of MAC (relapse) 
Proportion of subjects who achieved culture 
conversion and subsequently have at least 1 
MAC positive culture in agar media or positive 
cultures in broth media in at least 2 consecutive 
visits that is the same species and genome as 
cultured at Screening/Baseline. 
8. Recurrence of MAC (new 
infection) 
Proportion of subjects who achieved culture 
conversion and subsequently have at least 1 
MAC positive culture in agar media or positive 
cultures in broth media in at least 2 consecutive 
visits that is different than cultured at 
Screening/Baseline (different species or same 
species but different genome). 
9. Safety and tolerability of ALIS + 
background regimen 
Incidence and severity of AEs and TEAEs and 
other safety variables (eg, vital signs, physical 
examination, clinical laboratory values) from 
Baseline through the EOS 
2.3. 
Exploratory Objectives and Endpoints 
Objective 
Endpoint 
To evaluate the effect of each treatment arm (ALIS +background regimen and ELC + 
background regimen) on the following: 
1. Patient-reported non-respiratory 
symptoms at Month 7 
Change from Baseline to Month 7 in the QOL-B 
non-respiratory domains (physical, role, vitality, 
emotional, social, health perception) 
2. Within-subject meaningful change 
threshold estimated in respiratory 
symptoms from Baseline to 
Month 7 
Proportion of subjects meeting the within-
subject meaningful change threshold as reflected 
in PRO changes scores computed from Baseline 
in patient-reported symptoms 
3. Mean activity and sleep efficiency 
over time  
Longitudinal summary of mean activity and 
sleep efficiency as measured by Philips 
Actiwatch Spectrum PRO 

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3. 
STUDY DESIGN 
3.1. 
Overall Plan 
This is a randomized, double-blind, placebo-controlled, active comparator study in eligible 
subjects with a new diagnosis (initial or subsequent) of MAC lung infection who have not started 
treatment for their current infection (Figure 1). Subjects will be randomized at Baseline in a 1:1 
ratio to receive one of the two treatment regimens: ALIS + background regimen or 
ELC + background regimen for 6 months. Note that the background regimen in this study is 
defined as AZI+ETH per randomized treatment. 
Randomization will be stratified by region (North America, Europe, and Rest of World) and 
history of MAC lung infection (initial or subsequent). After Baseline, subjects will return to the 
study site for in-clinic visits at Months 1, 3, 5, 6/EOT, and 7/EOS. 
Visits at Months 2 and 4 do not require in-clinic appointments. At these non-in clinic visits, AEs 
and concomitant medications will be assessed, eDiary data will be collected continually for 
assessment of study drugs intake, and subjects will be required to produce and ship sputum 
samples. At the Month 6/EOT visit, subjects will discontinue all study drugs and will be 
followed for a 1 month off treatment period, during which medical or non-medical therapies for 
MAC lung infection should not be given.  
At Month 7/EOS, subjects will complete all protocol-specified assessments and the final EOS 
procedures.  
This study aims to validate PRO outcomes from the QOL-B and PROMIS F-SF 7a within the 
MAC lung disease population.  
The validating variables will utilize the following PRO tools: 
• EXACT  
• E-RS  
• SGRQ  
• FACIT – Fatigue Scale  
• PGI-S – Respiratory  
• PGI-S – Fatigue  
Clinical/Digital validating variables: 
• ppFEV1 
• Sputum cultures (Section 8.1) 
• Assessment of MAC isolates with amikacin MIC ≥ 128 μg/mL 
• Actigraphy  
The procedures and assessments conducted at each study visit in the study are provided in 
Table 4. Please refer to Figure 1 for a schematic diagram of the study design. 

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4. 
STUDY POPULATION 
4.1. 
Enrollment 
This study is planned to be conducted at approximately 150 sites in North America, Europe, and 
the Rest of World. Subject eligibility by initial or subsequent MAC lung infection is summarized 
in Figure 2. 
Figure 2: 
Subject Eligibility Flowchart 
 
Abbreviations: dx – diagnosis; Note: Subjects with a subsequent diagnosis of MAC who were previously 
successfully treated and now have a positive culture > 6 months from cessation of prior successful treatment would 
not be considered a relapse and would be eligible for enrollment.  

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To be eligible for enrollment, subjects must meet all of the following inclusion criteria and none 
of the following exclusion criteria. 
4.1.1. 
Inclusion Criteria  
Subjects must satisfy all of the following criteria to be included in the study: 
1. Male or female ≥ 18 years of age (19 years or older in South Korea) 
2. Current diagnosis of MAC lung infection. MAC or mixed infection with MAC as the 
dominant species is allowed, with MAC as the intended organism for treatment  
3. Positive sputum culture for MAC within 6 months prior to Screening 
4. Positive sputum culture for MAC at Screening 
5. A chest CT scan, read locally, within 6 months prior to Screening to determine presence 
and size of pulmonary cavities. Subjects who do not have a chest CT scan within 
6 months prior to Screening will be required to obtain a chest CT scan, read locally, 
during Screening 
6. In the Investigator’s opinion, documented respiratory signs/symptoms at Screening that 
are attributable to the current MAC lung infection 
7. An average QOL-B respiratory domain score of ≤ 85 based on scores at Screening and on 
the day of enrollment prior to randomization 
8. In the Investigator’s opinion, underlying lung disease (eg, COPD, bronchiectasis) have 
been managed according to best local standard of care, and on stable maintenance therapy 
for a minimum of 4 weeks prior to randomization 
9. Willingness and ability to adhere to prescribed study treatment during the study 
10. Ability to produce (spontaneously or with induction) approximately 2 mL of sputum for 
mycobacteriology at Screening 
11. WOCBP (ie, fertile following menarche and until becoming post-menopausal unless 
permanently sterile) and fertile men (ie, all men after puberty unless permanently sterile 
by bilateral orchidectomy) agree to practice a highly effective method of birth control 
from Day 1 to at least 90 days after the last dose. Examples of such birth controls are: 
• true abstinence (refraining from heterosexual intercourse during the entire study), 
• copper IUD,  
• hormonal methods (levonorgestrel-releasing intrauterine system, progestogen 
implant, combined oral contraceptive pill [combined with barrier method]),  
• exclusive homosexual relationship, or  
• sole male partner who has undergone surgical sterilization with confirmation of 
azoospermia at least 3 months post procedure while participating in the study. 
12. Provide signed informed consent prior to administration of study drugs or performing any 
study related procedure 
13. Be able to comply with study drugs use, study visits, and study procedures as defined by 
the protocol 
14. Men with partners who are WOCBP (pregnant or non-pregnant) agree to use condoms 
and non-pregnant partners should practice a highly effective method of birth control. 
4.1.2. 
Exclusion Criteria 
Subjects who meet any of the following criteria will be disqualified from entering the study: 

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1. Diagnosis of CF 
2. History of more than 3 MAC lung infections 
3. Received any mycobacterial antibiotic treatment for current MAC lung infection 
4. Refractory MAC lung infection, defined as having positive MAC cultures while being 
treated with a multidrug mycobacterial antibiotic treatment regimen for a minimum of 6 
consecutive months and no documented successful treatment, defined as negative sputum 
culture for MAC and cessation of treatment 
5. Relapse of prior MAC lung infection, defined as positive sputum culture for MAC 
≤ 6 months of cessation of prior successful treatment 
6. MAC isolate with MIC for amikacin ≥ 128 µg/mL at Screening 
7. Evidence of any pulmonary cavity ≥ 2 cm in diameter, as determined by chest CT scan, 
read locally, within 6 months prior to Screening 
8. Radiographic finding of new lobar consolidation, atelectasis, significant pleural effusion, 
or pneumothorax during routine clinical care within 2 months prior to Screening 
9. Active pulmonary malignancy (primary or metastatic) or any malignancy requiring 
chemotherapy or radiation therapy within 1 year prior to Screening or anticipated during 
the study 
10. Active pulmonary tuberculosis requiring treatment during Screening 
11. Hospitalization for underlying lung disease during Screening 
12. Acute pulmonary exacerbation (eg, COPD or bronchiectasis) requiring treatment with 
antibiotics, or corticosteroids (IV or oral), within 4 weeks prior to and during Screening 
13. Predicted FEV1 < 35%, pre-bronchodilator use 
14. Current smoker 
15. History of lung transplantation 
16. Use of inhaled or systemic aminoglycosides with activity against MAC (eg, amikacin, 
kanamycin, or streptomycin) during Screening 
17. Prior exposure to ALIS (including clinical study) 
18. Known hypersensitivity or contraindications to use to ALIS, aminoglycosides, or any of 
their excipients  
19. Disseminated MAC infection 
20. Positive pregnancy test or lactation at Screening. All WOCBP will be tested. Women not 
of child-bearing potential are defined as postmenopausal (ie, amenorrheic for 12 months 
without an alternative medical cause or confirmed by more than one FSH measurement), 
or naturally or surgically sterile through bilateral oophorectomy, hysterectomy, or 
bilateral salpingectomy. For women under the age of 45, confirmatory testing with FSH 
should be considered. 
21. Administration of any investigational drug within 8 weeks prior to Screening 
22. Known or suspected acquired immunodeficiency syndromes (HIV-positive, regardless of 
CD4 counts). Other immunodeficiency syndromes that may interfere with study 
participation in the opinion of the Investigator. 
23. Significant (as determined by the Investigator) hearing loss, vestibular dysfunction, 
neuromuscular weakness or a diagnosis of myasthenia gravis, where the potential risk of 
aminoglycoside toxicity outweighs the potential benefit 
24. Aspartate aminotransferase or alanine aminotransferase ≥ 3 times the ULN or total 
bilirubin ≥ 1.5 times ULN at Screening 
25. Absolute neutrophil count ≤ 500/μL at Screening 

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26. Serum creatinine > 2 times ULN at Screening 
27. Current alcohol, medication, or illicit drug abuse 
28. Any condition that, in the opinion of the Investigator, interferes with ability to safely 
complete the study or adhere to study requirements 
29. Known and active COVID-19 infection  
30. MAC isolate with MIC for clarithromycin ≥ 32 µg/mL at Screening 
31. Known hypersensitivity or contraindications to use to ethambutol, azithromycin 
(including other macrolides or ketolides), or any of their excipients per local labeling 
guidance  
4.2. 
Discontinuation of Study Drugs and Participant 
Discontinuation/Withdrawal 
4.2.1. 
Discontinuation of Study Drugs 
All subjects are encouraged to stay in the study for continued safety monitoring regardless of 
discontinuation of study drugs. If a subject discontinues one or more study drugs (ALIS/ELC, 
AZI, and/or ETH), they will remain on the other study drug(s) and continue with the scheduled 
study visits. For these subjects, it is highly encouraged to stop all MAC treatment at Month 6 
(per study design) to evaluate the primary and secondary endpoints during the off treatment 
period.  However, if deemed medically necessary per the Investigator, these subjects who 
prematurely discontinue one or more study drugs may be allowed to continue treatment during 
the off treatment period.  
If a subject discontinues ALIS or ELC:  
• The reason for ALIS or ELC discontinuation will be recorded in eCRF. 
• The subject will remain on the other study drugs (AZI and ETH) and continue with the 
next scheduled study visit. 
• At the next scheduled visit, the subject will complete the EOT visit assessments. 
• The subject will complete a Month 6 visit when they reach Month 6.  
If a subject discontinues AZI and/or ETH, the reason for drug discontinuation should be recorded 
in the eCRF. The EOT visit should not be completed at this time. The subject will remain on the 
other study drugs (ALIS/ELC and AZI or ETH) and should initiate therapy consistent with the 
2020 ATS/ERS/ESCMID/IDSA treatment guidelines (Daley et al., 2020), and continue with the 
next scheduled study visit. Any changes to therapy and treatment regimen should aim to prevent 
the development of macrolide resistance. Changes to treatment should be discussed with the 
Medical Monitor to ensure compliance with the 2020 ATS/ERS/ESCMID/IDSA treatment 
guidelines.  
For subjects who discontinue one or more study drugs, replacement therapy may be provided at 
the discretion of the Investigator; this is not considered rescue therapy.  
Subjects may be discontinued from one or more study drugs at the discretion of the Investigator 
if they meet treatment stopping criteria per local labeling guidance. 

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If a subject withdraws consent from continued safety monitoring, the EOS visit should be 
completed. 
4.2.2. 
Participant Discontinuation/Withdrawal from the Study 
A subject may decide to withdraw from the study at any time, for any reason. The Investigator 
and/or Sponsor also have the right to withdraw a subject from the study if it is no longer in the 
interest of the subject to continue in the study, or if the subject’s continuation in the study places 
the scientific outcome of the study at risk (eg, if a subject does not or cannot follow study 
procedures). All subjects who are withdrawn from the study should complete protocol-specified 
early discontinuation procedures (Section 4.2.3). 
4.2.3. 
Early Discontinuation Procedures 
If a subject prematurely discontinues the study, the subject will do the following: 
• Attend the EOT visit 
• Attend EOS visit 28 days after the last dose of study drugs  
• Complete EOS assessment 
If a subject withdraws from the study, the Investigator will complete and report the observations 
as thoroughly as possible up to the date of withdrawal including the date of last treatment and the 
reason for withdrawal. 
If the subject is discontinued from the study due to an AE, the Investigator will follow the 
subject until the Investigator deems that the AE has resolved or stabilized. In case of unresolved 
AEs including significant abnormal laboratory values at the EOS assessment, these events will 
be followed up until resolution or until they become stable. 
4.2.3.1. 
Lost-to-Follow-up 
A subject will be considered lost-to-follow-up if the site is unable to contact the subject after all 
reasonable efforts have been exhausted. 
4.2.4. 
Subject Replacement 
Subjects who prematurely discontinue from the study will not be replaced. 
4.2.5. 
Subject Rescreening Procedures 
Upon approval by Sponsor, subjects may be rescreened once, if the following apply: 
• The screening culture is not positive for MAC, or  
• The subject has a MAC isolate with MIC for amikacin ≥ 128 µg/mL at Screening, and/or  
• The average QOL-B respiratory domain score is > 85, and/or  
• The subject has active COVID-19 infection.  
Subject will only be allowed to be rescreened if all other entry criteria have been satisfied. If a 
subject’s average QOL-B respiratory domain score is > 85, the subject may take the 

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questionnaire again, once on the next day and again within 7 days to calculate a new average; all 
other Screening assessments do not have to be repeated. Subjects should be rescreened within 
the original screening period timeframe (approximately -70 to -1 days). 
If a subject is rescreened due to Screening culture that is not positive for MAC or MAC isolate 
has amikacin MIC ≥ 128 µg/mL, all other Screening assessments must be repeated. The subject 
will have a new Screening window (approximately -70 to -1 days).   
If a subject has active COVID-19 infection, the subject may be rescreened once recovered and 
the diagnostic tests are negative. All Screening assessments must be repeated. The subject will 
have a new Screening window (approximately -70 to -1 days).  Subjects who experienced 
COVID-19 related hospitalization, severe disease, and/or ARDS may not be rescreened.  
Rescreened subjects will be assigned a new subject number within the EDC system. 
4.3. 
Premature Termination of the Study  
The Sponsor may decide to terminate the study prematurely. If this occurs, written notification of 
the study termination is required to be sent to the site.  
Conditions that may warrant study termination may include the following: 
• Discovery of an unexpected, significant, or unacceptable risk to the subjects enrolled 
in the study 
• Decision on the part of the Sponsor to suspend or discontinue development of the 
drug 
• Decision by a regulatory authority or the Sponsor to stop the study at any time, where 
applicable 
In the event of study discontinuation, subjects will discontinue study drugs. Refer to 
Section 4.2.3 for early discontinuation procedures. 
Refer to Section 6.3 for considerations during public health emergencies. 
The Sponsor will notify the regulatory authorities in all countries where the study is being 
conducted regarding the reason for terminating the study. 

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formation. Once the liposomes are formed, the defiltration is started using 
 sodium chloride 
to the targeted lipid concentrations, eg 
 ELC. 
5.1.2. 
Azithromycin and Ethambutol Tablets 
The background regimen that will be used in the study are azithromycin 250 mg tablets and 
ethambutol 100 mg and ethambutol 400 mg tablets. These drugs are commercially available and 
will be sourced regionally and provided by the Sponsor. 
5.1.3. 
Methods of Assigning Subjects to Treatments 
Upon meeting all inclusion/exclusion criteria, subjects will be randomized through an IWRS 
vendor in a 1:1 ratio to either of the treatment groups. The randomization will be stratified by 
region (North America, Europe, and Rest of World) and history of MAC lung infection (initial or 
subsequent).  
Investigators (including independent evaluator/raters and clinicians providing care to the 
subject), Sponsor, and subjects/caregivers will be blinded to treatment group assignments 
throughout the study.  
Study personnel and subjects are strongly discouraged from discussing any aspect of study drugs 
that may lead to unintentional unblinding of treatment assignment in order to maintain study 
integrity. 
Selected individuals who are not involved in the conduct of the study may have access to 
unblinded data as needed for safety review or other data review (see Section 3.2). 
Unblinding is only to occur at the conclusion of the study or in the case of subject emergencies. 
5.1.4. 
Study Drugs Administration 
ALIS 590 mg or ELC will be administered QD by inhalation via nebulization over 
approximately 6 minutes to up to 15 minutes. Written directions for preparing and administering 
ALIS or ELC will be provided to subjects. On the day of study visits, ALIS or ELC 
administration will be the last procedure to be conducted (see Table 4). 
Azithromycin 250 mg tablets dosed 1 tablet QD, and ethambutol tablets dosed at 15 mg/kg will 
be taken by mouth QD, with or without food. The Investigator should refer to local labeling 
guidance:  
• To monitor AZI and ETH use 
• To conduct any necessary monitoring procedures (eg, ECG monitoring, ophthalmic 
exams, audiology testing) 
The Investigator is responsible for recording any AEs and SAEs as appropriate (see 
Section 9.10).   
Timing of Administration 
Study drugs should be administered QD around the same time each day, any time of day, in the 
fasted or as-fed condition. 

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5.1.4.1. 
Dose Interruption 
It is recommended that all subjects remain on prescribed daily treatment throughout the study. 
However, experience has shown that dose interruptions may be helpful to avoid discontinuation 
of ALIS (Swenson et al., 2020). If a subject experiences a nonserious AE that is distressing and 
an interruption of study drugs dosing (ALIS/ELC, AZI and/or ETH per Investigator discretion) is 
needed to avoid discontinuation of study drugs, contacting the Medical Monitor to discuss 
subject management is encouraged. 
At the discretion of the Investigator, dose adjustments of azithromycin and/or ethambutol may be 
allowed if criteria are met per local label recommendation (ie, renal or hepatic insufficiency).  
All dose interruptions must be documented in the subject’s source documentation and recorded 
in the eCRF. 
5.1.5. 
Method of Assessing Treatment Compliance  
Subjects will be required to bring all their used and unused study drugs supplies to in-clinic study 
visits during the treatment period or, if the visit is being conducted virtually, have all used and 
unused study drugs supplies available to be accounted for. 
Accountability for study drugs administration during the study is the responsibility of the 
Investigator or designees. Drug accountability will be recorded at each in-clinic study visit by 
review of electronic diary (eDiary) data (accounting for prescribed dose 
interruptions/adjustments) and count of returned study drugs.  
A subject will be considered noncompliant with use of study drugs if treatment adherence is less 
than 80% or more than 120% unless instructed by the Investigator to interrupt dosing for safety 
reasons (Section 5.1.4.1). Subjects who are non-compliant with study drugs should be retrained. 
5.1.6. 
Emergency Unblinding 
Unblinding of treatment assignment for a subject may be necessary due to a medical emergency, 
rescue therapy (Section 5.2.2), or any other significant medical event (eg, pregnancy). 
In the case of an emergency, the Investigator has the sole responsibility for determining if 
unblinding is warranted. The Investigator is required to follow the specific steps outlined in the 
unblinding procedure in the Study Reference Manual. Prior to unblinding, it is suggested that the 
Investigator contact the Sponsor and discuss the intended unblinding with the Medical Monitor 
or appropriate Insmed Incorporated study personnel (if this does not interfere with emergency 
treatment). In all cases of unblinding, the date, including justification for unblinding, must be 
fully documented and signed by the Investigator and written notification provided to the 
Sponsor. The originally signed copy is maintained in the study file at the site, and a copy is 
provided to the Sponsor or its designee. The date and reason for the unblinding is also entered in 
the study file and any associated AE reports. The Investigator can obtain the identity of the study 
drugs dispensed to a subject through IWRS. 

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5.1.7. 
Labeling and Packaging 
Subjects will receive kits containing vials of ALIS or ELC and the nebulizer system. The 
nebulizer system is manufactured by PARI Respiratory Equipment, Richmond, VA, a subsidiary 
of PARI Pharma GmbH, Germany. 
AZI tablets and ETH tablets will be sourced commercially. The packaging will vary depending 
on the manufacturer.  
Labels will be prepared in accordance with GMP requirements and local regulatory guidelines. 
Label text will be translated into local language.   
5.1.8. 
Storage 
ALIS and ELC must be stored at 2ºC to 8ºC (36ºF to 46ºF); do not freeze.  All sourced 
commercial drug supply, specifically Azithromycin 250 mg tablets and Ethambutol 100 mg and 
Ethambutol 400 mg tablets, should be stored according to the temperature ranges indicated on 
the commercial packaging. 
At the study site, all study drugs must be stored in a secured place with restricted access. 
5.1.9. 
Dispensing of Study Drugs 
At visits specified in Table 4, subjects will be dispensed adequate study drugs to allow for daily 
dosing, including extra supply for potential study visit scheduling delays. Study drugs may be 
dispensed directly to the subject’s home by courier if dispensing at the site is not feasible.  
5.1.10. 
Drug Accountability 
Drug accountability records will be maintained for all clinical supplies. All transactions will be 
recorded on the drug accountability records including shipment receipts and study subject doses. 
All transactions will be recorded on a real-time basis. 
The pharmacy or responsible study staff will maintain detailed documentation of the number and 
identification of vials and dispensing units with copies of these documents to be provided to the 
Sponsor at the end of the study. All used and unused study drugs will be maintained by the site 
until inventoried by the Clinical Trial Monitor. Upon completion of the drug inventory by the 
Study Monitor, the used and any unused vials and tablets will be disposed of in accordance with 
instructions provided to sites and according to site destruction policies. Documentation of 
destruction should be provided to the Sponsor. 
Accountability of the nebulizer system will be maintained and tracked at the site. Subjects must 
return the nebulizers to the study site at EOT. Additional instructions for handling the disposal or 
return of the devices will be provided to the sites and according to site destruction policies. 
5.2. 
Concomitant Medications 
Any medications the subject takes other than study drugs, including all vaccinations received, on 
or after the first dose of study drug are considered concomitant medications and will be collected 
and documented in the study eCRF. 

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5.2.1. 
Bronchodilator Therapy 
If a subject is being treated with or started on bronchodilator therapy for management of 
underlying lung disease, the subject should be pretreated with a bronchodilator prior to ALIS or 
ELC administration throughout the study. If a subject is not on bronchodilator therapy and 
experiences a TEAE or SAE that is a respiratory symptom, the Investigator may consider 
pretreatment with a short acting bronchodilator prior to the ALIS or ELC administration. If a 
subject is pretreated with a bronchodilator prior to the ALIS or ELC administration, the subject 
should consistently pretreat moving forward in the study. Data will be collected on the 
concomitant medication eCRF page. 
5.2.2. 
Rescue Therapy 
Rescue therapy is defined as any change from the randomized treatment (ALIS + background 
regimen or ELC + background regimen) as prescribed in the study (includes drug, dose, 
frequency, route of administration) due to progression of MAC lung infection. Rescue therapy 
does not include changes from randomized treatment (eg, removal or replacement of drug) due to 
intolerance or AEs from study drugs.  
If at any time during the study the Investigator believes that a subject has worsened clinically 
(eg, progressive worsening of signs/symptoms), the Investigator will determine the cause of the 
clinical deterioration (eg, intercurrent illness, noncompliance with pulmonary therapies, or 
progression of the MAC lung infection) and should contact the Medical Monitor. The clinical 
symptoms and cause should be documented in the subject’s source documentation. If non-urgent 
intervention is required, the Investigator will optimize concomitant therapy and will contact the 
subject within 7 days of presentation via a telephone visit to reassess the subject. Within 14 days 
of determination of clinical worsening, the subject should make all attempts to return to the study 
site for an unscheduled visit for in-clinic assessment. However, if the subject is unable to return 
for the unscheduled visit, the assessment of change in signs/symptoms can be confirmed with a 
telephone visit. At that visit, the Investigator will then confirm the cause of the worsening 
signs/symptoms and should contact the Medical Monitor. If the Investigator confirms that the 
cause of the worsening in signs/symptoms is due to progression of MAC lung infection and 
rescue therapy is warranted, the Investigator will contact the Sponsor to unblind the subject from 
treatment assignment (Section 5.1.6). All contacts with the Medical Monitor should be 
documented in the subject’s source documentation.   
Subjects who receive rescue therapy will stop randomized treatment (ALIS + background 
regimen or ELC + background regimen), be treated by local standard of care or as recommended 
by the Investigator, and will continue with their remaining scheduled study visits. 
Data will be collected on the appropriate eCRF pages. 
5.3. 
Prohibited Medications and Medications with Limited Use 
Subjects are prohibited from using any inhaled antibiotics or any aminoglycosides with activity 
against MAC, such as streptomycin or kanamycin at Screening and throughout the study. The 
use of these drugs should not be initiated during the study period unless as determined necessary 
by the Investigator. Subjects are also prohibited from using any antibiotics for the treatment of  
MAC lung infection (besides study drugs), unless required as rescue therapy (Section 5.2.2). 

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Other prohibited medications include those contraindicated with concomitant use with 
azithromycin and ethambutol per local labeling guidance. The reason for use must be 
documented in the eCRF. Some antibiotics used for the treatment of concomitant conditions that 
may have activity against MAC may be used, but not for more than 14 consecutive days.  
Any questions about prohibited medications should be discussed with the Medical Monitor. A 
list of prohibited medications and medications with limited use for the study is provided in 
Table 2. Refer to local labeling guidance for other prohibited medications with concomitant use 
with azithromycin and ethambutol. 
Table 2: 
List of Prohibited Medications and Medications with Limited Use 
PROHIBITED Drugs 
LIMITED USE Drugs (not more than 14 consecutive 
days) 
Aminoglycosides: 
Amikacin, Kanamycin, Streptomycin 
Other Macrolides: 
Erythromycin, Clarithromycin, etc. 
Rifamycins: 
Rifampin, Rifampicin, Rifabutin, 
Rifamycin, etc. 
Fluoroquinolones: 
Levofloxacin, Moxifloxacin, Sitafloxacin, Ciprofloxacin, 
etc. 
Bedaquiline 
Linezolid, Tedizolid 
Clofazimine 
Tigecycline, Eravacycline, Omadacycline 
Isoniazid 
Any other antibiotic with activity against MAC  
Ethambutol (only allowed per protocol) 
-- 
Azithromycin (only allowed per protocol) 
-- 
5.4. 
Precautionary Medications 
Chronic anti-inflammatory therapy (eg, high-dose ibuprofen, prednisone ≤ 10 mg/day or the 
equivalent) is permitted if the regimen remains unaltered for at least 28 days preceding 
Day 1/Baseline and throughout the study. The doses should not change except for safety reasons 
or as needed for medical management of the subject. 
Although systemic exposure to amikacin is low after ALIS administration, precaution should be 
taken if subjects require the following systemic medications that may have possible interactions 
with amikacin, including, but not limited to the following: potent diuretics (such as ethacrynic 
acid and furosemide), beta lactam antibiotics (such as penicillins and cephalosporins); 
bisphosphonates; platinum compounds and thiamine. 
The following may have possible interactions with azithromycin or ethambutol: digoxin, 
colchicine, and coumarin anticoagulants. Antacids should not be taken simultaneously with 
azithromycin or ethambutol. Azithromycin or ethambutol must be administered at least 1 hour 
before or 2 hours after antacid is taken.  
Local labeling guidance for azithromycin and ethambutol must be consulted.  
Examples of precautionary medications for ALIS are provided in Table 3. 

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Table 3: 
List of Examples of Precautionary Medications for ALIS 
Name of Drug 
Clinical Symptoms/ Treatment 
Mechanism/ Risk Factor(s) 
Potentially nephrotoxic blood 
substitutes such as Dextran 
Hydroxyethyl starch, etc. 
Since there is a risk that 
nephrotoxicity occurs or is 
aggravated, concomitant use 
should be avoided. 
When nephrotoxicity occurs, 
drug should be discontinued and 
appropriate treatment be 
implemented such as renal 
dialysis, etc. 
The mechanism of action is not 
completely clear but there are 
reports that the combination leads 
to deposits of aminoglycoside 
antibiotics in blood and to 
vacuolization of the proximal 
tubular epithelium. 
Loop diuretics 
Ethacrynic acid 
Furosemide 
Azosemide, etc. 
Since both drugs may cause or 
aggravate nephro- and 
ototoxicity, concomitant use 
should be avoided. 
The mechanism of action is not 
completely clear but there are 
reports that the combination leads 
to increased blood concentration 
and renal deposits of 
aminoglycoside antibiotics. 
Nephrotoxic and ototoxic 
drugs such as 
Vancomycin, Enviomycin, 
Platinum-containing 
anticancer drugs (cisplatin, 
carboplatin, nedaplatin), etc. 
Since both drugs may cause or 
aggravate nephro- and 
ototoxicity, concomitant use 
should be avoided. 
Both drugs are nephrotoxic/ 
ototoxic but the mechanism of 
action of the interaction is not 
known. 
Anesthetics 
Muscle relaxants 
Tubocurarine 
Pancuronium bromide 
Tolperisone 
Botulinum Type A toxin 
products, etc. 
Risk of respiratory suppression. 
If respiratory suppression occurs, 
choline esterase inhibitor or 
calcium preparation, etc. should 
be administered as appropriate. 
Both drugs have a neuro- 
muscular inhibitory effect. 
Concomitant use will aggravate 
this effect. 
Nephrotoxic drugs 
Cyclosporine A 
Amphotericin B, etc. 
Risk that renal impairment 
occurs or is aggravated. 
Both drugs are nephrotoxic but 
the mechanism of the interaction 
is not known. 
 

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6. 
STUDY PROCEDURES 
6.1. 
Schedule of Assessments 
The Schedule of Assessments is presented in Table 4.  
COVID-19 restrictions and/or concerns may impact subject attendance at in-clinic visits 
(Section 6.3). In the event subjects are restricted from attending in-clinic visits or if subjects have 
concerns regarding travel and attending in-clinic visits (due to potential public health concerns), 
the site should contact the Sponsor on how to conduct the scheduled assessments, and decisions 
should be documented in the source documentation. 
The PRO instruments will be provided to the subject in electronic format on a computer tablet 
and should be conducted at approximately the same time of day at the specified timepoints.  
All PRO assessments must be completed prior to other study assessments (eg, physical 
examination, vital signs, laboratory assessments, audiology, etc) with the exception of sputum 
collection. If the subject produces their best sputum samples first thing in the morning prior to 
being able to attend a clinic visit, the subject should consistently collect sputum samples first, 
then proceed with PRO assessments throughout the study.  
At each in-clinic visit, the subject will complete the PRO assessments in the order listed below. 
The approximate time to complete each assessment is provided; these are conservative estimates 
based on different studies and actual time may be less than indicated. 
1. QOL-B (~10-15 minutes) 
2. PROMIS F-SF 7a (~8-12 minutes) 
3. EXACT (~3 minutes) 
4. EXACT-RS (~3 minutes) 
5. SGRQ (~10 minutes)  
6. FACIT– Fatigue (~8-12 minutes) 
7. PGI-S– Respiratory (~1 minute) 
8. PGI-S– Fatigue (~1 minute) 
All remaining assessments must be completed prior to administration of study drugs. If 
additional assessments for monitoring are recommended per local labeling guidance, the site 
should complete unscheduled assessments.  
 

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Table 4: 
Schedule of Assessments 
INS-415  
 
Treatment Phase 
 
 
 
 
In-Clinic 
Non In-
Clinica 
In-Clinic 
Non In-Clinica 
In-Clinic 
Screening 
Baseline/ 
Day 1 
Month 1 
Month 2 
Month 3, 
5 
Month 4 
Month 6 
(EOT)b 
Month 7 
(EOS)c 
(V1) 
(V2) 
(V3) 
(V4) 
(V5, 7) 
(V6) 
(V8) 
(V9) 
Visit Window 
Approximately  
-70 days to -1 day 
-- 
(±7) 
(±7) 
(±7) 
(±7) 
(±7) 
(±7) 
Informed consent 
X 
-- 
-- 
-- 
-- 
-- 
-- 
-- 
Pregnancy testd 
X 
X 
X 
X 
X 
X 
X 
X 
Randomization 
-- 
X 
-- 
-- 
-- 
-- 
-- 
 
QOL-Be 
X 
X 
-- 
-- 
X 
-- 
X 
X 
PROMIS F-SF 7ae 
X 
X 
-- 
-- 
X 
-- 
X 
X 
EXACTe 
X 
X 
-- 
-- 
-- 
-- 
-- 
X 
EXACT RSe 
X 
X 
-- 
-- 
-- 
-- 
-- 
X 
SGRQe 
X 
X 
-- 
-- 
-- 
-- 
-- 
X 
FACIT-Fatiguee 
X 
X 
-- 
-- 
-- 
-- 
-- 
X 
PGI-S Respiratorye 
X 
X 
-- 
-- 
X 
-- 
X 
X 
PGI-S Fatiguee 
X 
X 
-- 
-- 
X 
-- 
X 
X 
Actigraphyf 
 
X 
X 
 
X 
-- 
X 
X 
Medical history 
X 
-- 
-- 
-- 
-- 
-- 
-- 
Physical 
examinationg 
X 
X 
-- 
-- 
X 
-- 
X 
X 
Vital signs and pulse 
oximetryh 
X 
X 
X 
-- 
X 
-- 
X 
X 
FEV1  
X 
X 
-- 
-- 
-- 
-- 
-- 
-- 
Audiologyj 
Xi 
-- 
-- 
-- 
-- 
X 
-- 

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INS-415  
 
Treatment Phase 
 
 
 
 
In-Clinic 
Non In-
Clinica 
In-Clinic 
Non In-Clinica 
In-Clinic 
Screening 
Baseline/ 
Day 1 
Month 1 
Month 2 
Month 3, 
5 
Month 4 
Month 6 
(EOT)b 
Month 7 
(EOS)c 
(V1) 
(V2) 
(V3) 
(V4) 
(V5, 7) 
(V6) 
(V8) 
(V9) 
Visit Window 
Approximately  
-70 days to -1 day 
-- 
(±7) 
(±7) 
(±7) 
(±7) 
(±7) 
(±7) 
ECGj 
X 
Ophthalmic Examj 
X 
Concomitant 
medications 
X  
X 
X 
X 
X 
X 
X 
AE assessment 
Xk 
Xl 
X 
X 
X 
X 
X 
X 
Sputum collection for 
microbiologym 
X 
X 
X 
X 
X 
X 
X 
X 
Chemistryn 
X 
X 
X 
-- 
X 
-- 
X 
X 
Hematology n 
X 
X 
X 
-- 
X 
-- 
X 
X 
Urinalysis n 
X 
X 
X 
-- 
X 
-- 
X 
X 
CRPn 
-- 
X 
X 
-- 
X 
-- 
X 
X 
CT scan of chest (by 
local read)o 
X 
-- 
-- 
-- 
-- 
-- 
-- 
-- 
Send sputum 
collection containers 
home 
X 
X 
X 
-- 
X 
-- 
X 
-- 
Administer study 
drugs at site or at 
homep 
-- 
X 
X 
-- 
X 
-- 
-- 
-- 
eDiary for study 
drugs compliance 
-- 
X 
X 
X 
X 
X 
X 
-- 
Dispense study 
drugsq 
-- 
X 
X 
-- 
X 
-- 
-- 
-- 
Collection of study 
drugs 
-- 
-- 
X 
-- 
X 
-- 
X 
-- 

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AE = adverse event; CRP = C-reactive protein; CT = computed tomography; EOS = end of study; EOT = end of treatment; EXACT = EXAcerbations of Chronic 
Pulmonary Disease Tool; ERS = EXACT Respiratory Symptoms; FACIT-Fatigue = Functional Assessment of Chronic Illness Therapy; FEV1 = forced 
expiratory volume in 1 second; ICF = informed consent form; MAC = Mycobacterium avium complex; PGI-S = Patient Global Impression of Severity; 
PRO = patient-reported outcomes; PROMIS Fatigue Short Form 7a = Patient-Reported Outcome Measure Information System Fatigue-Short Form 7a; QOL-
Bronchiectasis = Quality of Life Questionnaire – Bronchiectasis; SAE = serious adverse event; SGRQ = St George Respiratory Questionnaire; 
WOCBP = women of child-bearing potential. 
a. 
If applicable; may be converted to clinic visits if needed due to local requirements 
b. If a subject discontinues ALIS or ELC, the subject will have reason for ALIS or ELC withdrawal recorded and return at the next scheduled visit to 
complete the EOT visit assessments. The subject will remain on the other study drugs (AZI and/or ETH) and continue with the next scheduled study 
visit. The subject will complete a Month 6 visit when they reach Month 6. 
c. 
Subjects will remain off all study drugs and should avoid initiating any new medical or non-medical therapies for MAC lung infection.  
d. Serum pregnancy testing will be performed on WOCBP at Screening. A urine pregnancy test (at least 25 mIU/mL sensitivity) must be performed 
for all WOCBP at all subsequent visits starting at Baseline. Women not of childbearing potential are defined as postmenopausal (ie, amenorrheic for 
at least 12 months), or surgically or naturally sterile. 
e. 
All PRO assessments will be performed prior to any other assessments (with the exception of sputum collection) and administration of study drugs 
and should be performed in the following order: QOL-B, PROMIS F-SF 7a, EXACT, EXACT-RS, SGRQ, FACIT-Fatigue, PGI-S-Respiratory, and 
PGI-S-Fatigue. 
f. 
Collection of data is continuous. Data will be retrieved by study staff at in-clinic visits. 
g. The physical examination will also include measurement of body weight; the measurement of height, without shoes, will only be done at Screening. 
All physical examinations should be performed prior to administration of study drugs. 
h. Vital signs and pulse oximetry will be assessed prior to administration of study drugs. 
i. 
The Baseline audiology examination must be performed during Screening or on Day 1 before administration of study drugs and evaluated by the 
Investigator. 
j. 
Tests may be performed if required by local labeling guidance; Investigators should perform all monitoring according to local label  
k. 
Only SAEs will be collected after the ICF is signed until Baseline.  
l. 
At Baseline, AEs will be assessed only after administration of study drugs. Any AE that has occurred prior to the first dose must be included in the 
subject’s medical history, including any AEs that occur within the Screening period. 
m. Sputum cultures will be collected by study personnel at in-clinic study visits prior to administration of study drugs. Subjects will provide and ship 
sputum cultures at non in-clinic visits. Subjects who are not able to ship sputum samples may bring the samples to the clinic site. Two sputum 
samples will be obtained from each subject at each assessment; subjects will produce 1 sputum sample on the day prior to the scheduled visit and 
1 sputum sample on the day of the visit prior to dosing with study drugs. At Screening, subjects will produce 1 sputum sample on the first day of the 
visit and 1 sputum 1 week later. The second sputum sample provided at Screening can be produced any time during the week following the 
Screening visit.   
n. All laboratory testing should be performed prior to the administration of study drugs at in-clinic visits. Laboratory testing will not be performed at 
the Month 5 visit.  
o. A prior chest CT scan may be used as a subject’s Screening measurement if this CT scan was obtained within 6 months from the subject’s 
Screening visit.  Subjects who do not have a chest CT scan within 6 months prior to Screening will be required to obtain a scan during Screening. 
p. Study drugs may be administered at home during a home care visit (if applicable), if administration at site is not feasible 
q. Study drugs may be dispensed directly to the subject’s home by a courier if dispensing at site is not feasible 
 

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6.2. 
Protocol Deviations 
The Investigator should conduct the study in compliance with the protocol agreed to by the 
Sponsor and, if required, by the regulatory authority(ies), and which was given 
approval/favorable opinion by the IRB/EC. 
The Investigator should notify the IRB/EC of any deviations from the protocol in accordance 
with local procedures. 
6.3. 
Public Health Emergencies – COVID-19 
During the COVID-19 public health emergency, the Sponsor, IRB/IECs, and Investigators shall 
follow the most current version of local guidance to assure the safety of study subjects, maintain 
compliance with GCP, and minimize risks to study integrity. 
In anticipation that the COVID-19 pandemic may have an impact on the conduct of clinical 
studies, the Sponsor does not intend to screen any new subjects in this study unless the impact of 
the COVID-19 pandemic is deemed manageable and no longer interfering with the conduct of 
the study at individual sites, and subjects can safely participate in this study.  
The continuity of clinical study conduct and oversight may require implementation of temporary 
or alternative mechanisms, which will remain in effect only for the duration of the local public 
health emergency. Examples of such mechanisms may include, but are not limited to, any of the 
following: telephone contact, virtual visits, telemedicine visits, online meetings, non-invasive 
remote monitoring devices, use of local clinic or laboratory locations, and home visits by skilled 
staff. The site should contact the Sponsor on how and when to implement temporary and/or 
alternative mechanism of scheduled assessments, and all decisions taken should be documented 
in the source documentation. Additionally, all temporary mechanisms utilized, and the resulting 
deviations from planned study procedures are to be documented as being related to COVID-19.  
In a situation where local health authorities declare a public health emergency while the study is 
ongoing, the following suggested guidance should be followed: 
Continuation or suspension of the study  
The Sponsor, in consultation with clinical Investigators and IRBs/ECs, will determine if the 
protection of a subject’s safety, welfare, and rights are best served by continuing or suspending 
the study at a specific site. Such decision will depend on specific circumstances, including the 
ability to conduct appropriate safety monitoring, the potential impact on the investigational 
product supply chain, and other considerations. 
If the decision is to continue the study, the following considerations will be taken into account:  
Study recruitment 
The Sponsor will communicate to the sites the decision on whether to continue or suspend 
recruitment after considering the specific circumstances of each site, recommendation by the 
IRB/EC, and its local health authority mandates. If, due to COVID-19, study discontinuation 
exceeds the assumed rate, the Sponsor may allow enrollment past the assumed sample size 
(Section 10.1).  

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Subjects already enrolled in the study 
• If a subject is not able to complete a protocol specified study visit, it may be 
necessary to adjust the visit schedule, convert in-clinic visits to telemedicine visits, 
and/or postpone study procedures until the next available in-clinic study visit. If there 
is information available from previous visits (ie, laboratory assessments) that requires 
follow-up procedures or other safety assessments, the Investigator will decide if an 
on-site visit or home healthcare visit is required or whether the subject’s safety can be 
preserved by other means.  
• If subjects no longer have access to the investigational product, direct-to-subjects 
delivery by couriers may be implemented, provided that all safety considerations and 
applicable health authority requirements have been addressed. 
• If a subject has a documented COVID-19 infection while in the study, the event will 
be reported as an AE or SAE, depending on the criteria. The site will follow the 
guidance provided by health authorities in the treatment of those subjects.  
 
 

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7. 
PSYCHOMETRIC VALIDATION 
7.1. 
Variables to be Validated  
Psychometric validation will consist of cross-sectional and longitudinal validation analyses. At 
baseline, cross-sectional validation will consist of provisional modern psychometric methods. 
7.1.1. 
Quality of Life Questionnaire – Bronchiectasis  
The QOL-B is a validated, self-administered, reported outcome questionnaire used to assess 
symptoms, functioning, and health related quality of life in adults with non-CF bronchiectasis 
(Quittner et al., 2015). It measures outcomes over a recall period of 1 week. The questionnaire 
contains 37 items on 8 scales (physical, role, vitality, emotional, social, treatment burden, health 
perception, and respiratory) (Appendix 1).  
The QOL-B questionnaire will be completed at study visits in the order specified in Section 6.1 
and Schedule of Assessments (Table 4). Subjects will self-administer the questionnaire 
electronically. The QOL-B questionnaire will be the first assessment to be conducted at the 
specified study visits (with the exception of sputum collection, if applicable).  
Each of the 37 items is scored from 1 to 4, and each of the 8 scale scores is standardized on a 0 to 
100-point scale, with higher scores representing fewer symptoms or better functioning and 
quality of life. Scores are calculated for the 8 domains: physical, role, vitality, emotional, social, 
treatment burden, health perception, and respiratory.  
7.1.2. 
PROMIS Fatigue Short Form 7a 
The PROMIS F-SF 7a is a self-administered questionnaire assessing a range of self-reported 
symptoms over the past 7 days, from mild subjective feelings of tiredness to an overwhelming, 
debilitating, and sustained sense of exhaustion that likely decreases one’s ability to execute daily 
activities and function normally in family or social roles (Ameringer et al., 2016). Fatigue is 
divided into the experience of fatigue (frequency, duration, and intensity) and the impact of 
fatigue on physical, mental, and social activities over 7 items. Examples of items are: “How 
often did you feel tired,” and “How often were you too tired to take a bath/shower” 
(Appendix 2). 
The PROMIS F-SF 7a will be completed at study visits in the order specified in Section 6.1 and 
Schedule of Assessments (Table 4). Subjects will self-administer the questionnaire 
electronically. The PROMIS F-SF 7a will be the second assessment to be conducted at the 
specified study visits. 
Response options are on a 5-point Likert scale, ranging from 1=never to 5=always. The 
PROMIS F-SF 7a is universal rather than disease-specific and given its brevity, poses minimal 
burden to the subject. 

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7.2. 
Validating Variables 
7.2.1. 
EXAcerbations of Chronic Pulmonary Disease Tool (EXACT) 
The EXACT PRO was developed and qualified for use in characterizing COPD clinical 
endpoints (Jones et al., 2011; Leidy et al., 2010; Leidy et al., 2011; US FDA, 2013). Several of 
the concepts assessed by the EXACT are relevant to characterizing the symptomatic phenomena 
expected within bronchiectasis. These include, but are not limited to, dyspnea and fatigue. The 
EXACT total score measures acute, sustained, and worsening signs and symptoms exceeding 
subject-specific expected variability. The EXACT PRO is composed of 14 items from which a 
total score is generated. Domains assessed by the EXACT PRO include dyspnea, cough and 
sputum production, chest symptoms, difficulty expectorating, fatigue, sleep disturbance, and fear 
or concern (Appendix 4).  
The EXACT PRO will be completed at study visits in the order specified in Section 6.1 and 
Schedule of Assessments (Table 4). Subjects will self-administer the questionnaire 
electronically.  
7.2.2. 
Exact Respiratory Symptoms (EXACT-RS) 
The E-RS is an 11-item subset of the EXACT PRO assessing exacerbations of respiratory 
symptoms (Leidy et al., 2014a; Leidy et al., 2014b) (Appendix 4). 
The E-RS will be completed at study visits in the order specified in Section 6.1 and Schedule of 
Assessments (Table 4). Subjects will self-administer the questionnaire . 
7.2.3. 
St. George’s Respiratory Questionnaire (SGRQ)  
The SGRQ is a self-administered instrument for the assessment of overall health, daily life, and 
perceived well-being among individuals with obstructive airways disease (Jones et al., 1992). 
The instrument consists of 50 items with 76 weighted responses grouped into a set of 17 
questions. The items are divided into 2 parts and 3 categories: symptom, activity, and impact. 
Part 1 (symptom component) assesses an individuals’ perception of their recent respiratory 
problems. Part 1 evaluates frequency and severity of symptoms including cough, sputum 
production, wheezing, breathlessness, and the duration and frequency of attacks of breathlessness 
and wheeze. Part 2 (activity and impact components) addresses individuals’ current state. The 
activity component is composed of a series of items evaluating metabolic equivalence of 
incrementally increasingly physically demanding activities, ranging from sitting to climbing a 
flight of stairs. The impact component measures domains of social functioning and psychological 
disturbances resulting from airway disease (Appendix 5).  
The SGRQ will be completed at study visits in the order specified in Section 6.1 and Schedule of 
Assessments (Table 4). Subjects will self-administer the questionnaire .  
7.2.4. 
Functional Assessment of Chronic Illness Therapy (FACIT) – Fatigue Scale  
The FACIT-Fatigue Scale is a short, 13-item, easy to administer, tool measuring an individual’s 
level of fatigue during their usual daily activities during the past week (Smith et al., 2010). The 
level of fatigue is measured on a four-point Likert scale (4 = not at all fatigued to 0 = very much 

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fatigued). FACIT-Fatigue is routinely administered in studies of respiratory disease populations 
for accurately evaluating the common sequela of fatigue (Appendix 6).  
The FACIT-Fatigue will be completed at study visits in the order specified in Section 6.1 and 
Schedule of Assessments (Table 4). Subjects will self-administer the questionnaire 
electronically.  
7.2.5. 
PGI-S Respiratory 
The PGI-S Respiratory score is a simple categorical rating of symptom severity. The scale is 
1 = not at all to 5 = extremely severe (Appendix 3). 
The PGI-S Respiratory will be completed at study visits in the order specified in Section 6.1 and 
Schedule of Assessments (Table 4). Subjects will self-administer the questionnaire 
electronically.  
7.2.6. 
PGI-S Fatigue 
The PGI-S Fatigue score is a simple categorical rating of symptom severity. The scale is 
1 = not at all to 5 = extremely severe (Appendix 3). 
The PGI-S Fatigue will be completed at study visits in the order specified in Section 6.1 and 
Schedule of Assessments (Table 4). Subjects will self-administer the questionnaire 
electronically.  

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8. 
EFFICACY ASSESSMENTS 
8.1. 
Sputum Culture  
Microbiological assessment of sputum specimens will be used for secondary efficacy 
measurements.  
During the study, pre-dose expectorated or induced sputum samples (approximately 2 mL) are 
required at study visits specified in the Schedule of Assessments (Table 4). To improve the 
probability of obtaining a good sputum specimen, 2 sputum samples will be obtained from each 
subject at each assessment; subjects will provide 1 sputum sample on the day prior to the 
scheduled visit, and 1 sputum sample on the day of the visit prior to dosing with study drugs. At 
Screening, subjects will provide 1 sputum sample on the day of the visit and 1 sputum during the 
week following the Screening visit. If a subject is unable to produce sputum spontaneously, 
sputum may be induced. If after induction, a subject is still unable to produce sputum despite 
reasonable efforts, this will be recorded as non-productive at that time point. It is recommended 
to schedule an in-clinic visit as a backup to non in-clinic visits in case the subject is not able to 
spontaneously produce sputum at home. If a subject is unable to spontaneously produce sputum 
at home on the day prior to the scheduled visit, the subject should then come into the clinic for 
sputum induction on the scheduled visit. The induction should be performed within the specified 
visit window (Table 4). At the scheduled visit, once sputum is collected (spontaneously or by 
induction), study drugs can be administered. If the subject produces their best sputum samples 
first thing in the morning prior to being able to attend a clinic visit, the subject should 
consistently collect sputum samples first, then proceed with PRO assessments and other 
assessments throughout the study. 
Sterile, leak proof, non-wax, disposable plastic containers labeled with 2 subject identifiers will 
be used to collect specimens aseptically to avoid contamination. Sputum samples should be 
refrigerated, not frozen, until shipped to the central microbiology laboratory as soon as possible 
to avoid overgrowth by contaminating normal flora. No fixative or preservatives are to be used 
with sputum samples. Detailed instructions for collecting, processing, and shipping sputum 
specimens will be provided in the site laboratory manual. Subjects will be provided with 
instructions for collecting, processing, and shipping sputum specimens for samples collected at 
non in-clinic visits. 
Sites are strongly discouraged from performing local mycobacterium sputum cultures for the 
duration of the study, as this may introduce bias to subject assessments. Sputum may be sent to 
local laboratories to be cultured for organisms other than mycobacterium.  
Microbiological Assessment 
Sputum specimens will be cultured in broth media (liquid) in addition to agar media (solid), and 
will be held for up to 6 weeks. A negative culture result will not be reported until after this time 
has transpired. All contaminated samples will be retreated and re-cultured once. 
Growth of other bacteria due to co-infections (eg, Pseudomonas aeruginosa, M. abscessus, other 
NTM) will be reported as applicable. Colony counts of MAC growth will be reported. Isolates of 
MAC will be identified using a commercial RNA probe (AccuProbe, Gen Probe, Inc., GenoType 
NTM-DR Ver 1.0, Hain Lifescience) and subsequently identified to species using molecular 

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methodology (Cousins et al., 1996). Standard antibiotic sensitivity testing using MICs will be 
routinely performed on mycobacterial isolates (CLSI, 2018a; CLSI, 2018b; Forbes et al., 2008). 
The MAC species and genotype at the Screening and/or Baseline sputum specimen will be 
identified by whole genome sequencing (Illumina Nextseq500TM) in subjects who achieve 
sputum culture conversion and who subsequently have positive sputum culture(s) (broth or agar); 
typing by whole genome sequencing will also be conducted.  
MAC Culture Assessment Definitions 
MAC culture negative 
No MAC growth on agar media and broth media in all sputum 
cultures at a visit. 
Non-productive 
Prior to culture conversion or post recurrence: visits where 
subjects were recorded as non-productive are considered MAC 
culture positive. 
Post culture conversion: visits where subjects were recorded as 
non-productive are considered MAC culture negative. 
Culture conversion 
No MAC growth on agar media and broth media in all sputum 
cultures at 2 consecutive visits. The date of conversion is defined 
by the date of the first of 2 consecutive negative cultures. 
Recurrence: Relapse 
Subsequent to culture conversion, at least 1 MAC positive culture 
in agar media or positive cultures in broth media in at least 
2 consecutive visits. A MAC positive culture is defined as the 
same species and genome as cultured at Screening/Baseline. 
Recurrence: New 
infection 
Subsequent to culture conversion, at least 1 MAC positive culture 
in agar media or positive cultures in broth media in at least 2 
consecutive visits. A MAC positive culture is defined as a culture 
that is different than cultured at Screening/Baseline (different 
species, or same species but different genome). 
 
8.2. 
Actigraphy 
The Philips Actiwatch Spectrum PRO actigraphy device resembles a wristwatch and senses the 
activity of the wearer. It is to be worn continuously by the subject throughout the duration of the 
study. It is water-resistant and does not need to be removed for bathing. The subject will be 
provided with charging materials and should be instructed to charge the device once every 30 
days (if needed). The data collected should be downloaded at each in-clinic visit or during a 
home care visit (if applicable). 

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9. 
SAFETY ASSESSMENTS 
9.1. 
Vital Signs and Pulse Oximetry 
Systolic and diastolic BP, pulse rate, body temperature, RR, and oxygen saturation will be 
recorded in the eCRF at study visits specified in the Schedule of Assessments (Table 4). 
9.2. 
Physical Examination  
A physical examination of the head (external), eyes, ears, nose and throat, lungs, cardiovascular 
system, abdomen, musculoskeletal system, skin, lymph nodes, central nervous system, and, as 
appropriate, other body systems will performed at study visits specified in the Schedule of 
Assessments (Table 4). The physical examination will also include measurement of body weight. 
The measurement of height, without shoes, will only be done at Screening. Any abnormalities 
noticed at Screening will be recorded as medical history or as AEs if they occurred after 
randomization. 
9.3. 
Audiology Test 
Audiology testing will be performed at study visits specified in the Schedule of Assessments 
(Table 4). Additional assessments may be conducted if required per local labeling guidance. 
Frequencies of 250, 500, 1000, 2000, 4000, and 8000 Hz will be evaluated for each ear using air 
conduction. 
9.4. 
Forced Expiratory Volume in 1 Second (FEV1) 
FEV1 will be performed by trained personnel at the site and will be based on local assessments. 
Spirometers will be provided if not available at the study sites. FEV1 will be performed (prior to 
bronchodilator use if applicable) at Screening and Day 1/Baseline (Table 4) prior to the 
administration of study drugs.  
9.5. 
ECG Monitoring  
ECG monitoring should be performed if required by local labeling guidance to monitor QT/QTc. 
In the event of QT/QTc interval prolongation, monitoring should continue until QTcF returns to 
normal range for the subject. Investigators should manage subject per local labeling guidance.  
9.6. 
Ophthalmologic Test 
Ophthalmologic tests (eg, visual acuity, visual field, color vision and fundus) should be 
performed if required by local labeling guidance. Investigators should manage subjects per local 
labeling guidance.  
9.7. 
Clinical Laboratory Evaluations 
Clinical laboratory tests of hematology, blood chemistry, and urinalysis will be performed via 
the study designated laboratory at study visits specified in the Schedule of Assessments 
(Table 4). The clinical laboratory test parameters are listed in Table 5. Laboratory assessments 
will not be performed at Month 5 (Visit 7). 

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Mid-stream clean catch urine samples will be collected for urinalysis. Urine dipsticks will be 
used for urine pregnancy testing. The clinical laboratory test parameters are listed in Table 5. 
Instructions for collection, storage, and shipment of clinical laboratory samples will be provided 
in the clinical laboratory manual provided in the site study binder. 
Table 5 
Clinical Laboratory Parameters 
Clinical 
chemistry 
Sodium, chloride, potassium, CO2, magnesium, calcium, glucose, phosphate, 
total bilirubin (with direct and indirect fractionation, if total bilirubin is elevated 
≥ 2 ULN), alkaline phosphatase, LDH, AST, ALT, albumin, total protein, 
creatinine, urea-nitrogen, uric acid, estimated glomerular filtration rate from the 
Cockcroft-Gault method 
Hematology Hemoglobin, erythrocytes, hematocrit, MCH, MCV, MCHC, leukocytes, 
differential blood count of neutrophils, eosinophils, basophils, monocytes, 
lymphocytes, and platelets  
Urinalysis 
Qualitative analysis of glucose, ketones, nitrites, protein, pH, leukocytes, blood, 
bilirubin, specific gravity; microscopic examination for cells, casts, and bacteria 
ALT = alanine aminotransferase; AST = aspartate aminotransferase; CO2 = bicarbonate;  LDH = lactate 
dehydrogenase; MCH = mean corpuscular hemoglobin; MCHC = mean corpuscular hemoglobin concentration; 
MCV = mean corpuscular volume; ULN = upper limit of normal. 
C-reactive protein  
Blood samples will be drawn at study visits specified in the Schedule of Assessments (Table 4) 
to measure the concentration of CRP. 
Pregnancy Test  
A serum pregnancy test will be performed on WOCBP at Screening. A urine pregnancy test (at 
least 25 mIU/mL sensitivity) will be performed on WOCBP as specified in the Schedule of 
Assessments (Table 4). Results will be entered into the eCRF. Women not of childbearing 
potential are defined as postmenopausal (ie, amenorrheic for at least 12 months), or surgically or 
naturally sterile. 
9.8. 
Chest CT Scan  
A chest CT scan will be performed at Screening. A prior chest CT scan may be used if this CT 
scan was obtained within 6 months from the subject’s Screening visit. Chest CT scan will be 
read locally. 
9.9. 
Adverse Events 
The Investigator is responsible for detecting, documenting, and recording events that meet the 
definition of an AE or SAE as provided in the protocol and remain responsible for following up 
all AEs. 
The Investigator should proactively follow subjects with AEs until the EOS for each subject. At 
the EOS visit, the Investigator will record the AE status in the eCRF. 

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9.9.1. 
Definition of an Adverse Event 
An AE is defined as any untoward medical occurrence in a subject or clinical investigation 
subject administered a pharmaceutical product and which does not necessarily have to have a 
causal relationship with this treatment. An AE can therefore be any unfavorable and unintended 
sign (including an abnormal laboratory finding, for example), symptom, or disease temporally 
associated with the use of a medicinal product, whether or not considered related to the 
medicinal product. 
Medical occurrences that begin after obtaining informed consent, but before administration of 
study drugs will be recorded under medical history/Current Medical conditions, not as AEs. 
Treatment-emergent adverse events are AEs that occurred on or after the date of first dose of 
study drugs and within 28 days after the end of treatment.  
It is the responsibility of Investigators, based on their knowledge and experience, to determine, 
those circumstances or abnormal laboratory findings which should be considered adverse events. 
9.9.2. 
Definition of a Serious Adverse Event  
An SAE is any untoward medical occurrence that at any dose: 
• Results in death, 
• Is life-threatening, 
• Requires inpatient hospitalization or prolongation of existing hospitalization, 
• Results in persistent or significant disability/incapacity, 
• Is a congenital anomaly/birth defect, or 
• Is an important medical event. 
Note: The term “life-threatening” in the definition of “serious” refers to an event in which the 
subject was at risk of death at the time of the event; it does not refer to an event which 
hypothetically might have caused death if it were more severe (ICH E2A Guideline. Clinical 
Safety Data Management: Definitions and Standards for Expedited Reporting, October 1994). 
Medical and scientific judgment should be exercised in deciding whether expedited reporting is 
appropriate in other situations, such as important medical events that may not be immediately 
life-threatening or result in death or hospitalization but may jeopardize the subject or may require 
intervention to prevent one of the other outcomes listed in the definition above. Examples 
include allergic bronchospasm, convulsions, and blood dyscrasias or development of drug 
dependency or drug abuse. 
Note:  
• A procedure is not an AE or SAE, but the reason for the procedure may be an AE or 
SAE. 
• Pre-planned (prior to signing the ICF) procedures or treatment requiring 
hospitalizations for pre-existing conditions which do not worsen in severity are not 
SAEs. 

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• Suspected transmission of an infectious agent via a medicinal product should be 
considered as a SAE 
• Laboratory abnormalities are usually not recorded as AEs or SAEs.  However, 
abnormal laboratory findings (such as clinical chemistry, hematology, or urinalysis) 
or other abnormal assessments (physiologic tests such as electrocardiograms [ECG], 
imaging studies, or vital signs) that are associated with signs and/or symptoms, or are 
considered clinically significant in the judgment of the Investigator, require 
therapeutic intervention, or lead to discontinuation of the administration of study 
drugs, must be recorded as AEs or SAEs if they meet the definitions of an AE (or 
SAE). 
9.9.3. 
Adverse Events of Special Interest 
Adverse events of special interest are defined as events known to be attributed to parenteral 
amikacin and inhalation of antibiotics. Additional information on some AESIs will be collected 
in the eCRF. The AESI category groups and preferred terms include the following: 
• Hypersensitivity pneumonitis (allergic alveolitis, pneumonitis, interstitial lung disease) 
• Hemoptysis (hemoptysis) 
• Bronchospasm (asthma, bronchial hyperreactivity, bronchospasm, dyspnea, exertional 
dyspnea, prolonged expiration, throat tightness, and wheezing) 
• Exacerbation of underlying pulmonary disease (COPD, infective exacerbation of chronic 
obstructive pulmonary disease, and infective exacerbation of bronchiectasis) 
o Pulmonary exacerbation will be defined based on the Investigators best clinical 
judgment. Details of these events should be reported in an additional “pulmonary 
exacerbation” page of the eCRF. 
• Ototoxicity (deafness, neurosensory deafness, unilateral deafness, dizziness, hypoacusis, 
presyncope, tinnitus, vertigo)  
• Nephrotoxicity (nephropathy toxic, azotemia, oliguria, albuminuria, acute kidney injury, 
anuria, renal impairment) 
• Neuromuscular disorders (muscle weakness, peripheral neuropathy, and balance disorder) 
9.9.4. 
Assessment of Severity 
The following definitions should be used to assess intensity of AEs: 
• Mild: Awareness of sign or symptom, but easily tolerated, ie, does not interfere with 
subject’s usual function. 
• Moderate: Discomfort enough to cause interference with usual activity. 
• Severe: Incapacitating with inability to work or do usual activity, ie, interferes 
significantly with subject’s usual function. 

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9.9.5. 
Assessment of Causality 
The Investigator who identifies an AE will determine the causality of each based on the temporal 
relationship to administration of study drugs and clinical judgment. The degree of certainty about 
causality will be graded using the categories listed below. 
• Related: A reaction that follows a reasonable temporal sequence from administration 
of study drugs; that follows a known or expected response pattern to the study drugs; 
that disappears or decreases on cessation or reduction in study drugs dose; and/or that 
reappears or worsens when the study drugs is administered. Could not be reasonably 
explained by other factors such as underlying disease, complications, concomitant 
drugs, or concurrent treatments. 
• Not Related: A reaction for which sufficient data exist to indicate that the etiology is 
unrelated to the study drugs. 
9.9.6. 
Management of Adverse Events 
Initial education of adverse effect expectations is crucial for subjects initiating study drugs in 
order to maintain retention of subjects in the study. Based on data from the ALIS development 
program, there is an association with ALIS and respiratory symptoms (eg, cough, dyspnea) 
reported as AEs, likely from airway irritation by the inhaled antibiotic. Data observed from 
Study INS-212 (refractory MAC population) show that the majority of subjects treated with 
ALIS experienced their first AE within 60 days of initiating ALIS. Azithromycin may cause 
gastrointestinal symptoms. Subjects should be monitored for visual acuity when taking 
ethambutol. 
Data have shown that specific interventions may be helpful in the management of TEAEs 
(Swenson et al., 2020). Pretreatment with a bronchodilator, move administration of ALIS to the 
evening, antitussives, post-dose gargle (warm liquid or glycerin), and other interventions may 
help with management of TEAEs. 
9.10. 
Reporting Requirements 
9.10.1. 
Adverse Events 
All AEs will be reported on the Adverse Events Form of the eCRF. Adverse events that occur 
between the time subject signs the ICF for the study and the time when subject receives his/her 
first dose of study drugs on Day 1 will be summarized as medical history and not as a TEAE 
unless the event meets the definition of an SAE as defined above. Additional information on 
some AEs will be collected in the eCRF. 
9.10.2. 
Serious Adverse Events 
All SAEs, regardless of causality, must be reported to organization delegated by the Sponsor on 
an SAE Report Form within 24 hours of becoming aware of the event; corrections and additions 
are required to be submitted within 24 hours. Study-specific email, telephone, and fax number 
for SAE reporting are presented in the Study Reference Manual. 

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Unexpected drug related SAEs as assessed by Sponsor or authorized person qualify for expedited 
reporting and will be reported to the IRB/EC, regulatory authorities, participating Investigators 
and, if cross reporting is required for SUSARs, in accordance with all applicable global laws and 
regulations. A SUSAR is a Serious Adverse Reaction, which is suspected to be caused by the 
investigational medicinal product and which is unexpected, ie, its nature or severity is not 
consistent with the information in the relevant Reference Safety Information. SAEs, including 
those that do not meet requirements for expedited reporting, and all other AEs will be reported to 
the regulatory agencies as appropriate. 
9.10.3. 
Pregnancy 
Any pregnancy, including the pregnancy of a male subject’s female partner, that occurs during 
any phase of the study must be reported to the Sponsor or designated organization within 
24 hours of learning of the pregnancy using a Clinical Study Pregnancy Form. 
All study drugs should be discontinued, and the pregnancy should be followed to term. The 
details of termination must also be reported, including details of birth, the presence or absence of 
birth defects, congenital abnormalities or maternal and newborn complications, or whether 
termination was spontaneous or voluntary. 
9.10.4. 
Overdose 
An overdose is defined as a dose greater than the dose level evaluated in this study as described 
in Section 5. An overdose itself is not an AE unless it is an intentional overdose taken with 
possible suicidal/self-harming intent. Such overdoses must be reported regardless of sequelae. 
However, if the overdose results in clinical signs and symptoms, it requires an expedited 
reporting as if it is an SAE. In the case of a symptomatic overdose, the Investigator should use 
clinical judgment in treating the overdose and should inform the Sponsor immediately. The 
Investigators should refer to the relevant documents for detailed information regarding warnings, 
precautions, contraindications, AEs, and other significant data pertaining to the study drugs used 
in the study. Such document(s) may include, but not limited to, the IB for ALIS and approved 
product labeling for ARIKAYCE, or approved product labeling for azithromycin and 
ethambutol. 
9.11. 
Follow-up of Adverse and Serious Adverse Events 
After the initial AE/SAE report, the Investigator is required to proactively follow each subject at 
subsequent visits/contacts. All SAEs will be followed until resolution, stabilization, the event is 
otherwise explained, or the participant is lost to follow-up (as defined in Section 4.2.3.1). If the 
Investigator receives a report of any SAE, including a death, at any time after a subject has been 
discharged from the study, and the Investigator considers the event to be reasonably related to 
the study drugs or study participation, the Investigator must promptly notify the Sponsor.  
9.12. 
Regulatory Aspects 
The Sponsor has a legal responsibility to notify the FDA, National Competent Authorities and 
Central Ethics Committees of the European Union, and any other foreign regulatory competent 
agency, as well as all sites, about the safety of the drug. The Investigator has the responsibility to 
notify the local EC about SUSARs. 

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The Investigator(s)/institution(s) will permit study related monitoring, audits, IRB/EC review 
and regulatory inspection(s), providing direct access to source data/documents. Copies of the 
notification to the EC must be sent to the Sponsor. 

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10. 
STATISTICAL METHODS 
Statistical analyses methods pertaining to validation of PRO will be included in VAP, and all 
other analyses will be described in SAP. The SAPs will include detailed description of methods 
and will be finalized prior to the database lock. 
10.1. 
Sample Size and Power Considerations 
Power and Sample Size Determination for the Validation Study 
Cross-sectional validation will require baseline data from a maximum of 250 subjects to 
adequately power the planned MPMs. A total of 100 subjects will be enrolled in this study and 
will be used for this analysis. Additional baseline data from up to the first 150 subjects enrolled 
in a separate study will be used. 
Longitudinal validation will require 100 subjects to adequately power the planned within-subject 
meaningful change methods.   
The derivation of these sample sizes and the procedures used to compute power are described 
below. 
Cross-sectional Validation Power and Sample Size 
The estimated sample size required to conduct cross-sectional validation of the PRO endpoints 
within the NTM-MAC population was obtained from a power analysis assuming the PRO will be 
composed of 10 total items analyzed with 5 response categories each. This power procedure 
determines the sample size required to detect a domain specification that fits the data acceptably 
well. (Serrano and Iaconangelo, 2019; Serrano and Iaconangelo, 2017)  The model fit statistic for 
which power was computed is the RMSEA. The RMSEA is the primary fit index used in modern 
psychometric methods for determining the optimal domain structure. This fit assessment is the 
logical test to power, as the modern psychometric methods require the largest sample sizes of all 
validation analyses. Therefore, adequately powering modern psychometric methods is key to 
validation study success. In addition, the precision of all validation analyses subsequent to 
modern psychometric methods rely on correct domain specification, which itself relies on the 
RMSEA.  
For a 10-item questionnaire, approximately n=250 is required to achieve a power of 0.80 for the 
RMSEA-based test of acceptable MPM model fit. Therefore, a maximum of 250 subjects are 
planned for the study cross-sectional validation analyses. These subjects will contribute data at 
both screening and baseline for the purposes of estimated test-retest reliability as well. 
Longitudinal validation analyses will be conducted on the subset of 100 subjects enrolled into 
this study.  
Longitudinal Validation Power and Sample Size 
An empirical power analysis simulation was conducted to evaluate the optimal sample size to 
adequately characterize culture converter anchor-based within-subject meaningful change in this 
study.  
Inputs to the power analysis simulations were obtained from the MAC subset of the ALIS treated 
subjects in Insmed Study TR02-112, and simulation conditions considered reflected conservative 
variation around observed estimates (larger dispersion and smaller magnitudes of effect). The 

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following conditions were used to compute power: magnitudes of effect in change from baseline 
(6pt, 7pt, 8pt, 9pt, and 12pt change from baseline in converters, and 3 point change from baseline 
in non-converters); culture converter proportions (50%, 60%, and 70%); proportion data missing 
at random (MAR, 0%, 5%, 20%, 25%, and 30%); and sample size (n=100, n=120, and n=130). 
The polyserial correlation between simulated change from baseline in QOL-B respiratory 
domain and culture conversion varied around the observed estimate of 0.47, ranging from 0.3 to 
0.6. Within each unique simulation condition r=1000 replications were generated. Empirical 
power was computed as the number of replications for which statistically significant differences 
between converters and non-converters in change from baseline in QOL-B respiratory domain 
score were observed. For example, if 900 replications demonstrated significant differences using 
the 2-sided test conducted at α=0.05, then power was 90%. 
A total sample size of 100 subjects (50 subject per treatment arm) will provide at least 80% 
power for detecting 7 points mean difference in QOL-B respiratory domain response at 1-month 
post treatment between subjects achieving culture conversion during the study and those who did 
not via ANOVA testing. This derivation assumes 50%, 60%, or 70% culture conversion rate, at 
least 40% polyserial correlation between culture conversion and QOL-B respiratory domain 
response, and missing data of 0%, 5%, or 20%. 
10.2. 
Analysis Sets 
10.2.1. 
Intent-to-Treat Analysis Set 
The ITT analysis set comprises all subjects who were randomized. This set will be analyzed 
using the treatment to which the subject was randomized. 
10.2.2. 
Safety Analysis Set 
The safety analysis set comprises all subjects who were randomized and received at least 1 dose 
of ALIS, ELC, AZI, or ETH. 
10.2.3. 
Additional Analysis Sets 
Additional analysis sets may be defined in the SAP as appropriate. 
10.3. 
Data Handling Conventions 
For all variables, only observed data from subjects will be used in the statistical analyses, ie, 
there is no plan to estimate missing data, unless otherwise stated. Detailed data imputation rules 
required for handling of missing events dates for safety data will be described in related data 
handling documents. 
Unless otherwise stated, for subjects who discontinue ALIS or ELC and remain in the study for 
safety monitoring, data post-EOT will be programmatically relabeled to post-treatment visits; 
details will be included in SAP. 

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10.4. 
Multiplicity 
All summaries will be descriptive without multiplicity adjustment. Confidence intervals for 
estimation of treatment differences will not be adjusted for multiplicity, p-values if provide will 
be nominal.  
10.5. 
Study Population  
The ITT analysis set will be used for all study population summaries unless otherwise stated. 
Summaries will be presented by treatment group and for all subjects based on the data available. 
10.5.1. 
Study Population Disposition, Demographics and Baseline Characteristics 
Subject demographic and baseline characteristics, including medical history, prior medications 
and therapies will be summarized using descriptive statistics.  
For continuous variables, descriptive statistics (number [n], mean, standard deviation, median, 
minimum, and maximum) will be provided. For categorical variables, subject counts and 
percentages will be provided. Categories for missing data will be presented if appropriate.   
The total number of subjects who were screened, randomized, completed the study, discontinued 
study drugs (including the reason), and withdrew consent from the study (including the reason) 
will be summarized by treatment group. The reason for discontinuing study drugs or withdrawal 
of consent from the study will be listed by subject.  
Major protocol deviation will be summarized. 
Assessments collected exclusively prior to therapy will be listed and summarized as appropriate 
(including data for FEV1). 
10.5.2. 
Primary Objective 
The primary objective of this study is psychometric validation of PRO instruments.  
Psychometric validation will consist of cross-sectional and longitudinal validation analyses. At 
Baseline, cross-sectional validation will consist of modern psychometric methods (exploratory 
factor analysis, item response theory models and corresponding assessments of local dependence 
and differential item functioning), internal consistency, concurrent validity, and known-groups 
validity. Longitudinal validation analyses conducted between Screening and Baseline will 
consist of test-retest reliability. The test-retest reliability population will consist of subjects 
reporting no change on PGI-S (respiratory for QOL-B and fatigue for PROMIS F-SF 7a) 
between Screening and Baseline. Longitudinal validation analyses conducted between Baseline 
and EOS (Month 7) will consist of the estimation of within-subject meaningful change. The 
within-subject meaningful change anchor definition will be derived from the change in PGI-S 
anchors (respiratory for QOL-B and fatigue for PROMIS F-SF 7a) between Baseline and EOS. 
In addition, culture converter status will be used as an additional anchor variable. Point estimates 
of within-subject meaningful change will consist of the mean change score conditioned on the 
PGI-S anchor definition. In addition, the median estimate will be examined in sensitivity 
analyses. Point estimates will be validated through the use of eCDFs and ePDFs. 

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10.5.3. 
Cross-sectional Validation 
10.5.3.1. Modern Psychometric Methods 
Evidence associated with these methods will be estimated at baseline. The main function of the 
modern psychometric methods employed will be the detection of any demonstrably irrelevant, 
redundant, or biased items. Full-information EFA and IRT models will be estimated in the 
service of this goal. Irrelevant items will be identified by item loadings (EFA) and slopes (IRT) 
approaching zero. Redundant items will be identified by local dependence statistics. Biased items 
will be detected through DIF assessments, including effect-size estimates to discriminate 
between statistically significant but meaningless DIF. 
10.5.3.2. Internal Consistency 
Internal consistency will be estimated at baseline via Cronbach’s α and McDonald’s ω, the latter 
being the unbiased model-based analog of α. Whereas α assumes item exchangeability, ω does 
not. 
10.5.3.3. Concurrent Validity 
Concurrent validity will be estimated based on Pearson correlations for scores between the 
QOL-B respiratory domain and PROMIS F-SF 7a and the following concurrent validators: 
EXACT and EXACT RS, SGRQ, and FACIT-Fatigue.  
10.5.3.4. Known-Groups Validation 
Known-groups validity will be estimated at baseline only. Known-groups validators will consist 
of the PGI-S (both respiratory and fatigue for the QOL-B respiratory and PROMIS F-SF7a , 
respectively) and a median split on reported ppFEV1. Known-groups validity will be estimated 
by fitting a linear model to the PRO score(s) at baseline and contrasting marginal means 
LSMEANS across known-group validator levels. Known-groups contrasts will consist of 
comparing the low-severity PGI-S group (reference) against all other PGI-S groups (effect) and 
the ppFEV1 < median group (reference) against the ppFEV1 > median group (effect) in pairwise 
contrasts.  
10.5.4. 
Longitudinal Validation 
Longitudinal validation will consist of both test-retest reliability (conducted pre-exposure 
between screening and baseline) and within-subject meaningful change (conducted between 
baseline and EOS (Month 7). 
10.5.4.1. Test-retest Reliability 
Test-retest reliability correlations will be based on the 2-way random ICC (Shrout and Fleiss, 
1979). Test-retest reliability estimates of 0.7 and above will indicate satisfactory retest reliability.  
Test-retest reliability will be assessed in a group of subjects reporting no change over the retest 
interval. In this case, a 30-day retest interval occurring between screening and baseline will be 
used for TRTR. A symptomatically stable retest sample will be defined among subjects 

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experiencing no change on the PGI-S between Baseline and follow-up (PGI-S change score is 
zero). 
10.5.4.2. Within-Subject Meaningful Change 
Meaningful within-subject change will be estimated via change scores computed between 
Baseline and EOS (Month 7). Meaningful within-subject change will be characterized via point 
estimates obtained from the mean and median change score associated with the minimal 
improvement anchor group. 
The point estimates will be examined by generating eCDFs and ePDFs stratified on PGI-S 
change and culture conversion anchor groups. The separation of eCDFs and ePDFs at the 
meaningful change point estimates will be contrasted to assess separation between the minimal 
improvement and no-change anchor groups. 
10.5.5. 
Item-level Validation 
Item-level analogs of the analyses outlined above will also be conducted to provide a 
comprehensive set of validation evidence for FDA review. 
10.6. 
Other Efficacy Analyses 
10.6.1. 
Secondary Efficacy Endpoint Analyses 
Summaries of efficacy data will be presented by treatment group and by visit, as appropriate. 
Reporting of categorial secondary endpoints will include basic statistics, estimates derived via 
logistic regression and will include estimates of proportions, and difference of proportions, 
together with corresponding 95% CIs resulting, as appropriate. 
Reporting of continuous secondary endpoints will include basic statistics, estimates derived from 
ANCOVA model with change from baseline as response variable and treatment and baseline as 
independent variables, and will include estimates with corresponding 95% CIs as appropriate.  
ANCOVA and logistic regression models may not include adjustment for randomization strata 
due to expected small counts within each combination of strata.  
Time to culture conversion will be plotted via Kaplan-Meier method.  
10.6.2. 
Exploratory Efficacy Analyses 
All of the summaries pertaining to exploratory endpoints will utilize available data, unless 
otherwise stated in the SAP. Summaries will be presented by treatment group and by visit, as 
appropriate.  
Difference between treatment groups in change from baseline to Month 7 in the QOL-B non-
respiratory domains (physical, role, vitality, emotional, social, health perception) will be 
summarized. The data will be reported by timepoint and as change from baseline. Summary 
statistics estimates for means and difference between treatments together with corresponding 
95% CIs will be provided. 

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Difference in proportion of subjects meeting that within-subject meeting meaningful change 
from baseline criterion from Baseline to EOT and Month 7 in PRO (as assessed QOL-B and 
PROMIS F-SF 7a) will be evaluated. 
Note: The threshold for the criterion will be estimated via quantitative longitudinal analyses and 
will be available at the time of the analysis (post-unblinding). 
Actigraphy data will be collected continuously throughout the study. For the purpose of analysis, 
mean activity and sleep efficiency will be derived at the protocol specified visits. The data will 
be reported by timepoint over time. Summary statistics estimates for means and difference 
between treatments together with corresponding 95% CIs will be provided. 
Correlation between PRO respiratory domain mean responses and colony microbiology data will 
be explored. 
Exploratory analyses may be conducted in selected subgroups of the population or pertaining to 
an exploratory question of interest defined in the SAP. 
10.7. 
Safety Analyses 
Safety summaries will utilize safety analysis data set and will be provided by treatment group on 
available data. Descriptive statistics will be provided.  
10.7.1. 
Extent of Exposure 
The exposure data will be summarized descriptively by treatment group (separately for each 
medication, total as randomized) and will include total number of doses of each medication 
received (ALIS/ELC, AZI, ETH) and duration of exposure. The amount of medication taken and 
used for these summaries will be based on the pill count of returned medication. 
10.7.2. 
Concomitant Medications and Prior Therapy 
Concomitant medications are those medications taken on or after the first dose of study drugs. 
Prior medications are those medications taken before the first dose of study drugs. A medication 
that starts prior to first dose but continues after the first dose of study drugs is classified both in 
prior and concomitant medications. Any medications taken for MAC lung infection or COVID-
19 prior to Screening will be recorded. Non-study drugs taken 1 month prior to Screening and 
during the study will be recorded. Prior and concomitant medications will be summarized 
separately and will be mapped to an ATC class and Preferred Name using the WHO Drug 
Dictionary. These summaries will present the number and percentage of subjects using each 
medication. Subjects may have more than one medication per ATC class and Preferred Name. At 
each level of subject summarization, a subject is counted once if he/she reported one or more 
medications at that level. Each summary will be ordered by descending order of incidence of 
ATC class and preferred name within each ATC class.  
Prohibited medication will be reported as part of concomitant summaries and as protocol 
deviation summaries if appropriate.  
Data will be summarized descriptively by treatment over study duration.  

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10.7.3. 
Adverse Event Analyses 
Adverse events will be coded using MedDRA by system organ class and preferred term. The 
severity of AEs will be graded to either mild, moderate, or severe.  
The number and percent of subjects with AEs will be presented by treatment group. The severity 
of AEs, the relationship to study drugs (ALIS/ELC, AZI, ETH), AEs leading to study 
discontinuation, TEAEs, AESIs, and SAEs will be similarly presented. Treatment-emergent and 
treatment-related AEs will be tabulated by system organ class and preferred term.  
10.7.4. 
Clinical Laboratory Evaluation Analyses 
The results of hematology, blood chemistry, and urinalysis will be tabulated by treatment group. 
Laboratory values outside the normal ranges will be flagged. Subjects experiencing ALT or AST 
≥ 3* ULN and total bilirubin > 2* ULN according to Hy’s Law will be listed. 
Summary statistics (mean, median, range, change from Baseline) by treatment will be provided 
for each timepoint, as appropriate.  
Baseline value is defined by laboratory results collected prior to first study drugs administration. 
10.7.5. 
Vital Sign Analyses 
Systolic and diastolic BP, pulse rate, RR, oxygen saturation, and body temperature will be listed 
for each subject. If applicable, summary statistics (mean change, percentage change from 
Baseline, and absolute change from Baseline) by treatment at each time point will be provided. 
Baseline value is defined as vital signs collected prior to the first dose of study drugs on 
Day 1/Baseline. 
10.7.6. 
Physical Examination Analyses 
Postbaseline abnormal findings of the physical examinations that meet the criteria of AEs will be 
included within AE reporting. 
10.7.7. 
Audiology Analysis 
Audiology test results and the change from Baseline will be summarized. 
10.7.8. 
Other Safety Analyses 
C-reactive protein value will be summarized descriptively by visit including changes from 
baseline.  
Additional safety analyses may be specified in the SAP as appropriate.  
10.7.9. 
Planned Interim Analysis  
No interim analysis is planned for this study. 

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11. 
DATA INTEGRITY AND QUALITY ASSURANCE 
The Investigator/investigational site will permit study-related monitoring, audits, IRB/EC review 
and regulatory inspections by providing direct access to source data/documents. Direct access 
includes permission to examine, analyze, verify, and reproduce any records and reports that are 
important to the evaluation of a clinical study. 
11.1. 
Source Documents 
Study data will be collected on source documents. The Investigator is responsible for assuring 
that collected data are complete and accurate. Source documentation (the point of initial 
recording of a piece of data) should support data collected on the eCRF. Source documents 
include all recordings of observations or notations of clinical activities and all reports and 
records necessary for the evaluation and reconstruction of the clinical study. 
11.2. 
Data Collection 
All data obtained for this study will be entered into a local regulation (ie, 21 CFR Part 11 in the 
USA)-compliant Data Management System provided by the Sponsor or its designee. These data 
will be recorded with an EDC system using eCRFs. The Investigator will ensure the accuracy 
and completeness of the data reported to the Sponsor. All data entry, modification or deletion 
will be recorded automatically in an electronic audit trail. 
The Investigator will provide access to his/her original records to permit a representative from 
the Sponsor to verify the proper transcription of data. Data reported in the eCRFs should be 
consistent with and substantiated by the subject’s medical record and original source documents.  
The eCRF data will be monitored by the Sponsor or designee. The final, completed eCRF 
Casebook for each subject must be electronically signed and dated by the PI within the EDC 
system to signify that the Investigator has reviewed the eCRF and certifies it to be complete and 
accurate. 
The Sponsor will retain the final eCRF data and audit trail. A copy of all completed eCRFs will 
be provided to the Investigator. 
11.3. 
Study Records Retention 
Study documents should be retained for a minimum of 2 years after the last approval of a 
marketing application in an ICH region and until there are no pending or contemplated marketing 
applications in an ICH region or at least 2 years have elapsed since the formal discontinuation of 
clinical development of the investigational product. These documents should be retained for a 
longer period, however, if required by local regulations. No records will be destroyed without the 
written consent of the Sponsor. It is the responsibility of the Sponsor to inform the Investigator 
when these documents no longer need to be retained. 

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12. 
FINANCING AND INSURANCE 
12.1. 
Finances 
Prior to starting the study, the Investigator and/or institution will sign a clinical study agreement 
with Sponsor. This agreement will include the financial information agreed upon by the parties. 
12.2. 
Reimbursement, Indemnity, and Insurance 
Reimbursement, indemnity, and insurance shall be addressed in a separate agreement on terms 
agreed upon by the parties. 

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13. 
STUDY ADMINISTRATIVE INFORMATION 
13.1. 
Financial Disclosure by the Investigator 
The disclosed financial interest of the Investigator must be collected before Screening of the first 
subject, following study completion at the Investigator site and 1 year following overall study 
completion. The Investigator should promptly update this information if any relevant changes 
occur during this period. 
13.2. 
Study Registration and Results Disclosure 
The Sponsor will provide study information for inclusion in national registries according to local 
regulatory requirements. 
Results of this study will be disclosed according to the relevant national regulatory requirements. 
13.3. 
Study Files and Materials 
Before the start of any study related procedures, all initial documents required by ICH GCP, 
Good Pharmacoepidemiology Practice, and applicable local regulations must be available in the 
relevant files maintained by the Sponsor (or designee) and the Investigator. An Investigator Site 
File prepared by the Sponsor (or designee), containing all applicable documents for use at the 
study site, will be made available to the Investigator before the start of the study. A list of 
personnel and organizations responsible for conduct of the study as well as the list of 
Investigators at each site will be included in the Investigator Site File. The respective files will 
be kept and updated by the Sponsor (or designee) and the Investigator, as applicable. 
All study documentation and materials maintained in the Investigator Site File at the study site 
must be available for inspection by the Sponsor’s study monitor (or designee) to determine that 
all required documentation is present and correct. 
The study may be audited by qualified designees from the Sponsor or a competent regulatory 
authority (Section 13.11). 
13.4. 
Use of Stored Samples and Data 
Mycobacterial isolates will be stored for a period of up to 2 years after the completion 
(termination) of the study, or longer if required by the institution participating in the study and 
used for future selective susceptibility testing for correlation with microbiologic and clinical 
response and for molecular typing of serial isolates to look for multiple strains within individuals 
that might influence treatment outcome. Stored samples will be labeled with study and subject 
information and kept in a locked room with limited access. Electronic data will be kept in 
password-protected computers at the laboratory and then transferred to the Sponsor or CRO, as 
applicable, for data analysis. Samples and corresponding data will be tracked using the 
laboratory’s specimen tracking system. 
Prior Sponsor and IRB/EC approval are required before using or sharing study samples or data in 
ways not specified in the study protocol. 

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Any loss or unanticipated destruction of samples (eg, freezer malfunction) or data (eg, loss of a 
data sheet with individually identifiable information) that violates or compromises the scientific 
integrity of study data must be reported to the Sponsor and the IRB/EC. 
At any time, subjects may inform the Investigator that they do not wish to have their samples 
stored beyond the completion (termination) of the study. In this case, the Investigator will 
request that all known remaining samples be destroyed and report the disposition of samples to 
the requesting subjects and the IRB/EC. 
13.5. 
Disposition of Stored Samples and Data 
Access to stored samples will be limited by using a locked room. Samples stored by the central 
laboratories will be labeled with the subject’s study identification information. Data will be kept 
in password-protected computers at the laboratory and then transferred to the vendor for data 
analysis. Samples and corresponding data acquired will be tracked using the laboratory’s 
specimen tracking system. 
In the future, other Investigators may wish to study these samples and/or data. In that case, 
IRB/EC approval and Sponsor approval must be obtained before any sharing of samples and/or 
data. Any clinical information shared about the sample would similarly require prior Sponsor and 
IRB/EC approval. 
Any loss or unanticipated destruction of samples (eg, due to freezer malfunction) or data (eg, 
loss of a data sheet with individually identifiable information) that results in a violation that 
compromises the scientific integrity of the data collected for the study will be reported to the 
Sponsor and the IRB/EC. 
Additionally, subjects may decide at any point not to have their samples stored for a period of up 
to 2 years beyond the duration of the study. In this case, the PI will request the destruction of all 
known remaining samples and report what was done to both the subject and to the IRB/EC. This 
decision will not affect the subject’s participation in this protocol. 
13.6. 
Initiation of Study 
Before the start of the study at each study site, the Sponsor’s study monitor (or designee) will 
ensure adequacy of the facilities and to discuss responsibilities regarding study protocol 
adherence with the Investigator and other personnel involved in the study. 
The Investigator may not enroll any subject into the study before the Sponsor has received 
written approval or a favorable opinion from the EC or IRB for conducting the study and a 
formal meeting has been conducted by the Sponsor’s study monitor (or designee) to initiate the 
study. This meeting will include a detailed review of the study plan and completion of the eCRF. 
13.7. 
Subject Reimbursement, Liability, and Insurance 
The civil liability of the involved parties with respect to financial loss due to personal injury and 
other damage that may arise as a result of this study being conducted are governed by the 
applicable legal requirement(s). 
The Sponsor will provide insurance to the Investigator if required by the applicable regulatory 
and legal requirement(s). 

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If required by local law, subjects taking part in this study will be insured against any injury 
caused by the study in accordance with the applicable regulatory and legal requirement(s). 
13.8. 
Subject Identification and Confidentiality 
Subject names will not be supplied to the Sponsor. A subject number will be recorded in the 
eCRF, and if the subject name appears on any other document (eg, laboratory report), it must be 
obliterated on the copy of the document to be supplied to the Sponsor. All records will be kept 
confidential to the extent provided by federal, state, and local laws. Subjects will be informed 
that representatives of the Sponsor, IRB/EC, or regulatory authorities may inspect their medical 
records to verify the information collected, and that all personal information made available for 
inspection will be handled in strictest confidence and in accordance with local data protection 
laws. 
The Investigator will maintain a personal subject identification list (subject numbers with the 
corresponding subject names) to enable records to be identified. 
13.9. 
Study Monitoring 
Before study initiation, at a site initiation visit or at an Investigator’s meeting, a Sponsor 
representative will review the protocol, eCRF, IB, and any study related materials with the 
Investigators and their staff. During the study, the Study Monitor or a designee will visit the site 
regularly to check the completeness of subject records, the accuracy of entries on the eCRFs, 
adherence to the protocol, adherence to ICH GCP and applicable regulatory requirements, the 
progress of enrollment, and also to ensure that study drugs are being stored, dispensed, and 
accounted for according to specifications. 
The Investigator must give the Study Monitor access to relevant hospital or clinical records to 
confirm their consistency with the eCRF entries. No information in these records about the 
identity of the subjects will leave the study center. The monitoring standards of the study require 
full verification for the presence of informed consent, adherence to the inclusion/exclusion 
criteria, documentation of SAEs, and the recording of primary activity and safety variables. 
Additional checks of the consistency of the source data with the eCRFs are performed according 
to the study specific monitoring plan. 
13.10. 
Protocol Amendments 
Any substantial change or addition to this protocol requires a written protocol amendment that 
must be approved by the Sponsor, before implementation. Amendments significantly affecting 
the safety of subjects, the scope of the investigation, or the scientific quality of the study, require 
additional approval by the applicable regulatory authority(ies) and IRBs/ECs. Copies of the 
applicable written approvals must be given to the site monitor or their designee. 
The requirements for approval should in no way prevent any immediate action from being taken 
by the Investigator or by the Sponsor in the interests of preserving the safety of all subjects 
included in the study. If an immediate change to the protocol is felt to be necessary by the 
Investigator and is implemented by him/her for safety reasons, the Sponsor or its agent should be 
notified and the applicable regulatory authority(ies)/IRBs/ECs should be informed within 10 
working days. Any other regional reporting requirements must be adhered to. 

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Amendments affecting only administrative aspects of the study do not require formal protocol 
amendments or regulatory authority/IRB/EC approval, but the regulatory 
authority(ies)/IRBs/ECs must be kept informed of such administrative changes in accordance 
with country-specific requirements. 
13.11. 
Audits and Inspections 
Domestic and foreign regulatory authorities, the IRB/EC, and an auditor authorized by the 
Sponsor may request access to all source documents, eCRFs, and other study documentation for 
onsite audit or inspection. Direct access to these documents must be guaranteed by the 
Investigator, who must provide support at all times for these activities. Medical records and other 
study documents may be copied during audit or inspection provided that subject names are 
obliterated on the copies to ensure confidentiality. 
If an inspection is requested by a regulatory authority, the Investigator will inform the study 
Sponsor, immediately that this request has been made. 
13.12. 
Publication Policy 
Any formal presentation or publication of data collected from this study will be considered as a 
joint publication by the Investigator(s) and the appropriate personnel of the Sponsor. Authorship 
will be determined by mutual agreement. For multicenter studies, it is mandatory that the first 
publication be based on data from all centers, analyzed as stipulated in the protocol by the 
Sponsor and statisticians, and not by the Investigators themselves. Investigators participating in 
multicenter studies agree not to present data gathered from a single center or a small group of 
centers before the full, initial publication, unless formally agreed by all other Investigators and 
the Sponsor. 
The Sponsor must receive copies of any intended communication in advance of publication (at 
least 15 working days for an abstract or oral presentation and 45 working days for a journal 
submission). The Sponsor will review the communications for accuracy (thus avoiding potential 
discrepancies with submissions to regulatory authorities), verify that confidential information is 
not being inadvertently divulged, and provide any relevant supplementary information. 
Authorship of communications arising from pooled data may include members from each of the 
contributing centers as well as the Sponsor personnel. 
At the conclusion of the study, after the data are analyzed, the results of study will be reported in 
a clinical study report. 

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APPENDIX 1.  QOL-B QUALITY OF LIFE QUESTIONNAIRE 
 

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APPENDIX 2. PROMIS FATIGUE SHORT FORM 7A 
 

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APPENDIX 3. PGI-S INSTRUMENT 
 

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APPENDIX 4. EXACT & EXACT-RS INSTRUMENTS  
 

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APPENDIX 5. ST. GEORGE’S RESPIRATORY QUESTIONNAIRE  
 

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APPENDIX 6. FACIT FATIGUE SCALE