A Randomized, Double-Blind, Parallel-Group, 24-Week, Chronic-Dosing, Multi-Center Study to Assess the Efficacy and Safety of PT010, PT003, and PT009 Compared With Symbicort® Turbuhaler® as an Active Control in Subjects With Moderate to Very Severe Chronic Obstructive Pulmonary Disease
Phase: PHASE3
Conditions: COPD
Sponsor: Pearl Therapeutics, Inc.

 
 
Revised Clinical Study Protocol 
Study Code 
PT010006 
NCT #  
NCT02497001 
Date: 
   
  25AUGUST2017 
 
 
 
 
 
 
 
 
 
 
 
A Randomized, Double-Blind, Parallel-Group, 24-Week, Chronic-Dosing, 
Multi-Center Study to Assess the Efficacy and Safety of PT010, PT003, and 
PT009 Compared with Symbicort® Turbuhaler® as an Active Control in 
Subjects with Moderate to Very Severe Chronic Obstructive Pulmonary 
Disease 
 
 
This submission /document contains trade secrets and confidential commercial information, disclosure of which 
is prohibited without providing advance notice to AstraZeneca and opportunity to object. 
The following Amendment(s) are included in this revised protocol: 
  
Amendment No.        
Date of Amendment           
Version 1 
18 MAY 2015 
Version 2,  Amendment 1 
04 MAY 2016 
Version 3,  Amendment 2 
25 AUGUST 2017 
 
 

 
 
Clinical Trial Protocol: PT010006-02 
 
Study Title: 
A Randomized, Double-Blind, Parallel-Group, 24-Week, Chronic-
Dosing, Multi-Center Study to Assess the Efficacy and Safety of 
PT010, PT003, and PT009 Compared with Symbicort® Turbuhaler® 
as an Active Control in Subjects with Moderate to Very Severe 
Chronic Obstructive Pulmonary Disease 
Study Number: 
PT010006-02 
Study Phase: 
III 
Product Name: 
Budesonide, Glycopyrronium, and Formoterol Fumarate Inhalation 
Aerosol, PT010 
Glycopyrronium and Formoterol Fumarate Inhalation Aerosol, PT003 
Budesonide and Formoterol Fumarate Inhalation Aerosol, PT009 
EudraCT Number: 
2014-005672-29 
Indication: 
COPD 
Investigators: 
Multicenter 
Sponsor: 
Pearl Therapeutics, Inc. 
 
 
 
 
 
Sponsor Contact: 
 
 
 
 
Version Number 
Date: 
Original Protocol 
Version 1.0 
18 May 2015 
Amended Protocol 
Version 2.0 
04 May 2016 
Amended Protocol 
Version 3.0 
25 Aug 2017 
 
Confidentiality Statement 
Property of Pearl Therapeutics 
This document is confidential and may not be used, divulged, published or otherwise 
disclosed without consent of Pearl Therapeutics Inc. 
 
 
 

Budesonide, Glycopyrronium, and Formoterol Fumarate Inhalation Aerosol 
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Clinical Trial Protocol: PT010006-02 
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SUMMARY OF CHANGES TO PT010006-01 VERSION 2.0, 
DATED 04 MAY 2016 
Section(s)/Description of Change 
Rationale 
Synopsis, Section 2.2/Secondary Objectives, 
and Section 3.2/Secondary Efficacy 
Endpoints 
Added rate of moderate or severe COPD 
exacerbations. 
Added time to Clinically Important 
Deterioration (CID)-except for the US 
approach 
Exacerbations are an important endpoint and 
there is sufficient sample size to observe at 
least a numerical benefit in the form of a 
trend, even though the study is not optimized 
to demonstrate statistical significance. 
Time to CID encompasses lung function, 
symptomatic benefit, and exacerbations into 
a single endpoint. 
Section 2.3/Other Efficacy Objective 
Removed the rate of moderate or severe 
COPD exacerbations. 
Added time to sustained CID. 
Added time to CID (since not included as a 
secondary endpoint in US approach). 
The rate of moderate or severe exacerbations 
is now a secondary objective.  
Synopsis and Study Endpoint Sections 3, 
3.2.1, 3.2.2, 3.2.3, 3.3.1, 3.3.2, 3.4, 3.5, 3.6.1, 
3.6.2, 3.6.3.2, and 9.1. 
Added the following sentence to Section 3 
“Study Endpoints”, Section 9.1 and 
Synopsis: Countries not specifically 
mentioned will be decided by regulatory 
requirements and included in one of the three 
defined registration approaches. 
Addition of US endpoints 
The EXACT Total Score which was a 
secondary endpoint is now an Other 
endpoint. The E-RS:COPD RS-Total Score, 
which was an other endpoint, is instead a 
secondary endpoint in place of the EXACT 
Total Score for the EU/CAN approach. 
Added sentence to clarify the registration 
approach for countries that are not 
specifically mentioned. 
Added US endpoints to support registration 
in the US and other markets that use similar 
endpoints. 
The E-RS:COPD RS-Total score is more 
aligned with the population included in this 
study. The EXACT total is more appropriate 
for an exacerbation study. 
Though underpowered, analyses of severe 
COPD exacerbations will be conducted as 
well due to their clinical relevance. 
A table is needed to support the plot of FEV1 
over time in the 12-hr PFT sub-study. 
AUC0-4 is assessed in subjects outside of the 

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Severe COPD exacerbations were added 
Clarification of the endpoints for the 12-hr 
PFT sub-study  
AUC and trough SC at Week 24 were 
removed as HPA axis secondary endpoints. 
Day 1 assessments were clarified.  
sub-study as well, so is not needed. 
The AUC0-24 is already a key component in 
the primary endpoint. Trough SC 
concentration is not being defined as a 
distinct endpoint, since there will be 
summaries of serum cortisol concentration 
by time point.  
Day 1 assessments were edited to reflect that 
FEV1 AUC0-4 is already covered by that 
endpoint being specified elsewhere, and 
response defined as an improvement of 100 
mL is also of interest. 
Synopsis, Section 9.4.2, and Section 9.4.4.2 
A separate margin of 75 mL is specified for 
post-dose FEV1 measures. 
The margin for FEV1 AUC0-4 is larger since 
larger benefits and greater variability is 
expected.  
Section 5.4.4/Other Prohibited Medications 
Table 3 - Added NaSSAs to row containing 
SSRIs and SNRIs. Added note to 
specify/clarify use topical medications. 
Table 4 - Moved Carvedilol from table to a 
footnote. Added footnote to clarify usage. 
Paragraph below Table 4 - For consistency 
added language clarifying continuation in the 
study after randomized treatment 
discontinuation. 
Added or reorganized language to provide 
consistency across protocol sections. 
Section 5.7/Reasons for Treatment 
Discontinuation or Study Withdrawal 
Created third-level sections for “Reasons for 
Treatment Discontinuation” and “Reasons 
for Study Withdrawal”. 
Reorganized language to separate reasons for 
treatment discontinuation and study 
withdrawal. 
Sections 4.1, 7.1.4.5 and 9.4.4.5 and 
Appendix 12 
Modified based on name change.  The 
EXACT name was used in the protocol 
Noted the updated EXACT questionnaire 
nomenclature based on recognition of the 
new name “the Evaluating Respiratory 
Symptoms (E-RS) measure”, announced 7 
March 2016. When referring specifically to 
its use in COPD, the proposed context of use 

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unless specifically noted otherwise. 
for qualification, the full name is now 
“Evaluating Respiratory Symptoms in COPD 
(E-RS™: COPD)”. 
Section 7.2.1/Medical/Surgical History and 
Physical Examination. 
Added “or Treatment Discontinuation 
Withdrawal Visit”. 
Changed to maintain consistency throughout 
the protocol and reflect study conduct. 
Section 7.5.7.3/Pneumonia 
Replaced PAC with CEC. 
Corrected the name of the adjudication 
committee. 
Section 7.5.13/Paternal Exposure  
Added New Section “Paternal Exposure”. 
Added to clarify protocol conduct and 
consistency across protocol sections. 
Section 9.3/Study Populations 
A more complete definition of the mITT 
Population is provided. 
Demography and baseline characteristics will 
be produced for the mITT Population.  
Added to provide additional clarity about the 
data to be included in the mITT Population. 
The main population for demography and 
baseline characteristics was changed from the 
ITT to the mITT Population to reflect the 
primary analyses. Note that the baseline 
information is expected to be identical for the 
mITT and ITT Populations. 
Section 9.4/Efficacy Analyses 
Added Section 9.4.1 on “Estimands” and 
modified text based on estimands in Sections 
9.4.2.1, 9.4.2.2, 9.4.3, 9.4.3.7, 9.4. 
Added the attributable estimand. 
Added missing approaches by comparison in 
9.4.2.1. 
Added estimands to Section 9.4.5 “Control of 
Type I Error” and sub-sections 9.4.5.1, 
9.4.5.2, and 9.4.5.3. 
Added Type I error control for the US 
approach. 
Added Estimands to Section 9.15 “Handling 
The efficacy analysis section has been 
updated using wording around estimands in 
keeping with current statistical thinking. As 
such, analyses previously using the mITT 
Population, the ITT Population, and the Per-
Protocol Population have been replaced with 
the efficacy estimand and attributable 
estimand, the treatment policy estimand, and 
the per-protocol estimand, respectively. The 
new estimand called the attributable estimand 
has been added to further evaluate benefit of 
treatments in the context of having missing 
data. This attributable estimand has been 
added to the Type I error control. 
Type I error control was added for the US 
approach corresponding to the addition of US 
endpoints. 

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of Missing Data”. 
The non-inferiority margin for TDI was 
changed from 1.0 to 0.75. 
The TDI margin was tightened to be less than 
the minimum clinically relevant difference.  
Non-inferiority margins for other secondary 
measures are specified in the SAP. 
Section 9.5/Subgroup Analyses 
Important Chinese and Asian subgroups were 
added as were primary endpoints. 
The Chinese and Asian subgroups are also 
important to mention that they are planned 
for analysis.  The mention of primary 
endpoints was inadvertently left out of 
previous versions. 
Section 9.7/Pharmacokinetic Analyses 
Comparison to Symbicort was added. 
The comparison to Symbicort TBH was 
inadvertently left out of previous versions. 
Section 9.15/Handling of Missing Data 
Text was edited to specify that exploration of 
the potential impact of missing data will be 
explored and that details will be provided in 
the SAP. 
It is not considered optional to explore the 
potential impact of missing data. 
Other administrative changes to correct and/or clarify protocol language were also 
addressed. These changes included edits for consistency, grammar, and typographical 
errors, which are not summarized in this table. 
 
 
 

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SYNOPSIS 
Sponsor: 
Pearl Therapeutics, Inc.  (“Pearl”) 
 
 
Name of Finished Product: 
Budesonide, Glycopyrronium, and Formoterol Fumarate Inhalation Aerosol (PT010, BGF 
metered dose inhaler [MDI])  
Glycopyrronium and Formoterol Fumarate Inhalation Aerosol (PT003, GFF MDI)  
Budesonide and Formoterol Fumarate Inhalation Aerosol (PT009, BFF MDI)  
Symbicort® Turbuhaler® (TBH) Inhalation Powder  
Name of Active Ingredient: 
Budesonide, Glycopyrronium, and Formoterol Fumarate 
Glycopyrronium and Formoterol Fumarate 
Budesonide and Formoterol Fumarate  
Study Title: 
A Randomized, Double-Blind, Parallel-Group, 24-Week, Chronic-Dosing, Multi-Center 
Study to Assess the Efficacy and Safety of PT010, PT003, and PT009 Compared With 
Symbicort® Turbuhaler® as an Active Control in Subjects with Moderate to Very Severe 
Chronic Obstructive Pulmonary Disease  
Study Number: PT010006-02 
Study Phase: Phase III 
Primary Objective:  
• To assess the effects of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH on lung 
function. 
Secondary Objectives: 
• To assess the effects of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH on 
dyspnea  
• To assess the effects of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH on quality 
of life  
• To assess the effects of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH on 
symptoms of chronic obstructive pulmonary disease (COPD) 
• To assess the effects of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH on COPD 
exacerbations  
• To determine the time to onset of action of BGF MDI, GFF MDI, BFF MDI, and 
Symbicort TBH  

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Clinical Trial Protocol: PT010006-02 
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Safety Objective: 
• To assess the safety of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH 
Healthcare Resource Utilization Objective: 
• To assess overall and COPD-specific Healthcare Resource Utilization of BGF MDI, GFF 
MDI, BFF MDI, and Symbicort TBH. 
12-Hour Pulmonary Function Test Sub-study Objective: 
• To assess the effect of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH on 
pulmonary function test (PFT) parameters over 12 hours.   
Pharmacokinetic Sub-study Objective: 
• To characterize the steady state pharmacokinetics of budesonide, glycopyrronium, and 
formoterol based on pharmacokinetic (PK) assessments.   
HPA Axis Sub-study Objective: 
• To assess the effect of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH on 
hypothalamic-pituitary-adrenal (HPA) axis function. 
Study Design: 
This is a multicenter, randomized, double-blind, parallel-group, chronic-dosing (24 weeks) 
study to assess the efficacy and safety of BGF MDI, GFF MDI, BFF MDI compared with 
Symbicort TBH as an active control, in subjects with moderate to very severe COPD. 
This study will be conducted at approximately 160 sites, contributing approximately 10 to 20 
subjects per site.  Across these sites, it is planned that approximately 1800 subjects with 
moderate to very severe COPD will be randomized to the study to provide approximately 
1600 subjects who will complete the study. 
Subjects will be randomized in a 2:2:1:1 scheme.  Approximately 600 subjects each will be 
randomized to the BGF MDI and GFF MDI treatment groups, and 300 subjects each will be 
randomized to the BFF MDI and Symbicort TBH treatment groups.  Randomization will be 
stratified by reversibility to Ventolin HFA, country, and disease severity. 
This study will evaluate the benefit of BGF MDI compared to BFF MDI, GFF MDI, and 
Symbicort TBH, and will also compare BFF MDI to Symbicort TBH with respect to lung 
function in subjects with moderate to very severe COPD that remain symptomatic (COPD 
Assessment Test ≥10) on 2 or more inhaled maintenance therapies.  A history of 
exacerbations in the prior year will be obtained to characterize the population, but the entry 
criteria do not require an exacerbation in the prior year.  COPD severity as defined as post-
bronchodilator forced expiratory volume in 1 second (FEV1) must be <80% predicted normal 
value, calculated using the Third National Health and Nutrition Examination Survey 
reference equations or local reference equations provided by the Sponsor, and the measured 
FEV1 must also be ≥25% of predicted normal value. 
Reversibility of FEV1 to Ventolin HFA, a short acting β2 agonist and to Atrovent HFA, a 
short-acting muscarinic antagonist will be tested at Visits 2 and 3, respectively.  The 
spirometry data obtained at Visit 2 will be used for stratification purposes. 
After the Randomization Visit (Visit 4), subjects will be examined at Visit 5 (Week 4), Visit 
6 (Week 8), Visit 7 (Week 12), Visit 8 (Week 16), Visit 9 (Week 20) and Visit 10a (Week 
24). 

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For subjects who remain on treatment throughout the study (i.e., complete Visit 10a), a 
follow-up telephone call will be performed at least 14 days after the last study drug dose.   
Subjects who discontinue study treatment prior to Week 24 (Visit 10a) will be encouraged to 
remain in the study to complete all remaining study visits during the 24 week treatment 
period.  Subjects who agree to continue to be followed post treatment discontinuation will 
sign an ICF addendum.  All subjects who agree to continue study participation beyond 
treatment discontinuation will complete a Treatment Discontinuation/Withdrawal Visit (refer 
to Table 8) prior to transitioning back to regularly scheduled study visits.  Subjects 
participating in a sub-study who choose to discontinue from treatment will only complete 
regularly scheduled visits and not complete any remaining sub-study assessments.  Treatment 
discontinuation subjects will return to appropriate maintenance COPD medications, per the 
investigators discretion.  For subjects recorded as Treatment Discontinuations that do not 
complete at least one post-treatment data collection a telephone follow-up call is required at 
least 14 days after last study drug dose. 
If a subject chooses not to continue with study assessments, at a minimum the subject will 
complete the Treatment Discontinuation/Withdrawal Visit (refer to Table 8).  These subjects 
will return to appropriate maintenance COPD medications, per the investigators discretion.  
A follow-up telephone call will be performed at least 14 days after the last study drug dose.  
In the event the Treatment Discontinuation/Withdrawal Visit is performed >14 days post last 
study drug dosing, a follow-up telephone call will not be required.  These subjects will be 
followed for vital status at 24 weeks post randomization in accordance with the informed 
consent. 
Subjects participating at study centers in Japan will be invited to participate in a 28-week 
safety extension study, Study PT010007.  Any additional assessments required for this 
extension study will be obtained as stipulated in the Study PT010007 protocol. 
This study includes the following 3 sub-studies: 12-hour Pulmonary Function Test (PFT), 
Pharmacokinetic (PK) Profile, and HPA Axis. 
12-Hour Pulmonary Function Test Sub-study: Serial PFTs will be conducted over 12 
hours in a subset of approximately 600 randomized subjects (200 subjects from each of BGF 
MDI and GFF MDI treatment groups, and 100 subjects from each of the BFF MDI and 
Symbicort TBH treatment groups) at Visit 10a (Week 24). 
The PFT sub-study will be conducted at specific sites in the United States (US) that have 
agreed to participate.  Once the target number of subjects has been met, no further enrollment 
will be allowed in the PFT sub-study. 
Pharmacokinetic Sub-study: Pharmacokinetic assessments will be performed in a subset of 
subjects who participate in the PFT sub-study.  Approximately 240 randomized subjects (80 
subjects from each of the BGF MDI and GFF MDI treatment groups, and 40 subjects from 
each of the BFF MDI and Symbicort TBH treatment groups) will be assessed at Visit 10a 
(Week 24). 
Pharmacokinetic assessments will be performed on a subset of PFT sub-study subjects at the 
sites in the US that have agreed to participate.  Once the target number of subjects has been 
met, no further enrollment will be allowed in the PK sub-study. 
HPA Axis Sub-study: Adrenocorticosteroid activity will be assessed in a subset of subjects 
in the PK sub-study.  Serum cortisol will be measured in approximately 108 randomized 

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subjects (36 subjects from each of the BGF MDI and GFF MDI treatment groups, and 18 
subjects from each of the BFF MDI and Symbicort TBH treatment groups) over 24 hours 
between Visits 3 and 4 prior to dosing at Randomization and Visit 10a (Week 24).   
Adrenocorticosteroid activity assessments will be conducted on a subset of PK sub-study 
subjects at specific sites in the US that have agreed to participate in the HPA axis sub-study.  
Once the target number of subjects has been met, no further enrollment will be allowed in the 
HPA axis sub-study. 
Study Population:  
It is planned that approximately 1800 subjects with moderate to very severe COPD will be 
randomized to provide approximately 1600 subjects to complete the study. 
Product, Dose, and Mode of Administration:  
Investigational materials will be provided by Pearl Therapeutics (Pearl), as shown below: 
Product Name & Dose 
Product Strength 
Dosage Form/ 
Fill Count 
Administration 
Study Medications 
BGF MDI (PT010)  
320/14.4/9.6 µg ex-actuator 
160/7.2/4.8 µg per actuation 
MDI/ 
120 inhalations 
Taken as 
2 inhalations BID 
GFF MDI (PT003) 
14.4/9.6 µg ex-actuator 
7.2/4.8 µg per actuation 
MDI/ 
120 inhalations 
Taken as 
2 inhalations BID 
BFF MDI (PT009)  
320/9.6 µg ex-actuator 
160/4.8 µg per actuation 
MDI/ 
120 inhalations 
Taken as 
2 inhalations BID 
Open-Label Products 
Budesonide and formoterol 
fumarate inhalation powder 
(Symbicort Turbuhaler) 400/12 
µga 
EU Source: Symbicort Turbuhaler 
200/6 µg per actuation 
Each metered dose contains: 
budesonide 200 µg per inhalation and 
formoterol fumarate dihydrate 6 µg 
which corresponds to a delivered dose 
of 160 µg budesonide and 4.5 µg 
formoterol fumarate dihydrate per 
inhalation. 
DPI/ 
60 inhalations 
Taken as 
2 inhalations BID 
Supplies are open-
label 
Albuterol Sulfate inhalation 
aerosol 90 μgb 
ex-actuatorc  
US sourced: Ventolin® HFA 
HFA inhalation aerosol will be the 
US-supplied product.” Albuterol 
sulfate inhalation aerosol.  Each 
inhalation contains 108 μg 
corresponding to 90 µg albuterol base 
from the mouthpiece 
MDI/ 
60 or 200 actuations 
Taken as directed 
Supplies are open-
label  
 
Ipratropium bromide HFA 
inhalation aerosol 34 μg  
ex-actuatore 
US sourced: Atrovent® HFA 
HFA will be the US-supplied 
product.” Ipratropium bromide HFA 
Each inhalation contains 17 μg per 
actuation 
MDI/ 
200 actuations 
Taken as 
2 inhalations QID 
during Screening 
Supplies are open-
label  
  

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BID=twice daily; BGF MDI=Budesonide, Glycopyrronium and Formoterol Fumarate Inhalation Aerosol;  
GFF MDI=Glycopyrronium and Formoterol Fumarate Inhalation Aerosol; BFF MDI=Budesonide and Formoterol 
Fumarate Inhalation Aerosol; HFA=Hydrofluroalkane; MDI=Metered Dose Inhaler; DPI=dry powder inhaler;  
QID=4 times daily; EU=Europe; US=United States. 
a Active control.  Symbicort Turbuhaler is also known as Symbicort Turbohaler in some countries 
b Active control.  Albuterol sulfate is also known as salbutamol sulfate in some countries. 
c Reversibility testing at Visit 2, rescue medication during the study. 
d US-sourced products are the preferred product.  In cases where it is not possible for the US-sourced product to be used, a 
locally available product will be provided by Pearl. 
e Reversibility testing at Visit 3 and COPD maintenance therapy during Screening Period. 
 
Note: All study drugs will be administered by oral inhalation.  Glycopyrronium 14.4 µg in GFF MDI is equivalent to 
18 µg of glycopyrrolate (glycopyrronium bromide). 
 
Note: It is preferred that Atrovent and Ventolin be US-sourced products.  In cases where it is not possible for the US-
sourced product to be used, a locally available product will be provided by the Sponsor.  The EU-sourced Symbicort TBH 
must be used for the active control, and a locally available product cannot be substituted for the sponsor-provided 
Symbicort TBH. 
Duration of Treatment:  
It is planned that each subject will receive study treatment for 24 weeks. 
Duration of Study:  
The entire study period is scheduled to take approximately 30 weeks (expected range 
between 27 to 30 weeks) for each individual subject.  The study is anticipated to run for 
approximately 18 months and is not expected to exceed 30 months. 
Efficacy Assessments: 
All efficacy assessments are relative to pre-dose baseline obtained at or prior to Visit 4.  The 
primary endpoints, treatment comparisons of interest, and analysis timeframes may differ by 
country or region due to local regulatory agency requirements.  The 3 different registration 
approaches will be called: (1) Japan/China, (2) Europe (EU)/Canada, and (3) US.  Countries 
not specifically mentioned will be decided by regulatory requirements and included in one of 
the three defined registration approaches.  The multiplicity controls for the primary and 
secondary measures will be delineated by approach. 
Primary Efficacy Endpoints: 
Primary Endpoint (Japan/China Approach) 
• Change from baseline in morning pre-dose trough FEV1 over Weeks 12 to 24 (BGF MDI 
versus BFF MDI, BGF MDI versus GFF MDI, and BFF MDI versus Symbicort TBH) 
 
Primary Endpoints (EU/Canada Approach) 
• FEV1 area under the curve from 0 to 4 hours (AUC0-4) over 24 weeks (BGF MDI versus 
BFF MDI and BGF MDI versus Symbicort TBH) 
• Change from baseline in morning pre-dose trough FEV1 over 24 weeks (BGF MDI 
versus GFF MDI and BFF MDI versus Symbicort TBH[non-inferiority]) 
 
 

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Primary Endpoints (US Approach) 
• FEV1 AUC0-4 at Week 24 (BFG MDI versus BFF MDI) 
• Change from baseline in morning pre-dose trough FEV1 at Week 24 (BGF MDI 
versus GFF MDI) 
 
Secondary Efficacy Endpoints: 
Endpoints that are not considered primary for an approach or region have been included 
under secondary endpoints.  In addition, perspectives vary about time points to be included 
from some end points.  Therefore, secondary endpoints differ between approaches. 
 
Secondary Endpoints (Japan/China Approach): 
• Change from baseline in morning pre-dose trough FEV1 over 24 Weeks  
• FEV1 area under the curve from 0 to 4 hours (AUC0-4) over Weeks 12 to 24 (BGF MDI 
versus BFF MDI and BFF MDI versus Symbicort TBH) 
• Change from baseline in St. George’s Respiratory Questionnaire (SGRQ) total score over 
Weeks 12 to 24 
• Transition Dyspnea Index focal score over Weeks 12 to 24 
• Change from baseline in average daily rescue Ventolin HFA use over 24 weeks 
• Peak change from baseline in FEV1 within 4 hours post-dosing over Weeks 12 to 24 
• Time to clinically important deterioration (CID) 
• Time to onset of action on Day 1 
 
Secondary Endpoints (EU and Canada Approach): 
• Change from baseline in morning pre-dose trough FEV1 over 24 weeks (BGF MDI 
versus BFF MDI) 
• Transition dyspnea index (TDI) focal score over 24 weeks (EU only) 
• Change from baseline in St. George Respiratory Questionnaire (SGRQ) total score over 
24 weeks 
• Change from baseline in average daily rescue Ventolin HFA use over 24 weeks 
• Peak change from baseline in FEV1 within 4 hours post-dosing over 24 weeks 
• Rate of moderate or severe COPD exacerbations 
• Change from baseline in the Evaluating Respiratory Symptoms in COPD (E-RS: COPD) 
RS-Total score over 24 weeks  
• Time to CID 
• Time to onset of action on Day 1 
 
Secondary Endpoints (US Approach): 
• Change from baseline in morning pre-dose trough FEV1 over 24 weeks  

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• Percentage of subjects achieving an MCID of 4 units or more in SGRQ total score 
(SGRQ responders) at Week 24 
• Change from baseline in average daily rescue Ventolin HFA use over 24 weeks 
• Peak change from baseline in FEV1 within 4 hours post-dosing at Week 24 
• Rate of moderate or severe COPD exacerbations 
• Time to onset of action on Day 1 
 
Safety Endpoints: 
• Adverse events (AEs) 
• 12-lead electrocardiograms (ECG) 
• Clinical laboratory testing 
• Vital sign measurements 
12-Hour Pulmonary Function Test Sub-study Endpoints: 
The primary endpoint is:  
• FEV1 AUC0-12 at Week 24 
 
Additional assessments at Week 24: 
• FEV1 at each time point 
• Serial spirometry parameters including FEV1 AUC0-6, FEV1 AUC6-12, and time to peak 
FEV1 
• FVC, PEFR, and FEF25-75 will be evaluated using AUC0-12  
 
Pharmacokinetic Sub-study Endpoints: 
The endpoints at Week 24 are: 
• Steady state AUC0-12 
• Time to peak concentration (Tmax) 
• Maximum (or peak) serum concentration (Cmax) 
• Terminal elimination rate (λz) and terminal half-life (t1/2)  
• Minimum observed concentration (Cmin), time-average concentration (Cavg), 
%Fluctuation, %Swing 
HPA Axis Sub-study Endpoints: 
Primary Endpoint: 
• Ratio to Baseline of the 0- to 24-hour weighted mean serum cortisol concentration curve 
at Visit 10a (Week 24) 
Statistical Methods:  
Primary Efficacy Analysis:  
The change from baseline in pre-dose trough FEV1 will be analyzed using a linear model 
with repeated measures.  The model will include visit, treatment, treatment by visit, and ICS 

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use at Screening as categorical covariates and baseline trough FEV1, baseline eosinophil 
count, and percent reversibility to Ventolin HFA as continuous covariates.  An unstructured 
covariance matrix will be used to model correlation within a subject.  If this model fails to 
converge, a first order autoregressive structure will be used; for this model, subject will be 
considered a random effect.  Two-sided p-values and point estimates with  
2-sided 95% confidence intervals will be produced for each treatment difference.  All 
comparisons will be for superiority, except the comparison of BFF MDI to Symbicort TBH, 
which will be for non-inferiority and will use margins of 50 mL for trough FEV1 and 75 mL 
for FEV1 AUC0-4.  Analyses of change from baseline in FEV1 AUC0-4 will use a similar 
model to trough FEV1.  Sensitivity analyses will also be conducted to evaluate the robustness 
of the primary analyses to the nature of the missing data. 
Sample Size:  
It is estimated that a sample size of 1800 randomized subjects (600 per arm in the BGF MDI 
and GFF MDI groups and 300 per arm in the BFF MDI and Symbicort TBH groups) will 
provide the following power estimates, all assuming Type I error control at a 2-sided alpha 
level of 0.05 unless specified otherwise: 99% power to detect a difference of 75 mL between 
BGF MDI and BFF MDI in FEV1 AUC0-4 over 24 weeks; 96% power to detect a difference 
of 35 mL between BGF MDI and GFF MDI in morning pre-dose trough FEV1 over 24 weeks 
and approximately 92% power over Weeks 12 to 24; 97% power to detect a difference of 50 
mL between BGF MDI and BFF MDI in morning pre-dose trough FEV1 over Weeks 12 to 
24; and 96% power to demonstrate non-inferiority of BFF MDI to Symbicort TBH in 
morning pre-dose trough FEV1 over 24 weeks and approximately 92% power over Weeks 12 
to 24 based on a margin of 50 mL (1-sided, alpha=0.025) assuming no true difference.   
Assumptions regarding variability for the primary endpoint are based on Pearl’s experience 
with Phase IIb and III clinical studies.  A composite value standard deviation (SD) of 200 mL 
for the change from baseline at each visit has been assumed for trough FEV1 and 220 mL for 
FEV1 AUC0-4.  Dropout is anticipated to be approximately 12% by the end of the study.  
Based on the repeated-measures analysis, an effective SD for the change over 24 weeks of 
157 mL and 173 mL for trough FEV1 and FEV1 AUC0-4, respectively, is assumed.  For 
Weeks 12 to 24, an effective SD for trough FEV1 of 171 mL is assumed.  

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Data Monitoring and Clinical Endpoint Committees:  
Data Monitoring Committee:  
An external Data Monitoring Committee will be set up to provide systematic and unbiased 
assessment of safety for Study PT010006.  Members of the DMC will review data at 
predetermined intervals.  If significant safety issues arise in between scheduled meetings, ad 
hoc meetings will be scheduled to review the data.  Based on the safety implications of the 
data, the DMC may recommend modification or termination of the study. 
Clinical Endpoint Committee: 
An external clinical endpoint committee will be established for this study.  The committee 
will provide systematic and unbiased assessment of pre-defined, Investigator reported 
adverse events.  The committee will consist of experts who will provide a centralized review 
functioning independently of Pearl.  Three Clinical Endpoint Adjudication Charters will 
outline the clinical endpoints for adjudication.   
• Cardiovascular and Cerebrovascular Clinical Endpoint Adjudication Charter 
• Cause-Specific Mortality Clinical Endpoint Adjudication Charter 
• Pneumonia Clinical Endpoint Adjudication Charter 

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TABLE OF CONTENTS 
SYNOPSIS .................................................................................................................................6 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ..........................................22 
1 
INTRODUCTION ...........................................................................................................24 
1.1 
Study Rationale ......................................................................................................25 
2 
STUDY OBJECTIVES ....................................................................................................26 
2.1 
Primary Objective ..................................................................................................26 
2.2 
Secondary Objectives.............................................................................................26 
2.3 
Safety Objective .....................................................................................................26 
2.4 
Healthcare Resource Utilization Objective ............................................................26 
2.5 
Sub-study Objectives .............................................................................................26 
2.5.1 
12-Hour Pulmonary Function Test Sub-study Objective.............................26 
2.5.2 
Pharmacokinetic Sub-study Objective .........................................................26 
2.5.3 
HPA Axis Objective ....................................................................................27 
3 
STUDY ENDPOINTS .....................................................................................................28 
3.1 
Primary Efficacy Endpoints ...................................................................................28 
3.1.1 
Primary Endpoint (Japan/China Approach) .................................................28 
3.1.2 
Primary Endpoints (EU/Canada Approach).................................................28 
3.1.3 
Primary Endpoints (US Approach) ..............................................................28 
3.2 
Secondary Efficacy Endpoints ...............................................................................28 
3.2.1 
Secondary Endpoints (Japan/China Approach): ..........................................28 
3.2.2 
Secondary Endpoints (EU/Canada Approach): ...........................................29 
3.2.3 
Secondary Endpoints (US Approach) ..........................................................29 
3.3 
Other Efficacy Endpoints:......................................................................................29 
3.3.1 
Day 1 Assessments: .....................................................................................29 
3.3.2 
Assessments Over 24 Weeks (Unless Otherwise Stated) ............................30 
3.4 
Safety Endpoints ....................................................................................................30 
3.5 
Health Care Resource Utilization Endpoints: ........................................................31 
3.6 
Sub-Study Endpoints .............................................................................................32 
3.6.1 
12-Hour Pulmonary Function Test Sub-study Endpoints: ...........................32 
3.6.1.1 
Primary 12-Hour Pulmonary Function Test Endpoint .......................32 
3.6.1.2 
Other Pulmonary Function Test Assessments at Week 24 ................32 
3.6.2 
Pharmacokinetic Sub-study Endpoints: .......................................................32 
3.6.3 
HPA Axis Sub-study Endpoints: .................................................................32 
3.6.3.1 
Primary Endpoint ...............................................................................32 
4 
INVESTIGATIONAL PLAN ..........................................................................................33 
4.1 
Overall Study Design and Plan ..............................................................................33 

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4.2 
Rationale of Study Design .....................................................................................39 
4.3 
Rationale of Dose/Regimen and Duration of Treatment .......................................39 
5 
STUDY POPULATION SELECTION AND WITHDRAWAL CRITERIA .................41 
5.1 
Inclusion Criteria ...................................................................................................41 
5.2 
Exclusion Criteria ..................................................................................................42 
5.3 
Subject Identification .............................................................................................46 
5.4 
Prior, Concomitant, and Prohibited Medications ...................................................46 
5.4.1 
Allowed Medications to Treat a COPD Exacerbation .................................47 
5.4.2 
Pneumococcal and Annual Influenza Vaccination ......................................47 
5.4.3 
Prohibited COPD Medications and Required Washout Period Prior to 
Visit 2 ...........................................................................................................47 
5.4.4 
Other Prohibited Medications ......................................................................50 
5.5 
Other Restrictions, Illicit Drugs, or Drugs of Abuse .............................................52 
5.5.1 
Illicit Drugs ..................................................................................................52 
5.5.2 
Dietary Restrictions .....................................................................................52 
5.6 
Smoking Status ......................................................................................................52 
5.7 
Reasons for Treatment Discontinuation or Study Withdrawal ..............................52 
5.7.1 
Reasons for Treatment Discontinuation.......................................................52 
5.7.2 
Reasons for Study Withdrawal ....................................................................53 
6 
LABELING, PACKAGING, STORAGE, DISPENSING, AND RETURN OF 
CLINICAL SUPPLIES ....................................................................................................54 
6.1 
Subject Information ...............................................................................................54 
6.2 
Product Descriptions ..............................................................................................54 
6.3 
Primary Packaging and Labeling Information .......................................................56 
6.4 
Secondary Packaging and Labeling Information (Box) .........................................57 
6.5 
Emergency Unblinding of Treatment Assignment ................................................57 
6.6 
Storage Requirements ............................................................................................58 
6.7 
Instructions for Preparation of Treatments for Administration and Dispensing....58 
6.7.1 
BGF MDI, GFF MDI, BFF MDI .................................................................58 
6.7.2 
Symbicort® Turbuhaler ................................................................................59 
6.7.3 
Atrovent® HFA (Ipratropium Bromide) ......................................................59 
6.7.4 
Ventolin HFA® (Albuterol Sulfate) .............................................................59 
6.8 
Drug Accountability/Return of Clinical Supplies ..................................................59 
7 
STUDY PROCEDURES .................................................................................................61 
7.1 
Efficacy Assessments.............................................................................................61 
7.1.1 
Pulmonary Function Tests ...........................................................................61 
7.1.1.1 
Characterization of Reversibility .......................................................62 
7.1.1.2 
FEV1 Baseline Stability Criteria ........................................................63 

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7.1.2 
Subject Electronic Diary Data Collection ....................................................63 
7.1.2.1 
Rescue Medication Usage ..................................................................64 
7.1.2.2 
Medication Compliance .....................................................................64 
7.1.2.3 
Major/Minor Symptom Worsening Assessment and Alert System ...64 
7.1.3 
COPD Exacerbations ...................................................................................64 
7.1.3.1 
Severity of COPD Exacerbation ........................................................65 
7.1.3.2 
Duration of COPD Exacerbation .......................................................65 
7.1.3.3 
Approach for Capturing COPD Exacerbations ..................................66 
7.1.3.4 
Other Information ..............................................................................66 
7.1.3.5 
Investigator-Judged COPD Exacerbations ........................................66 
7.1.4 
Subject Questionnaires.................................................................................66 
7.1.4.1 
Chronic Obstructive Pulmonary Disease Assessment Test (CAT)....67 
7.1.4.2 
Baseline and Transition Dyspnea Indices ..........................................67 
7.1.4.3 
St.  George Respiratory Questionnaire ..............................................68 
7.1.4.4 
European Quality-of-Life-5 Dimension Questionnaire .....................68 
7.1.4.5 
Exacerbations of Chronic Pulmonary Disease Tool (EXACT) .........69 
7.2 
Safety Assessments ................................................................................................69 
7.2.1 
Medical/Surgical History and Physical Examination ..................................69 
7.2.2 
Vital Sign Measurements .............................................................................70 
7.2.3 
12-Lead Electrocardiogram .........................................................................70 
7.2.4 
Clinical Laboratory Tests .............................................................................72 
7.2.4.1 
Hematology ........................................................................................72 
7.2.4.2 
Clinical Chemistry .............................................................................72 
7.2.4.3 
Urinalysis ...........................................................................................73 
7.2.4.4 
Pregnancy Test ...................................................................................73 
7.3 
Pharmacokinetic Sub-Study Assessments .............................................................73 
7.3.1 
Procedure for Blood Sample Collection and Schedule ................................74 
7.3.1.1 
Procedure for Shipping Blood Samples .............................................74 
7.4 
HPA Axis Sub-Study Assessments ........................................................................74 
7.5 
Adverse Events ......................................................................................................74 
7.5.1 
Performing Adverse Event Assessments .....................................................74 
7.5.2 
Adverse Event Definitions ...........................................................................75 
7.5.3 
Pre-Randomization Adverse Events ............................................................75 
7.5.4 
Severity ........................................................................................................76 
7.5.5 
Relationship .................................................................................................76 
7.5.6 
Chronic Obstructive Pulmonary Disease Exacerbations .............................76 
7.5.7 
Adverse Events of Special Interest ..............................................................77 
7.5.7.1 
LABA and LAMA Effects .................................................................77 
7.5.7.2 
Local Steroid Effects..........................................................................77 
7.5.7.3 
Pneumonia..........................................................................................77 
7.5.7.4 
Paradoxical Bronchospasm ................................................................78 
7.5.8 
Major Adverse Cardiovascular Events ........................................................78 

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7.5.9 
Clinical Laboratory Adverse Events ............................................................78 
7.5.10 
Serious Adverse Events ...............................................................................79 
7.5.10.1 
Reporting of Serious Adverse Events ................................................79 
7.5.10.2 
Supplemental Investigations of SAEs ................................................80 
7.5.10.3 
Post-Study Follow-Up of Adverse Events .........................................80 
7.5.10.4 
Notification of Post-Study Serious Adverse Events ..........................80 
7.5.10.5 
Investigational Research Board/Independent Ethics Committee 
Notification of Serious Adverse Events .............................................80 
7.5.10.6 
Health Authority Safety Reports ........................................................81 
7.5.11 
Overdose ......................................................................................................81 
7.5.12 
Pregnancy .....................................................................................................81 
7.5.13 
Paternal Exposure ........................................................................................81 
7.5.14 
Hy’s Law ......................................................................................................82 
7.5.15 
Use of Steroids During the Study ................................................................82 
7.5.16 
Clinical Endpoint Committee ......................................................................82 
7.5.16.1 
Cardiovascular and Cerebrovascular Clinical Endpoint 
Adjudication Charter ..........................................................................82 
7.5.16.2 
Cause-Specific Mortality Clinical Endpoint Adjudication Charter ...83 
7.5.16.3 
Pneumonia Clinical Endpoint Adjudication Charter .........................83 
7.5.17 
Data Monitoring Committee ........................................................................83 
7.6 
Health Care Resource Utilization ..........................................................................83 
7.7 
Termination of the Study .......................................................................................83 
8 
STUDY ACTIVITIES .....................................................................................................84 
8.1 
Visit 1 (Screening Period) ......................................................................................91 
8.2 
Visit 2 (Screening Period) ......................................................................................92 
8.3 
Visit 3 (Screening Period) ......................................................................................93 
8.4 
Visit 4 (Randomization) .........................................................................................93 
8.5 
Visits 5 to 9 (Treatment Period) .............................................................................95 
8.6 
Visit 10a (Week 24; Final Visit) ............................................................................96 
8.7 
Procedures for Treatment Discontinuation and Study Withdrawal Subjects.........97 
8.8 
Unscheduled Visit and Treatment Discontinuation/Withdrawal Visit ..................98 
8.9 
Telephone Follow-up .............................................................................................99 
8.10 
24-Week Post-Randomization Vital Status Confirmation .....................................99 
8.11 
Completion of Study ..............................................................................................99 
9 
PLANNED STATISTICAL METHODS ......................................................................101 
9.1 
Introduction ..........................................................................................................101 
9.2 
Protocol Variables ................................................................................................101 
9.2.1 
Efficacy Endpoints .....................................................................................101 
9.2.2 
Safety Endpoints ........................................................................................102 
9.3 
Study Populations ................................................................................................102 

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9.4 
Efficacy Analyses ................................................................................................103 
9.4.1 
Estimands ...................................................................................................103 
9.4.2 
Primary Efficacy Analyses ........................................................................104 
9.4.2.1 
Change from Baseline in Morning Pre-dose Trough FEV1 .............104 
9.4.2.2 
FEV1 AUC0-4 ....................................................................................105 
9.4.3 
Analysis of Secondary Endpoints ..............................................................105 
9.4.3.1 
Transition Dyspnea Index ................................................................105 
9.4.3.2 
Peak FEV1 ........................................................................................106 
9.4.3.3 
St. George Respiratory Questionnaire .............................................106 
9.4.3.4 
Rescue Ventolin HFA Use ...............................................................107 
9.4.3.5 
RS-Total Score .................................................................................107 
9.4.3.6 
COPD Exacerbations .......................................................................107 
9.4.3.7 
Time to Clinically Important Deterioration .....................................109 
9.4.3.8 
Time to Onset of Action ..................................................................109 
9.4.4 
Analysis of Other Endpoints ......................................................................110 
9.4.4.1 
Other Spirometry Endpoints ............................................................110 
9.4.4.2 
12-Hour Pulmonary Function Tests .................................................110 
9.4.4.3 
Percentage of Days with No Rescue Ventolin HFA Use over the 
Treatment Period ..............................................................................110 
9.4.4.4 
Time to Treatment Discontinuation .................................................111 
9.4.4.5 
Exacerbations of Chronic Pulmonary Disease Tool ........................111 
9.4.4.6 
European Quality-of-Life-5 Dimension-5 Level Questionnaire ......111 
9.4.5 
Control of Type I Error ..............................................................................111 
9.4.5.1 
Japan/China Approach: ....................................................................112 
9.4.5.2 
EU/Canada Approach ......................................................................112 
9.4.5.3 
US Approach ....................................................................................113 
9.5 
Subgroup Analyses ..............................................................................................114 
9.6 
Safety Analyses ....................................................................................................114 
9.6.1 
Adverse Events ..........................................................................................114 
9.6.2 
Cardio- and Cerebrovascular Events Determined by Clinical Endpoint 
Committee ..................................................................................................114 
9.6.3 
Pneumonia Events Determined by Clinical Endpoint Committee .............115 
9.6.4 
Clinical Laboratory Measurements ............................................................115 
9.6.5 
Vital Signs ..................................................................................................115 
9.6.6 
Electrocardiograms ....................................................................................116 
9.6.7 
Exposure ....................................................................................................116 
9.7 
Pharmacokinetic Analyses ...................................................................................116 
9.8 
HPA Axis .............................................................................................................116 
9.9 
Health Care Resource Utilization ........................................................................116 
9.10 
Randomization .....................................................................................................117 
9.11 
Experimental Design ............................................................................................117 

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9.12 
Sample Size ..........................................................................................................117 
9.13 
Data Validation and Transformation ...................................................................117 
9.14 
Analysis Plan .......................................................................................................118 
9.15 
Handling of Missing Data ....................................................................................118 
9.16 
Statistical Software ..............................................................................................118 
10 ADMINISTRATIVE CONSIDERATIONS ..................................................................119 
10.1 
Regulatory Authority Approval ...........................................................................119 
10.2 
Ethical Conduct of the Study and Institutional Review Board or Independent 
Ethics Committee Approval .................................................................................119 
10.3 
Subject Information and Consent.........................................................................119 
10.4 
Laboratory Accreditation .....................................................................................120 
10.5 
Confidentiality .....................................................................................................120 
10.5.1 
Confidentiality of Data ..............................................................................120 
10.5.2 
Confidentiality of Subject/Patient Records ................................................120 
10.6 
Quality Control and Assurance ............................................................................120 
10.7 
Data Management ................................................................................................120 
10.8 
Study Monitoring .................................................................................................121 
10.9 
Retention of Data .................................................................................................121 
10.10 Financial Disclosure.............................................................................................122 
10.11 Investigator’s Final Report ..................................................................................122 
10.12 Publication Policy ................................................................................................122 
11 REFERENCE LIST .......................................................................................................124 
12 APPENDICES ...............................................................................................................127 
 

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LIST OF IN-TEXT TABLES 
Table 1.  
Prohibited COPD Medications and Required Washout Periods, Prior to 
Visit 2 
....................................................................................................................48 
Table 2.  
Other Respiratory/Nasal Medications and Required Washout Periods 
Prior to Visit 2 ..............................................................................................................50 
Table 3.  
Non COPD Medications Allowed Under Certain Conditions ...................50 
Table 4.  
Prohibited Medications ..............................................................................51 
Table 5.  
Product Descriptions ..................................................................................55 
Table 6.  
Description of Boxes..................................................................................57 
Table 7.  
Clinical Laboratory Tests ...........................................................................72 
Table 8.  
Schedule of Events .....................................................................................85 
Table 9.  
Timed Assessments at Each Treatment Visit (Visit 4 to Visit 10a) ..........88 
Table 10.  
Timed Assessments at Visit 10a (Week 24) for 12-hour PFT, PK-
Profile and HPA Axis Sub-studies ...............................................................................90 
Table A1-1.  Recommended Minimal Scale Factors for Time, Volume and Flow on 
Graphical Output ........................................................................................................153 
Table A1-2.  Summary of Equipment Quality Control .................................................154 
Table A1-3.  Range and Accuracy Recommendations Specified for Forced 
Expiratory Maneuvers ................................................................................................156 
 
LIST OF IN-TEXT FIGURES 
Figure 1.   
 Study Design .............................................................................................38 
Figure A2-1.   Example of a Usable Spirogram ..............................................................158 
LIST OF APPENDICES 
Appendix 1 
Dose Indicator Reading............................................................................128 
Appendix 2 
Subject Instructions for Use of  BGF MDI, GFF MDI, and BFF MDI ...129 
Appendix 3 
Instructions for Use of Symbicort® Turbuhaler® Inhalation Powder 
Device 
..................................................................................................................138 
Appendix 4 
Instructions for Use of Atrovent® HFA Inhalation Aerosol Device ........140 
Appendix 5 
Instructions for Use of Ventolin HFA Inhalation Aerosol Device ..........144 
Appendix 6 
Spirometry Performance Recommendations ...........................................152 
Appendix 7 
Spirometry Assessment Criteria ..............................................................158 
Appendix 8 
Chronic Obstructive Pulmonary Disease Assessment Test .....................160 
Appendix 9 
Baseline Dyspnea Index/Transition Dyspnea Index Questionnaire.........161 
Appendix 10 St.  George Respiratory Questionnaire ....................................................167 
Appendix 11 European Quality of Life 5 Dimensions-5 Level Questionnaire (EQ-
5D-5L) 
..................................................................................................................173 
Appendix 12 EXACT ....................................................................................................176 
Appendix 13 Rules for Evaluation of Abnormal Liver Laboratory Values ..................180 
Appendix 14 Sponsor Signatures...................................................................................183 
Appendix 15 Investigator’s Signature ...........................................................................184 
 

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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
AE 
adverse event 
ALT 
alanine aminotransferase (SGPT) 
ANOVA 
analysis of variance 
AP 
alkaline phosphatase 
AST 
aspartate aminotransferase (SGOT) 
bid 
twice daily 
BMI 
body mass index 
BUN 
blood urea nitrogen 
CEC 
Clinical Endpoint Committee 
CFR 
Code of Federal Regulations 
CI 
confidence interval 
CMH 
Cochran-Mantel-Haenszel 
COPD 
Chronic Obstructive Pulmonary Disease 
CRF 
case report form 
CV 
coefficient of variation 
E-RS-COPD 
Evaluating Respiratory Symptoms in COPD 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GGT 
gamma glutamyl transferase 
Hct 
hematocrit 
Hgb 
hemoglobin 
HIPAA 
Health Information Portability and Accountability Act 
ICH 
International Conference on Harmonisation  
IEC 
Independent Ethics Committee 
IND 
Investigational New Drug  
IRB 
Institutional Review Board 
ITT 
intent-to-treat 
LDH 
lactic dehydrogenase 

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MedDRA 
Medical Dictionary for Regulatory Activities 
NDA 
New Drug Application 
qd 
once daily 
qid 
four times daily 
RBC 
red blood cell (count) 
SAE 
serious adverse event 
SD 
standard deviation 
SE 
standard error  
SGOT 
serum glutamic oxaloacetic transaminase (AST) 
SGPT 
serum glutamic pyruvic transaminase (ALT) 
tid 
three times daily 
US 
United States 
WBC 
white blood cell (count) 

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1 
INTRODUCTION 
Chronic obstructive pulmonary disease (COPD) is a common preventable and treatable 
disease characterized by persistent airflow limitation that is usually progressive and 
associated with an enhanced chronic inflammatory response in the airways and the lung to 
noxious particles or gases.  Exacerbations and co-morbidities contribute to the overall 
severity in individual patients.  Chronic obstructive pulmonary disease is a leading cause of 
morbidity and mortality worldwide and results in significant economic and social burden that 
is both substantial and increasing.  Pharmacologic therapy in COPD is used to reduce 
symptoms, reduce the frequency and severity of exacerbations, and improve health status and 
exercise tolerance as described in the Global Initiative for Chronic Obstructive Lung Disease 
(GOLD) and Japanese Respiratory Society (JRS) guidelines (GOLD 2014, JRS 2013) 
Bronchodilator medications are central to the symptomatic management of COPD.  The 
principal bronchodilator treatments are β2-agonists, anticholinergics, and methylxanthines 
used as monotherapy or in combination.  Treatment with long acting bronchodilators is more 
convenient and more effective at producing maintained symptom relief than treatment with 
short acting bronchodilators. 
Regular treatment with inhaled corticosteroids (ICS) improves symptoms, lung function, and 
quality of life and reduces the frequency of exacerbations in subjects with COPD with a 
forced expiratory volume in 1 second (FEV1) value of <60% of predicted.  Withdrawal from 
treatment of ICS may lead to exacerbations in some patients.  When combined with a long 
acting β2 agonist (LABA), an ICS is more effective than the individual components in 
improving lung function, quality of life, and reducing exacerbations in subjects with 
moderate to very severe COPD (GOLD, 2014). 
Pearl Therapeutics, Inc.  (hereinafter referred to as Pearl) is developing the fixed-dose ICS/ 
long-acting anti-muscarinic agent (LAMA)/LABA triple combination product, Budesonide, 
Glycopyrronium, and Formoterol Fumarate Inhalation Aerosol (PT010), hereafter referred to 
as budesonide, glycopyrronium, and formoterol fumarate metered dose inhaler (BGF MDI), 
for the treatment of patients with COPD.  Budesonide and Formoterol Fumarate Inhalation 
Aerosol (PT009, hereinafter referred to as budesonide and formoterol fumarate (BFF) MDI is 
also being developed as a twice daily (BID) fixed dose ICS/LABA treatment for patients 
with COPD.  Glycopyrronium and Formoterol Fumarate Inhalation Aerosol (PT003) 
hereinafter referred to as glycopyrronium and formoterol fumarate (GFF) MDI is being 
developed as a BID maintenance bronchodilator treatment in patients with COPD. 
Budesonide is a well-established corticosteroid approved worldwide in monotherapy and 
combination therapies for treatment of asthma and allergic rhinitis.  It is available in both 
intranasal and orally inhaled formulations.  Inhaled budesonide in combination with 
formoterol fumarate dihydrate, i.e., Symbicort is approved for use in patients with COPD.   
Glycopyrronium is a LAMA which exerts its bronchodilatory effect via muscarinic receptors 
located on smooth muscle cells within the trachea and bronchi.  Glycopyrronium is approved 
in many countries in multiple formulations for different indications, including for the 

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treatment of COPD.  In addition, tiotropium bromide (Spiriva®) is approved worldwide and 
has been shown to reduce the rate of COPD exacerbations and to improve the effectiveness 
of pulmonary rehabilitation (Niewoehner, 2005; Casaburi, 2005). 
Formoterol fumarate is a selective LABA approved worldwide for use in asthma and COPD.  
In addition, formoterol fumarate is also approved worldwide in combination with budesonide 
(e.g., Symbicort® MDI, Symbicort® Turbuhaler® (TBH [AstraZeneca, LP]) for use in patients 
with asthma and COPD.  When inhaled, formoterol fumarate acts locally in the lung as a 
bronchodilator.  Formoterol fumarate stimulates β2-adrenoreceptors in the airways, inducing 
airway smooth muscle relaxation and reducing or preventing bronchoconstriction. 
In clinical studies, Symbicort MDI 320/9 µg administered BID demonstrated significant 
improvements in lung function compared with Budesonide MDI 320 µg BID or formoterol 
fumarate (Oxis® Turbuhaler) 9 µg BID in patients with COPD.  In the clinical studies, 
improvements in secondary endpoints of morning and evening peak expiratory flow and 
reduction in rescue medication use were supportive of the efficacy of Symbicort MDI 320/9 
µg (Symbicort Inhalation Aerosol Prescribing Information, 2012; Rennard, 2009; Tashkin, 
2008). 
This study will assess the efficacy of the triple combination therapy (BGF MDI) to its 
relevant LABA/LAMA and ICS/LABA dual combinations (GFF MDI and BFF MDI) as well 
as to an approved ICS/LABA product (Symbicort TBH).  The study will also evaluate the 
safety of BGF MDI, BFF MDI, GFF MDI, and Symbicort TBH for subjects with moderate to 
very severe COPD. 
1.1 
Study Rationale 
This Phase III study is designed to assess the long-term efficacy and safety of BGF MDI 
compared with GFF MDI, BFF MDI, and Symbicort TBH on lung function, subject-reported 
symptom outcomes, and health status over 24 weeks.  While studies of shorter duration (e.g., 
8 to 12 weeks) may be sufficient for the assessment of bronchodilators, Pearl has chosen to 
characterize efficacy and safety of the aforementioned investigational products for at least 24 
weeks to fully characterize the ICS benefit compared with GFF MDI and to fully characterize 
the LAMA benefit compared with BFF MDI to allow for global registration of BGF MDI.   
Consistent with feedback from global regulatory agencies, this study will evaluate a patient 
population that remains symptomatic despite treatment with 2 or more inhaled maintenance 
medications.  Due to the duration of the Study, a randomized, double-blind (other than the 
open-label active control), parallel-group design was adopted in order to minimize bias in 
treatment allocation and to allow unbiased comparisons of treatment groups. 
BGF MDI, GFF MDI, and BFF MDI will be randomly assigned in a double-blind fashion, 
while Symbicort TBH is included as an open-label treatment arm to allow for safety and 
efficacy comparisons relative to an approved ICS/LABA dual combination. 

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2 
STUDY OBJECTIVES 
2.1 
Primary Objective 
• To assess the effects of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH on lung 
function. 
 
2.2 
Secondary Objectives 
• To assess the effects of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH on 
dyspnea.   
• To assess the effects of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH on quality 
of life.   
• To assess the effects of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH on 
symptoms of COPD. 
• To assess the effects of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH on COPD 
exacerbations 
• To determine the time to onset of action of BGF MDI, GFF MDI, BFF MDI, and 
Symbicort TBH. 
 
2.3 
Safety Objective 
• 
To assess the safety of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH. 
 
2.4 
Healthcare Resource Utilization Objective 
• To assess overall and COPD-specific Healthcare Resource Utilization (HCRU) of BGF 
MDI, GFF MDI, BFF MDI, and Symbicort TBH 
 
2.5 
Sub-study Objectives 
2.5.1 
12-Hour Pulmonary Function Test Sub-study Objective 
• To assess the effect of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH on 
pulmonary function test (PFT) parameters over 12 hours 
 
2.5.2 
Pharmacokinetic Sub-study Objective 
• To characterize the steady state pharmacokinetics of budesonide, glycopyrronium, and 
formoterol based on pharmacokinetic (PK) assessments. 
 

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2.5.3 
HPA Axis Objective 
• To assess the effect of BGF MDI, GFF MDI, BFF MDI, and Symbicort TBH on 
hypothalamic-pituitary-adrenal (HPA) axis function. 
 

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3 
STUDY ENDPOINTS 
All efficacy assessments are relative to pre-dose baseline obtained at or prior to Visit 4.  The 
primary endpoints, treatment comparisons of interest, and analysis timeframes may differ by 
country or region due to local regulatory agency requirements.  The 3 different registration 
approaches will be called: (1) Japan/China, (2) Europe (EU)/Canada, and (3) United States 
(US).  Countries not specifically mentioned will be decided by regulatory requirements and 
included in one of the three defined registration approaches.  The delineation of multiplicity 
controls for the primary and secondary measures will be separated by approach. 
3.1 
Primary Efficacy Endpoints 
3.1.1 
Primary Endpoint (Japan/China Approach) 
• Change from baseline in morning pre-dose trough FEV1 over Weeks 12 to 24 (BGF MDI 
versus BFF MDI, BGF MDI versus GFF MDI, and BFF MDI versus Symbicort TBH) 
 
3.1.2 
Primary Endpoints (EU/Canada Approach) 
• FEV1 AUC0-4 over 24 weeks (BGF MDI versus BFF MDI; BGF MDI versus Symbicort 
TBH) 
• Change from baseline in morning pre-dose trough FEV1 over 24 weeks (BGF MDI 
versus GFF MDI and BFF MDI versus Symbicort TBH[non-inferiority]) 
 
3.1.3 
Primary Endpoints (US Approach) 
• FEV1 AUC0-4 at Week 24 (BFG MDI versus BFF MDI) 
• Change from baseline in morning pre-dose trough FEV1 at Week 24 (BGF MDI 
versus GFF MDI) 
 
3.2 
Secondary Efficacy Endpoints 
Endpoints that are not considered primary for an approach or region have been included 
under secondary endpoints.  In addition, perspectives vary about time points to be included 
from some end points.  Therefore, secondary endpoints differ between approaches. 
3.2.1 
Secondary Endpoints (Japan/China Approach): 
• Change from baseline in morning pre-dose trough FEV1 over 24 weeks  
• FEV1 area under the curve from 0 to 4 hours (AUC0-4) over Weeks 12 to 24 (BGF MDI 
versus BFF MDI and BFF MDI versus Symbicort TBH) 
• Change from baseline in St. George’s Respiratory Questionnaire (SGRQ) total score over 
Weeks 12 to 24 
• Transition Dyspnea Index focal score over Weeks 12 to 24 

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• Change from baseline in average daily rescue Ventolin HFA use over 24 weeks 
• Peak change from baseline in FEV1 within 4 hours post-dosing over Weeks 12 to 24 
• Time to clinically important deterioration (CID) 
• Time to onset of action on Day 1 
 
3.2.2 
Secondary Endpoints (EU/Canada Approach): 
• Change from baseline in morning pre-dose trough FEV1 over 24 weeks (BGF MDI 
versus BFF MDI) 
• Transition dyspnea index (TDI) focal score over 24 weeks (EU only) 
• Change from baseline in SGRQ total score over 24 weeks 
• Change from baseline in average daily rescue Ventolin HFA use over 24 weeks 
• Peak change from baseline in FEV1 within 4 hours post-dosing over 24 weeks 
• Rate of moderate or severe COPD exacerbations 
• Change from baseline in the Evaluating Respiratory Symptoms in COPD (E-RS: COPD) 
RS-Total score over 24 weeks  
• Time to CID 
• Time to onset of action on Day 1 
 
3.2.3 
Secondary Endpoints (US Approach) 
• Change from baseline in morning pre-dose trough FEV1 over 24 weeks  
• Percentage of subjects achieving an MCID of 4 units or more in SGRQ total score 
(SGRQ responders) at Week 24 
• Change from baseline in average daily rescue Ventolin HFA use over 24 weeks 
• Peak change from baseline in FEV1 within 4 hours post-dosing at Week 24 
• Rate of moderate or severe COPD exacerbations 
• Time to onset of action on Day 1 
 
3.3 
Other Efficacy Endpoints:  
Endpoints that are not considered secondary for an approach have been included under other 
endpoints. 
3.3.1 
Day 1 Assessments:  
• Change from baseline at each post-dose time point in FEV1, forced vital capacity (FVC), 
peak expiratory flow rate (PEFR), and forced expiratory flow between 25% to 75% 
(FEF25-75) 
• Proportion of subjects achieving an improvement from baseline in FEV1 using different 
thresholds (e.g., ≥10%, ≥12%, , ≥100 mL, ≥200 mL; and ≥12% and ≥200 mL) 

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3.3.2 
Assessments Over 24 Weeks (Unless Otherwise Stated) 
• Rate of moderate or severe COPD exacerbations 
• Rate of COPD exacerbations of any severity 
• Rate of severe COPD exacerbations 
• Time to first moderate or severe exacerbation 
• Time to first COPD exacerbation of any severity 
• Time to first severe COPD exacerbation  
• Time to CID  
• Time to sustained CID 
• Time to treatment failure (discontinuation for any cause, moderate or severe 
exacerbation, or death). 
• Additional spirometry assessments over 24 weeks, over Weeks 12 to 24, and at each post 
randomization visit: 
- 
Change from baseline in morning pre-dose trough for FEV1, FVC, PEFR, and 
FEF25-75 
- 
Peak change from baseline within 4 hours in FEV1, FVC, PEFR, and FEF25-75 
- 
FEV1 AUC0-4, FVC AUC0-4, PEFR AUC0-4, and FEF25-75 AUC0-4 
• Change from baseline in: the EXACT total score, the E-RS:COPD Total Score, as well as 
3 subscale scores (RS-Breathlessness, RS-Cough and Sputum, and RS-Chest Symptoms) 
over each 4-week interval of the 24-week Treatment Period  
• TDI focal score at each post-randomization visit 
• Individual components of the TDI: functional impairment, magnitude of task, and 
magnitude of effort over 24 weeks, over Weeks 12 to 24, and at each post-randomization 
visit 
• Percentage of subjects achieving a minimal clinically important difference (MCID) 
threshold of 1 unit or more on average in TDI focal score over 24 weeks and over Weeks 
12 to 24  
• Changes from baseline at each post-randomization visit for SGRQ total score 
• Change in individual domain scores of SGRQ: Symptoms, Activity, and Impacts over 24 
weeks, over Weeks 12 to 24, and at each post-randomization visit  
• Percentage of subjects achieving an MCID of 4 units or more in SGRQ total score, at 
Week 24, over 24 weeks, and over Weeks 12 to 24 
• Quality-of-Life Endpoints: European Quality-of-Life-5 Dimensions (EQ-5D-5L) 
Questionnaire scored at each post-randomization visit 
 
3.4 
Safety Endpoints 
• Adverse events (AEs) 
• 12-lead electrocardiograms (ECG) 

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• Clinical laboratory testing 
• Vital sign measurements 
 
3.5 
Health Care Resource Utilization Endpoints:  
• Number of days missed from work due to COPD 
• Number of days that primary caregivers of subjects missed from work as a result of the 
subject’s COPD  
• Percentage of subjects with telephone calls to health care providers 
- 
call to any health-care provided (physician or other) 
- 
calls to physician 
- 
calls to other healthcare provider 
• Mean number of telephone calls to health care providers 
- 
call to any health-care provided (physician or other) 
- 
calls to physician 
- 
calls to other healthcare provider 
• Percentage of subjects with visits to health care providers 
- 
visits to any health-care provider (general practitioner [GP], specialist, or other) 
- 
visits to general practitioner (GP) 
- 
visits to specialist 
- 
visits to other health-care provider 
• Mean number of visits to health care providers 
- 
visits to any health-care provider (GP, specialist, or other) 
- 
visits to GP 
- 
visits to specialist 
- 
visits to other health-care provider 
• Percentage of subjects with Emergency Room (ER) visits 
• Mean number of visits to ERs 
• Percentage of subjects hospitalized 
• Mean number of subject hospitalizations  
• Mean number of days in the hospital 
• Mean number of hospitalizations in which subject spent some time in the ICU or CCU 
• Percentage of subjects hospitalized with some time spent in the ICU or CCU 
• Mean number of days in the hospital with some time spent in the ICU or CCU 
• Mean number of hospitalizations in which subject spent no time in the ICU or CCU 
• Percentage of subjects hospitalized with no time in the ICU or CCU 
• Mean number of days in the hospital with no time spent in the ICU or CCU 
• Mean number of days in Intensive Care Units (ICU) 
• Percentage of subjects in the ICU 

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• Mean number of days in Coronary Care Units (CCU) 
• Percentage of subjects in the CCU 
• Percentage of subjects who required ambulance transport 
• Mean number of times ambulance transport was required 
 
3.6 
Sub-Study Endpoints  
3.6.1 
12-Hour Pulmonary Function Test Sub-study Endpoints: 
• Pulmonary function tests will be performed at Visit 10a (Week 24). 
 
3.6.1.1 
Primary 12-Hour Pulmonary Function Test Endpoint 
• FEV1 AUC0-12 at Week 24 
 
3.6.1.2 
Other Pulmonary Function Test Assessments at Week 24 
• FEV1 at each time point 
• Serial spirometry parameters including FEV1 AUC0-6, FEV1 AUC6-12, and time to peak 
FEV1 
• FVC, PEFR, and FEF25-75 will be evaluated using AUC0-12  
 
3.6.2 
Pharmacokinetic Sub-study Endpoints: 
Pharmacokinetic assessments will be performed at Visit 10a (Week 24).   
Pharmacokinetic Endpoints 
• AUC0-12 
• Time to peak concentration (Tmax) 
• Maximum (or peak) plasma concentration (Cmax) 
• Terminal elimination rate (λz) and terminal half-life (t1/2)  
• Minimum observed concentration (Cmin), time-average concentration during a dosing 
interval (Cavg), %Fluctuation, %Swing 
 
3.6.3 
HPA Axis Sub-study Endpoints: 
3.6.3.1 
Primary Endpoint 
• Ratio to Baseline of the 0- to 24-hour weighted mean serum cortisol (SC) concentration 
curve at Visit 10a (Week 24) 
 

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4 
INVESTIGATIONAL PLAN 
4.1 
Overall Study Design and Plan 
This is a multi-center, randomized, double-blind, parallel-group, chronic-dosing (24 weeks), 
active-controlled study to assess the efficacy and safety of BGF MDI, GFF MDI, BFF MDI, 
compared with Symbicort TBH as an active control in subjects with moderate to very severe 
COPD. 
This study will assess the benefit of BGF MDI compared with BFF MDI, GFF MDI, and 
Symbicort TBH and will also compare BFF MDI to Symbicort TBH with respect to lung 
function in subjects with moderate to very severe COPD that remain symptomatic (COPD 
Assessment Test [CAT] ≥10) on 2 or more inhaled maintenance therapies.  A history of 
exacerbations in the prior year will be obtained to characterize the population, but the entry 
criteria do not require an exacerbation in the prior year.  COPD severity as defined as post-
bronchodilator FEV1 must be <80% predicted normal value, calculated using Third National 
Health and Nutrition Examination Survey (NHANES III) reference equations or local 
reference equations provided by the Sponsor, and the measured FEV1 must also be ≥25% of 
predicted normal value. 
This study will be conducted at approximately 160 sites, contributing approximately 10 to 20 
subjects per site.  Across these sites, approximately 1800 subjects with moderate to very 
severe COPD will be randomized into the study to provide approximately 1600 subjects to 
complete the study. 
Subjects will be randomized in a 2:2:1:1 scheme.  Approximately 600 subjects each will be 
randomized to the BGF MDI and GFF MDI treatment groups, and 300 subjects each will be 
randomized to the BFF MDI and Symbicort TBH treatment groups.  Randomization will be 
stratified by reversibility to Ventolin HFA, country, and disease severity. 
The Screening Period will be comprised of 3 study visits. 
At Visit 1 (Screening), all subjects are to sign an informed consent form (ICF) prior to the 
conduct of any screening assessments.  Subject participation in the sub-studies also will be 
determined at Screening, prior to any study procedures.  At the Screening Visit, the 
Investigator will obtain a medical history including specific cardiovascular history, COPD 
exacerbations within the last year, clinical laboratory tests, physical examination, and any 
required documentation in order to determine eligibility for participation (i.e., inclusion 
/exclusion criteria).  Subjects must meet spirometry criteria for COPD as detailed in the 
inclusion/exclusion criteria. 
During the screening period subjects that are receiving an ICS/LABA will discontinue the 
ICS/LABA, but will continue the ICS component for the remainder of the screening period.   
Similarly, subjects treated with an ICS as part of their inhaled maintenance therapy will also 
be permitted to continue their ICS for the remainder of the screening period.  All subjects 
will receive sponsor-provided open-label Atrovent® hydrofluoroalkane (HFA; ipratropium 

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bromide inhalation aerosol) administered QID for COPD maintenance.  All subjects will 
receive sponsor-provided Ventolin® HFA (albuterol sulfate inhalation aerosol) for rescue use 
throughout the study.  NOTE: ICS and Atrovent HFA administered during screening will be 
discontinued at Visit 4 prior to randomization. 
Subjects will be issued and trained on the use of the electronic diary (eDiary) at Visit 1 
(Screening) and will be instructed to collect practice data during the Screening Period 
(between Visit 1 and Visit 4).  Subject eDiary compliance will be reviewed at Visits 2 and 3, 
and the subject will be retrained if necessary. 
Subjects who meet all entry criteria (Section 5.1 and Section 5.2) will discontinue any 
prohibited COPD medications for the duration of the study, with a minimum washout period 
observed between Visits 1 and 2 (see Table 1) followed by an adjustment of medications to 
protocol-allowable COPD therapy (see Section 5.4.1) 
Reversibility of FEV1 to Ventolin HFA, a short acting β2 agonist (SABA) and to Atrovent 
HFA, a short-acting muscarinic antagonist (SAMA) will be tested at Visit 2 and 3, 
respectively.  Reversibility testing is described in Section 7.1.1.1.  The spirometry data 
obtained at Visit 2 will be used as an inclusion criterion (Section 5.1).  Re-screening is not 
allowed for subjects who do not meet the spirometry criteria at Visit 1. 
Subjects participating at study centers in Japan will be invited to participate in a 28-week 
safety extension study, Study PT010007.  Any additional assessments required for this 
extension study will be obtained as stipulated in the Study PT010007 protocol. 
This study includes the following 3 sub-studies: 12-hour pulmonary function test (PFT), 
pharmacokinetic (PK), and HPA axis. 
12 Hour Pulmonary Function Test Sub-study (US sub-study only): Serial PFTs will be 
conducted over 12 hours in a subset of approximately 600 randomized subjects (200 subjects 
from each of BGF MDI and GFF MDI treatment groups, and 100 subjects from each of the 
BFF MDI and Symbicort TBH treatment groups) at Visit 10a (Week 24).  On the test day, 
additional serial spirometry will be obtained at 6, 8, 10, 11.5 and 12 hours post-dose (refer to 
Section 7.1.1 and Table 10 for details). 
The PFT sub-study will be conducted at specific sites in the US that have agreed to 
participate.  Once the target number of subjects for recruitment has been met, no further 
enrollment will be allowed in the PFT sub-study. 
Pharmacokinetic Sub-study: Pharmacokinetic assessments will be performed in a subset of 
subjects who participate in the PFT sub-study.  Approximately 240 randomized subjects (80 
subjects from each of the BGF MDI and GFF MDI treatment groups, and 40 subjects from 
each of the BFF MDI and Symbicort TBH treatment groups) will be assessed at Visit 10a 
(Week 24).  Refer to Section 7.3 for PK sample collection requirements and Table 10 for 
timing of PK assessments. 

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Pharmacokinetic assessments will be performed on a subset of PFT sub-study subjects at 
specific sites in the US that have agreed to participate.  Once the target number of subjects 
for recruitment has been met, no further enrollment will be allowed in the PK sub-study. 
Pharmacokinetic assessments will be performed on a subset of PFT sub-study subjects at 
specific sites that have agreed to participate.  Once the target number of subjects for 
recruitment has been met, no further enrollment will be allowed in the PK sub-study. 
HPA Axis Sub-study: Adrenocorticosteroid activity will be assessed in a subset of subjects 
in the PK sub-study.  Serum cortisol (SC) will be measured in approximately 108 
randomized subjects (36 subjects from each of the BGF MDI and GFF MDI treatment 
groups, and 18 subjects from each of the BFF MDI and Symbicort TBH treatment groups) 
over 24 hours, between Visits 3 and 4 prior to dosing at Randomization and Visit 10a (Week 
24).  Refer to Section 7.4 for HPA Axis sample collection requirements and Table 10 for 
timing of HPA Axis assessments. 
Adrenocorticosteroid activity assessments will be conducted on a subset of PK sub-study 
subjects at specific sites in the US that have agreed to participate in this HPA Axis sub-study.  
Once the target number of subjects for recruitment has been met, no further enrollment will 
be allowed in the HPA Axis sub-study. 
At Visit 4 (Day 1, Randomization), subject eDiary compliance will be reviewed, and subjects 
who are unable to meet the compliance requirement (>70% subject completion of diary 
assessments) in the last 7 days preceding Visit 4, or who are unable to meet the FEV1 
baseline stability criteria, will be considered screen failures (Refer to Section 7.1.2).  
Subjects will be evaluated for FEV1 baseline stability criteria (baseline FEV1 at Visit 4 must 
be within ±20% or 200 mL of mean of the pre-dose FEV1 values obtained at the 2 preceding 
visits [see Section 7.1.1.2]).  Those subjects who remain eligible for participation in the study 
will discontinue their ICS and Atrovent HFA administered during screening and will be 
randomized into 1 of the 4 treatment arms.  Randomization will be centralized through the 
use of an Interactive Web Response System (IWRS). 
Subjects will inhale 2 puffs from their MDI in the morning between 6:00 and 10:00 AM 
(breakfast time) and in the evening between 6:00 and 10:00 PM (dinner time).  Symbicort 
TBH also will be administered as 2 inhalations twice daily. 
After the Randomization Visit (Visit 4), subjects will be examined at Visit 5 (Week 4), Visit 
6 (Week 8), Visit 7 (Week 12), Visit 8 (Week 16), Visit 9 (Week 20) and Visit 10a (Week 
24).  In total, each completed subject will attend 10 scheduled visits in this study for a 
maximum of 30 weeks.  For the assessments scheduled at each of these visits, refer to the 
Schedule of Events (Table 8). 
Mean pre-dose morning PFTs will be assessed at every visit.  Post-dose PFTs will also be 
assessed at all visits (refer to Section 7.1.1 for details). 
Throughout the course of the study the subjects will be required to complete the following 
questionnaires; Baseline Dyspnea Index/Transition Dyspnea Index (BDI/TDI) , St.  George’s 

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Respiratory Questionnaire (SGRQ), EuroQol 5 Dimensions Questionnaire (EQ-5D-5L), 
Chronic Obstructive Pulmonary Disease Assessment Test (CAT) and Exacerbations of 
Chronic Pulmonary Disease Tool – Patient Reported Outcomes (EXACT, please note new 
name in Section 7.1.4.5 and see Section 8 for details and timing of the assessments).  The 
EXACT nomenclature will be used throughout the protocol unless otherwise noted.  Site will 
be requested to complete HCRU questionnaire throughout the study (see Section 8 for details 
and timing of the assessments).   
For subjects who remain on treatment throughout the study (i.e., complete Visit 10a), a 
follow-up telephone call will be performed at least 14 days after the last study drug dose.   
Subjects who discontinue study treatment prior to Week 24 (Visit 10a) will be encouraged to 
remain in the study to complete all remaining study visits during the 24 week treatment 
period.  Subjects who agree to continue to be followed post treatment discontinuation will 
sign an ICF addendum.  All subjects, who agree to continue study participation beyond 
treatment discontinuation, will complete a Treatment Discontinuation/Withdrawal Visit 
(refer to Table 8) prior to transitioning back to regularly scheduled study visits.  Subjects 
participating in a sub-study who choose to discontinue from treatment will only complete 
regularly scheduled visits and not complete any remaining sub-study assessments.  Treatment 
discontinuation subjects will return to appropriate maintenance COPD medications, per the 
investigators discretion.  For subjects recorded as Treatment Discontinuations that do not 
complete at least one post-treatment data collection a telephone follow-up call is required at 
least 14 days after last study drug dose. 
If a subject chooses not to continue with study assessments, at a minimum the subject will 
complete the Treatment Discontinuation/Withdrawal Visit (refer to Table 8).  These subjects 
will return to appropriate maintenance COPD medications, per the investigators discretion.  
A follow-up telephone call will be performed at least 14 days after the last study drug dose.  
In the event the Treatment Discontinuation/Withdrawal Visit is performed >14 days post last 
study drug dosing, a follow-up TC will not be required.  These subjects will be followed for 
vital status at 24 weeks post randomization in accordance with the informed consent. 
Further details will be provided in the DMC charter and in the Statistical Analysis Plan 
(SAP). 
General Considerations for Treatment Visits 4 through Visit 10a 
• Subjects that are randomized will be instructed to discontinue all previous inhaled 
medication used during the screening period, including protocol adjusted ICS therapy as 
defined at Visit 1 (screening), and only use sponsor provided inhaled study medications 
for the remainder of the study. 
• At the start of each study visit, prior to any study procedures being performed, site 
personnel must confirm the subject withheld all COPD medications, including study 
medication, rescue Ventolin HFA or locally available product (where necessary), for at 
least 6 hours, by confirming the last time of dosing for all COPD medication(s).   

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• Note: Subjects who inadvertently took COPD medication(s) within 6 hours of the start of 
study procedures must be rescheduled as soon as is practical but within the specified visit 
window.  In addition, before the in-clinic dose is administered, the site must confirm the 
subject met all other protocol specified requirements (e.g., FEV1 baseline stability and 
eDiary compliance). 
• All post-randomization visits will be scheduled relative to Visit 4 (Day 1).  Visits 5, 6, 7, 
8, 9, and 10a will be scheduled 4, 8, 12, 16, 20 and 24 Weeks (± 2 days) of Visit 4, 
respectively.  Sites should make every effort to maintain subjects within the scheduled 
visit window.  If a visit falls outside the expected visit window the subsequent visit 
should still be scheduled as planned relative to Visit 4. 
• Subjects must not ingest xanthine and/or xanthine analogue (caffeine)-containing foods, 
medications, and beverages for at least 6 hours prior to each study visit and for the 
duration of each study visit.  Examples of such products include coffee, tea, chocolate, 
and cola.  Decaffeinated beverages are acceptable. 
• Subjects will be required to refrain from smoking (nicotine gums or patches are allowed) 
for at least 4 hours prior to each study visit and throughout the duration of each study 
visit. 
• In order to minimize diurnal variance, sites should make every effort to assess subjects at 
the same time throughout the study and to discuss the importance of dosing in a timely 
manner, every 12 hours. 
• Subjects will be required to return to the clinic at approximately the same time as Visit 4 
for all treatment visits (± 2 hours) but no later than 10:00 AM and will be required to 
remain at the clinic until completion of all protocol-defined assessments. 
• Sites should make every effort to ensure that the in-clinic dosing time is before 10:00 AM 
and within 12±2 hours of the prior at home evening dosing time. 
• The in-clinic dosing time for study drug (BGF MDI, GFF MDI, and BFF MDI) will be 
recorded as the time of administration of the second puff. 
• To ensure standardization of dosing times, it is recommended that sites encourage 
subjects to maintain a dosing schedule consistent with their in-clinic dosing time and that 
sites call the subject on the day before a scheduled visit and remind the subject of the 
following: 
- 
To take their last dose the evening before the scheduled visit; 
- 
To bring their study medications and eDiary with them to the clinic and to withhold 
all COPD medications (locally available products, if applicable) for at least 6 hours 
prior to PFTs; 
- 
To refrain from ingesting xanthine (caffeine)-containing foods, beverages, or 
medications for at least 6 hours prior to each study visit and for the duration of each 
study visit; 
- 
To refrain from smoking for at least 4 hours prior to the study visit and throughout the 
duration of each study visit. 
• Site personnel will instruct subjects not to take any COPD medications, without site 
personnel permission during a visit until all study procedures have been completed, and 
the subject is discharged.  Site personnel should take every precaution to prevent subject 

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use of COPD medications during the test day.  Site personnel may request the subject to 
surrender all COPD medications prior to the start of the visit before performing any study 
procedures and return the COPD medications to the subject at the end of the visit when 
all study procedures are completed.  Subjects will be asked to abstain wherever possible 
from using rescue Ventolin HFA during study visits.  If a subject is experiencing severe 
symptoms and requires Ventolin HFA for relief of COPD symptoms at any time during a 
test day, site personnel must note the time and justification of use in the subject’s chart 
and all subsequent spirometry assessments should be stopped.  However, safety 
assessments should be continued at the discretion of the Investigator. 
• Subjects completing Visit 10a may be invited to participate in a safety extension study in 
Japan (Study PT010007) to evaluate the long-term safety of BGF MDI, BFF MDI, and 
GFF MDI for an additional 28 weeks.  All subjects from Japan who volunteer to 
participate in the extension study will complete Visit 10a (Final Study Visit) and Visit 
10b (Safety Extension Study Entry Visit) (refer to the protocol for Study PT010007 for 
additional details).   
• Subjects not participating in the safety extension study (Study PT010007) will complete 
all Visit 10a (Final Study Visit) assessments and will be scheduled for a post study 
follow-up telephone call at least 14 days from Visit 10a. 
 
An overall study design is summarized and displayed in Figure 1. 
Figure 1.   
 
Study Design 
 
 

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4.2 
Rationale of Study Design 
This Phase III study is designed to assess the long-term efficacy and safety of BGF MDI 
compared with GFF MDI, BFF MDI, and Symbicort TBH on lung function, subject-reported 
symptom outcomes, exacerbations and health status over 24 weeks.  While studies of shorter 
duration (e.g., 8 to 12 weeks) may be sufficient for the assessment of bronchodilators, Pearl 
has chosen to characterize efficacy and safety of the aforementioned investigational products 
for at least 24 weeks to fully characterize the ICS benefit compared with GFF MDI and to 
fully characterize the LAMA benefit compared with BFF MDI to allow for global 
registration of BGF MDI.   
Consistent with feedback from global regulatory agencies, this study will evaluate a patient 
population that remains symptomatic despite treatment with 2 or more inhaled maintenance 
medications.   
Due to the duration of the Study, a randomized, double-blind (other than the open-label 
active control), parallel-group design was adopted in order to minimize bias in treatment 
allocation and to allow unbiased comparisons of treatment groups. 
BGF MDI, GFF MDI, and BFF MDI will be randomly assigned in a double-blind fashion, 
while Symbicort TBH is included as an open-label treatment arm to allow for safety and 
efficacy comparisons relative to an approved ICS/LABA dual combination. 
In order to place the efficacy and safety of BGF MDI into context, BFF MDI, GFF MDI and 
Symbicort TBH are included in the study.  It is important to ensure that subjects only receive 
the inhaled treatment assigned at randomization.  Those subjects on oral phosphodiesterase 
inhibitors (e.g., roflumilast, theophylline) may continue to use these medications as 
prescribed.  When necessary, subjects will be allowed to use sponsor-provided Ventolin 
(albuterol sulfate) HFA or a locally available and comparable rescue product.   
No currently approved treatment prevents death or irreversible morbidity by influencing the 
course of disease. 
4.3 
Rationale of Dose/Regimen and Duration of Treatment 
The safety and efficacy of the individual components, budesonide, glycopyrronium, and 
formoterol fumarate are well characterized, and all 3 components are components (alone or 
in combination) of approved inhalation products for the treatment of patients with COPD. 
The doses of the glycopyrronium and formoterol fumarate components of BGF MDI and 
BFF MDI match the doses utilized in the GFF MDI development program.  The GFF MDI 
clinical program consisted of 12 clinical studies to support the dose selection of 
glycopyrronium and formoterol fumarate for the dual combination GFF MDI, as well as its 
components GP MDI and FF MDI, in subjects with moderate to very severe COPD.  Based 
on the data obtained through this Phase II program, a dose of GFF MDI 14.4/9.6 μg BID was 
selected for progression into Phase III.  Two Phase III pivotal efficacy and safety studies, and 
one long-term extension study, have recently completed which evaluated the efficacy and 

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safety of GFF MDI, GP MDI, and FF MDI as bronchodilator treatments in subjects with 
moderate to very severe COPD.   
In order to select the appropriate budesonide dose for Phase III studies, Pearl Therapeutics 
has conducted 2 Phase I PK and safety studies.  Pearl Therapeutics has conducted an initial 
Phase I, single-dose, PK and safety study in healthy adult subjects (Study PT010001) with 3 
doses of the triple combination product, BGF MDI, compared with 2 doses of Symbicort 
MDI and a single dose of the Pearl dual combination product GFF MDI.  The study 
demonstrated that formoterol and glycopyrrolate plasma concentrations following 
administration of all BGF MDI doses were similar to those following GFF MDI 
administration, and budesonide plasma concentrations were comparable between BGF MDI 
and Symbicort MDI.  All treatments were well tolerated with a low frequency of AEs, and no 
untoward safety signals were observed.  The results of Study PT010001 supported the 
evaluation of BGF MDI 320/14.4/9.6 μg and lower doses in further clinical studies, and 
suggested that the addition of budesonide to GFF MDI does not impact the systemic levels of 
either component.   
Pearl Therapeutics also conducted a randomized, double-blind, single-dose crossover study 
(Study PT010002) to evaluate the safety and PK of BGF MDI (320/14.4/9.6 μg), BFF MDI 
(320/9.6 μg), and Symbicort TBH (400/12 μg) in healthy adult subjects.  Study PT010002 
was conducted to investigate the PK comparability of BGF MDI and BFF MDI to Symbicort 
TBH.  The budesonide component of BGF MDI was nearly identical on Cmax with a GMR 
of 1.02 and 90% confidence interval (CI) of (0.81, 1.30), but AUC0-12 was approximately 
25% higher than Symbicort TBH.  Similar results were obtained for the comparison of BFF 
MDI to Symbicort TBH.  Study PT010002 also investigated the potential for a DDI by 
comparing the budesonide and formoterol 12-hour PK profiles following a single dose of 
BGF MDI or BFF MDI.  No DDI was observed as both budesonide and formoterol Cmax and 
AUC0-12 were similar, following administration of either BGF MDI or BFF MDI. 
Based on results from Studies PT010001 and PT010002 and given that higher doses of 
budesonide are approved in many countries for asthma, it is reasonable to progress to the 
320 µg budesonide as the highest dose of BGF MDI and BFF MDI in this study. 

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5 
STUDY POPULATION SELECTION AND WITHDRAWAL 
CRITERIA 
5.1 
Inclusion Criteria 
Each subject must meet the following criteria to be enrolled in this study. 
1. Give their signed written informed consent to participate. 
2. Are at least 40 years of age and no older than 80 at Visit 1. 
3. A female is eligible to enter and participate in the study if she is of: 
a. Non-childbearing potential (i.e., physiologically incapable of becoming pregnant, 
including any female who is 2 years post-menopausal) 
b. Childbearing potential, has a negative serum pregnancy test at Visit 1, and agrees to one 
of the following acceptable contraceptive methods used consistently and correctly as 
outlined below (i.e., in accordance with the approved product label and the instructions of 
the physician for the duration of the study – from Visit 1 (Screening) until 14 days after 
the Final Visit): 
- 
Complete abstinence from intercourse (when it is preferred and usual lifestyle of the 
patient); or 
- 
Implants of levonorgestrel inserted for at least 1 month prior to the study drug 
administration but not beyond the third successive year following insertion; or 
- 
Injectable progestogen administered for at least 1 month prior to study drug 
administration; or 
- 
Oral contraceptive (combined or progestogen only) administered for at least one 
monthly cycle prior to study drug administration; or 
- 
Double barrier method: condom or occlusive cap (diaphragm or cervical/vault caps) 
plus spermicidal agent (foam/gel/film/cream/suppository); or 
- 
An intrauterine device, inserted by a qualified physician, with published data showing 
that the highest expected failure rate is less than 1% per year; or 
- 
Estrogenic vaginal ring; or 
- 
Percutaneous contraceptive patches. 
4. COPD Diagnosis: Subjects with an established clinical history of COPD as defined by 
the American Thoracic Society (ATS)/European Respiratory Society (ERS) (Celli, 2004) 
or by locally applicable guidelines e.g., JRS Guidelines (JRS, 2013) characterized by: 
- 
Progressive airflow limitation associated with an abnormal inflammatory response of 
the lungs to noxious particles or gases, primarily caused by cigarette smoking. 
5. Tobacco Use: Current or former smokers with a history of at least 10 pack-years of 
cigarette smoking.  (Number of pack-years = [number of cigarettes per day/20] x number 
of years smoked [e.g., 20 cigarettes per day for 10 years, or 10 cigarettes per day for 20 
years represent 10 pack-years]).   
6. COPD Severity: Subjects with an established clinical history of COPD and severity 
defined as: 
- 
At Visit 1, FEV1/FVC ratio must be <0.70 and FEV1 must be <80% predicted normal 
value calculated using NHANES III reference equations (Or reference norms 
applicable to other regions, e.g., for Japan, use JRS reference equations; [JRS, 2013]). 

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- 
At Visit 2, post-bronchodilator FEV1/FVC ratio of <0.70 and post-bronchodilator 
FEV1 must be ≥25% to <80% predicted normal value, calculated using NHANES III 
reference equations (Or reference norms applicable to other regions, e.g., for Japan, 
use JRS reference equations [JRS, 2013]). 
- 
At Visit 4, the average of the 60 min and 30 min pre-dose FEV1 assessments must be 
<80% predicted normal value, calculated using NHANES III reference equations (Or 
reference norms applicable to other regions, e.g., for Japan, use JRS reference 
equations [JRS, 2013]). 
- 
Symptomatic (CAT ≥10) at Screening (Visit 2). 
7. Required COPD Maintenance Therapy:  
- 
All Subjects must have been on two or more inhaled maintenance therapies for the 
management of their COPD for at least 6 weeks prior to Screening.  Scheduled SABA 
and/or scheduled SAMA are considered inhaled maintenance therapies 
8. Subject is willing and, in the opinion of the investigator, able to adjust current COPD 
therapy, as required by the protocol. 
9. Screening clinical laboratory tests must be acceptable to the Investigator. 
10. Screening ECG must be acceptable to the Investigator. 
11. Chest x-ray or computed tomography (CT) scan of the chest/lungs within 6 months prior 
to Visit 1 must be acceptable to the Investigator.  Subjects who have a chest x-ray that 
reveals clinically significant abnormalities not believed to be due to the presence of 
COPD should not be included.  A chest x-ray must be conducted if the most recent chest 
X-ray or CT scan are more than 6 months old at the time of Visit 1, except in countries 
with restrictive radiology assessment practice where only subjects who have had a chest 
X-ray or CT scan (thorax) performed outside of the study in the last 6 months are allowed 
to be enrolled.  Alternatively, in these countries an MRI may be used instead of a CT 
scan or chest X-ray, as per local practice assessment. 
12. Compliance: Subjects must be willing to remain at the study center as required per 
protocol to complete all visit assessments. 
 
5.2 
Exclusion Criteria 
Subjects who meet any of the following criteria will be excluded from the study. 
1. Significant diseases or conditions other than COPD which, in the opinion of the 
Investigator, may put the patient at risk because of participation in the study or may 
influence either the results of the study or the subject’s ability to participate in the study. 
2. Women who are pregnant or lactating, or are planning to become pregnant during the 
course of the study, or women of childbearing potential who are not using an acceptable 
method of contraception. 
3. Respiratory  
a. Asthma: Subjects that, in the opinion of the Investigator, have a current diagnosis of 
asthma. 
b. Alpha-1 Antitrypsin Deficiency: Subjects who have alpha-1 antitrypsin deficiency as the 
cause of COPD. 
c. Other Respiratory Disorders: Subjects who have other active pulmonary disease such as 
active tuberculosis, lung cancer, bronchiectasis (High Resolution CT evidence of 

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bronchiectasis that cause repeated acute exacerbations), sarcoidosis, idiopathic interstitial 
pulmonary fibrosis (IPF), primary pulmonary hypertension, or uncontrolled sleep apnea 
(i.e., in the opinion of the Investigator severity of the disorder would impact the conduct 
of the study).  Note: Allergic rhinitis is not exclusionary. 
d. Lung Volume Reduction: Subjects who have undergone lung volume reduction surgery, 
lobectomy or bronchoscopic lung volume reduction (endobronchial blockers, airway 
bypass, endobronchial valves, thermal vapor ablation, biological sealants, and airway 
implants) within 6 months of Visit 1. 
e. Hospitalization: Subjects who have been hospitalized due to poorly controlled COPD 
within 3 months prior to Visit 1 (Screening) or during the Screening Period (Visit 1 to 
Visit 4). 
f. Poorly Controlled COPD: Subjects who have poorly controlled COPD, defined as acute 
worsening of COPD that requires treatment with oral corticosteroids or antibiotics within 
6 weeks prior to Visit 1 (Screening) with less than a 4 week washout of corticosteroids 
and/or antibiotics prior to Visit 1 or during the Screening Period (Visit 1 to Visit 4). 
Note: Subjects who are steroid dependent and maintained on an equivalent of 5 mg 
prednisone per day or 10 mg every other day for at least 3 months prior to Visit 1 are 
eligible for enrollment providing the dose of oral steroids remains stable during the 
Screening Period Visit 1 through Visit 4. 
g. Lower Respiratory Tract Infection: Subjects who had lower respiratory tract infections 
that required antibiotics within 6 weeks prior to Visit 1 (Screening) with less than a 4 
week washout of antibiotics prior to Visit 1 (Screening) 
h. Upper Respiratory tract infections (URTI) that have not resolved at least 7 days prior to 
Screening  
i. Chest x-ray (frontal and lateral) with suspicion of pneumonia or other 
condition/abnormality that will require additional investigation/treatment, or put the 
subject at risk because of participation in the study. 
j. Risk factors for pneumonia: immune suppression (HIV) severe neurological disorders 
affecting control of the upper airway or other risk factors that in the opinion of the 
Investigator would put the subject at substantial risk of pneumonia  
k. Pneumonia not clinically resolved within 14 days of Visit 1. 
l. Spirometry Performance:  
- 
Acceptability: Subjects who cannot perform acceptable spirometry (i.e., meet 
ATS/ERS acceptability criteria)  
- 
Repeatability: Subjects who cannot perform technically acceptable spirometry with at 
least 3 acceptable flow-volume curves with 2 or more meeting ATS repeatability 
criteria for FEV1 during at least 1 of the pre-bronchodilator assessments at Visit 2 
(60 minute or 30 minute) and at the post-bronchodilator assessment at Visit 2. 
- 
FEV1 Baseline Stability: Subjects who cannot meet protocol-specified baseline 
stability criteria.  FEV1 baseline stability is defined as the average of the 60 minute 
and 30 minute pre-dose FEV1 assessments at Visit 4 being within ±20% or 200 mL of 
the mean of the pre-bronchodilator FEV1 assessments obtained at the 2 preceding 
visits (average of pre-dose FEV1 assessments obtained at Visit 2 and Visit 3). 
m. Oxygen: Subjects receiving long-term-oxygen therapy (LTOT) or nocturnal oxygen 
therapy required for greater than 15 hours a day.  Note: As needed oxygen use is not 
exclusionary. 

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n. Subject use of any non-invasive positive pressure ventilation device.   
Note: Subjects using continuous positive airway pressure or bi-level positive airway 
pressure for Sleep Apnea Syndrome are allowed in the study if not used for ventilatory 
support. 
o. Change in smoking status (i.e., start or stop smoking) or initiation of a smoking cessation 
program within 6 weeks of Visit 1 and throughout the Screening Period (Visit 1 to 
Visit 4). 
p. Pulmonary Rehabilitation: Subjects who have participated in the acute phase of a 
pulmonary rehabilitation program within 4 weeks prior to Visit 1 (Screening) or who will 
enter the acute phase of a pulmonary rehabilitation program during the Screening Period.  
Subjects who are in the maintenance phase of a pulmonary rehabilitation program are not 
to be excluded. 
q. Subjects who have initiated or altered the dose regimen of intranasal corticosteroids, 
intranasal antihistamines, or a combination thereof within 7 days prior to Visit 1 or 
during the Screening Period (Visit 1 to Visit 4). 
4. Cardiac disease 
a. Subjects who have unstable ischemic heart disease, left ventricular failure, or 
documented myocardial infarction within 6 months of enrollment.  Subjects with a recent 
history of acute coronary syndrome, or who have undergone percutaneous coronary 
intervention or coronary artery bypass graft within the past 3 months are to be excluded. 
b. Subjects with congestive heart failure (CHF NYHA Class III/IV). 
c. Clinically significant abnormal ECG: A clinically significant abnormal ECG is defined as 
(but not limited to) any of the following: 
- 
Clinically significant conduction abnormalities [e.g., left bundle branch block, Wolff-
Parkinson-White syndrome or evidence of second degree (Mobitz Type II) or third 
degree atrioventricular block (unless pacemaker or defibrillator has been inserted)]. 
- 
Clinically significant arrhythmias (e.g., atrial fibrillation with irregular ventricular 
response, atrial flutter, ventricular tachycardia).  Note: atrial fibrillation that has been 
clinically stable for at least 6 months and that has been appropriately treated with 
anticoagulation and controlled with a rate control strategy (i.e., selective beta blocker, 
calcium channel blocker, digoxin or ablation therapy) for at least 6 months is allowed 
for inclusion.  In such subjects, atrial fibrillation must be present at pre-randomization 
visits, with a resting ventricular rate <100 beats per minute (bpm).  At screening, the 
atrial fibrillation must be confirmed by central reading. 
- 
QT interval corrected for heart rate (using Fridericia’s formula; QTcF) ≥500 
milliseconds (msec) in patients with QRS <120 msec and QTcF ≥530 msec in 
patients with QRS ≥120 msec  
- 
Ventricular rate <45 bpm. 
- 
ST-T wave abnormalities deemed to be clinically significant by the Investigator.  
Note: Subjects with non-specific ST-T wave abnormalities that are not deemed 
clinically significant (per Investigator) are allowed. 
- 
Any other ECG abnormalities not listed above that in the opinion of the Investigator 
are clinically significant. 
d. Clinically Uncontrolled Hypertension: Subjects who have clinically significant 
uncontrolled hypertension. 

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5. Neurological  
a. Subjects with seizures requiring anticonvulsants within 12 months prior to Visit 1 
(Screening).  Note: Subjects treated with anticonvulsant medication for 12 months or 
more with no seizure events are eligible. 
b. Subjects taking selective serotonin reuptake inhibitors (SSRIs) or serotonin–
norepinephrine reuptake inhibitors (SNRIs) whose dose has not been stable for at least 4 
weeks prior to Visit 1 or is altered at any point during the Screening Period (Visit 1 to 
Visit 4), or exceeds the maximum recommended dose. 
c. Subjects who have experienced a cerebrovascular accident within the 6 months prior to 
Visit 1 
6. Renal  
a. Subjects with symptomatic prostatic hypertrophy that is clinically significant and not 
adequately controlled with appropriate therapy, in the opinion of the Investigator.  
Subjects with a trans-urethral resection of prostate or full resection of the prostate within 
6 months prior to Visit 1 are excluded from the study.   
b. Subjects with bladder neck obstruction or urinary retention that is clinically significant in 
the opinion of the Investigator.   
c. Subjects with a calculated creatinine clearance ≤30 mL/minute using Chronic Kidney 
Disease Epidemiology Collaboration. 
(CKD-EPI) formula (Levey, 2009) at Visit 1 and on repeat testing prior to Visit 2. 
Note: Subjects with overactive bladder syndrome treated with oral anticholinergics that 
have been on treatment for at least one month are allowed in the Study. 
7. Endocrine  
a. Subjects who, in the opinion of the Investigator have uncontrolled hypo-or 
hyperthyroidism, hypokalemia or hyperadrenergic state 
b. Subjects, who in the opinion of the Investigator, have uncontrolled Type I or Type II 
diabetes 
8. Liver: Subjects with abnormal liver function tests defined as AST, ALT, or total bilirubin 
≥1.5 times upper limit of normal at Visit 1 and on repeat testing prior to Visit 2.  Note: 
Chronic stable hepatitis B and C is acceptable if the subject otherwise meets study entry 
criteria. 
9. Cancer: Subjects who have cancer that has not been in complete remission for at least 5 
years.  Note: Subjects with squamous cell carcinoma of the skin, basal cell carcinoma of 
the skin, or localized prostate cancer are eligible, if in the opinion of the Investigator, the 
condition has been adequately worked up, is clinically controlled and the subject’s 
participation in the study would not represent a safety concern. 
10. Glaucoma: Subjects with a diagnosis of narrow-angle glaucoma that, in the opinion of the 
Investigator, has not been adequately treated.  All medications approved for control of 
intraocular pressures are allowed including topical ophthalmic non-selective beta-
blockers (such as betaxolol, carteolol, levobunolol, metipranolol, timolol) and 
prostaglandin analogues. 
11. Drug Allergy: Subjects who have a history of hypersensitivity to β2 agonists, budesonide 
or any other corticosteroid components, glycopyrronium or other muscarinic 
anticholinergics, or any component of the MDI or dry powder inhaler (DPI). 
12. Substance Abuse: Subjects who in the opinion of the Investigator significantly abuse 
alcohol or drugs (refer to Exclusion Criterion 1). 

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13. Medication prior to spirometry: Subjects who are medically unable to withhold their 
short-acting bronchodilators for the 6-hour period required prior to spirometry testing at 
each study visit will be excluded. 
14. Prohibited Medications: Subjects who, in the opinion of the Investigator, would be unable 
to abstain from protocol-defined prohibited medications during the Screening Period and 
treatment phases of this study (refer to Section 5.4). 
15. Subjects using any herbal inhalation and nebulizer products within 2 weeks prior to Visit 
1 (Screening) and do not agree to stop using them during the study drug treatment. 
Note: Nebulized albuterol is acceptable, but requires a minimum 6 hours washout prior to 
Visit 1 and must be discontinued at Visit 1 and throughout the study. 
16. Vaccinations: Subjects who received a live attenuated vaccination within 7 days prior to 
Visit 1 (Screening).   
17. Non-compliance: Subjects unable to comply with study procedures including non-
compliance with diary completion (i.e., <70% subject completion of diary assessments in 
the last 7 days preceding Visit 4). 
18. Affiliations with Investigator site: Study Investigators, sub-Investigators, study 
coordinators, employees of a participating Investigator or immediate family members of 
the aforementioned are excluded from participation in this study. 
19. Questionable Validity of Consent: Subjects with a history of psychiatric disease, 
intellectual deficiency, poor motivation, substance abuse (including drug and alcohol), or 
other conditions that will limit the validity of informed consent to participate in the study. 
20. Subjects using prohibited medications (refer to Table 4). 
21. Investigational Drugs or Devices: Treatment with investigational study drug or device in 
another clinical Study within the last 30 days or 5 half-lives prior to Visit 1 (Screening), 
whichever is longer.   
Note: Subject participation in observational studies (i.e., studies that do not require 
change to medication or an additional intervention) is not exclusionary. 
22. Hand-to-Breath Coordination: Subjects who require the use of a spacer device to 
compensate for poor hand-to-breath coordination with a MDI.  Note: Use of a nebulizer 
to deliver maintenance COPD medications is prohibited throughout the Study. 
23. Previous Participation: Subjects who were previously enrolled in any previous PT009 or 
PT010 study.  However, subjects will be permitted to participate in any supplemental or 
extension study to this study (PT010006). 
 
5.3 
Subject Identification 
All subjects who undergo screening will be assigned a unique screening identification 
number at the Screening Visit (Visit 1).  Only subjects continuing to meet entry 
inclusion/exclusion criteria at Visit 4 will be assigned a unique subject randomization 
number.  Randomization will be centralized through the use of an IWRS. 
5.4 
Prior, Concomitant, and Prohibited Medications 
All prescription and over-the-counter (OTC) medications taken by the subject within 30 days 
before Visit 1 (Screening) will be recorded on the prior/concomitant medications eCRF.  Any 
additions, deletions, or changes in the dose of these medications while in the study should be 

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entered on the eCRF.  Any current ongoing medications, including OTC drugs and herbal 
supplements, will be allowed provided they are not prohibited by the protocol (refer to 
Section 5.4.1) and are approved by the Investigator.  Subjects should also be instructed to 
contact the Investigator if they develop any illnesses.   
All concomitant medications taken during the study will be recorded on the Concomitant 
Medications eCRF with indication, dose, dose regimen, and dates of drug administration. 
5.4.1 
Allowed Medications to Treat a COPD Exacerbation 
Medications to treat an exacerbation should not be used for more than 14 days.  Recent data 
have suggested that treatment with systemic steroids for shorter periods of time results in 
similar outcomes with less systemic steroid exposure.  Therefore, it is recommended that 
subjects are treated with a 5 day course of steroids (Leuppi, 2013) and no longer than 14 
days.  During a COPD exacerbation, it is important for subjects to be treated as deemed 
appropriate by the treating health care provider.  However, subjects should return to their pre-
exacerbation medication regimen as soon as practical.  
5.4.2 
Pneumococcal and Annual Influenza Vaccination 
All subjects should be vaccinated per local guidelines [current global recommendation per 
local policies, availability, and affordability: GOLD, 2016].  For subjects that have been 
previously vaccinated with pneumococcal vaccine, the investigator should assess whether a 
booster vaccination is required.  Annual influenza vaccine should also be administered per 
local guidelines.  Pneumococcal and/or annual influenza vaccine can be given at Visit 1 or at 
any other visit throughout the study at the discretion of the investigator; however, 
administration should occur after obtaining all requisite PFT assessments for that specific test 
day.  There should be at least 7 days between vaccination and subsequent PFT assessments. 
5.4.3 
Prohibited COPD Medications and Required Washout Period Prior to Visit 2 
Subjects who meet the screening criteria at Visit 1 that are being treated with any of the 
medications listed in Table 1 need to discontinue these medication and observe the minimum 
washout requirement before returning for Visit 2.  These medications are prohibited 
throughout the course of the study, and should a subject require use of any of the listed 
medications, they should be discontinued, unless meeting conditions described in 
Section 5.4.1. 

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Table 1.  
Prohibited COPD Medications and Required Washout Periods, 
Prior to Visit 2 
Class of medication 
Minimum Washout Period prior to Visit 2 
LAMAs 
Tiotropium: 14 days 
Aclidinium: 7 days 
Glycopyrronium: 7 days 
Umeclidinium: 7 days  
Short-acting muscarinic antagonists (SAMA) a  
6 hours 
LABAs (inhaled) 
7 days (14 days for indacaterol and olodaterol) 
Fixed-combinations of LABA/LAMA 
7 days (14 days for indacaterol/glycopyrronium 
and olodaterol/tiotropium)  
Fixed-combinations of LABA/ICS 
7 days  
Fixed-combinations of SABAs and SAMAs  
6 hours 
SABAs b  
6 hours 
Oral β-agonists 
2 days  
Theophylline (total daily dose >400 mg/day)c 
7 days 
Abbreviations: COPD=chronic obstructive pulmonary disease; HFA=hydrofluoroalkane; ICS=inhaled 
corticosteroid; LABA=long acting β2 agonist; LAMA=long acting muscarinic antagonist;  
SABA=short-acting β2 agonist; SAMA=short-acting muscarinic antagonist 
Note: Roflumilast (or any PDE4 inhibitor) is allowed provided the subject has been on stable dose of therapy 
for at least 2 months prior to Randomization. 
a 
Discontinue and use only sponsor provided Atrovent HFA during screening  
b 
Discontinue and use only sponsor provided rescue Ventolin HFA throughout the study 
c 
Theophylline (≤400 mg/day) is permitted provided the subject has been on a stable dose of therapy for at 
least 4 weeks prior to Randomization. 
 
Subjects who have received depot corticosteroids including intra-articular or intraocular 
corticosteroids require a 3-month washout prior to Screening (Visit 1).  Subjects that have 
received oral, intravenous or intramuscular corticosteroids for any reason require a 4-week 
washout prior to Screening (Visit 1).  Any subject that requires systemic corticosteroids 
during the Screening Period (Visit 1 to Visit 4) will be screen failed. 
Note: 
• Subjects who are steroid dependent and maintained on an equivalent of up to 5 mg oral 
prednisone per day or up to 10 mg oral prednisone every other day for at least 3 months 
prior to Visit 1 are eligible for enrollment, provided the dose of oral steroids remains 
consistent and does not exceed this threshold for the last two weeks prior to 
randomization (Visit 4). 
• During the Treatment Period (Visit 4 to Visit 10a), subjects may be treated with systemic 
corticosteroids if required. 
 

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Subjects who meet all entry criteria but are using 1 or more of the prohibited COPD 
medications (previously listed) will have their maintenance therapy for COPD adjusted as 
follows:  
• Subjects taking COPD medications (listed previously) at Visit 1 (Screening) will 
discontinue these medications for the duration of the Study and be switched to Sponsor 
provided Atrovent HFA administered 4 times daily (QID) and Sponsor provided Ventolin 
HFA to be administered up to 4 times per day, as needed, for control of symptoms during 
the Screening Period. 
• Subjects receiving a maintenance dose of an ICS as part of a fixed-dose combination 
therapy containing fluticasone and salmeterol, mometasone and formoterol, budesonide 
and formoterol or fluticasone and formoterol or other approved fixed dose ICS/LABA 
combinations must have been on the ICS component for at least 4 weeks prior to Visit 1 
(Screening) and maintained on a stable dose for at least 4 weeks prior to Visit 1 
(Screening).  These subjects will be switched to the corresponding dose of fluticasone, 
mometasone, or budesonide administered as a single agent BID, with Sponsor-provided 
Atrovent HFA administered QID, and Sponsor-provided Ventolin HFA to be 
administered up to QID, as needed, to control symptoms during the Screening Period. 
• Subjects receiving a maintenance dose of an ICS that is not administered as a fixed-dose 
combination together with a LABA will be permitted to continue the ICS provided they 
have been maintained on a stable dose for at least 4 weeks prior to Visit 1 (Screening). 
• All subjects treated with either a LABA (salmeterol, formoterol, indacaterol, vilanterol, 
olodaterol), or currently-marketed LAMA (tiotropium, aclidinium, glycopyrronium, 
umeclidinium) administered alone, as a loose combination, or as a fixed combination 
(e.g., umeclidinium/vilanterol, Glycopyrronium/indacaterol, aclidinium 
bromide/formoterol fumarate ) will have these medications discontinued and replaced 
with Sponsor-provided Atrovent HFA administered QID, and Sponsor-provided Ventolin 
HFA to be administered up to QID, as needed for control of symptoms during the 
Screening Period. 
 
Note: All adjusted maintenance therapy for COPD, including ICS will be stopped at 
randomization. 
It is preferred that Atrovent and Ventolin be US-sourced products.  In cases where it is not 
possible for the US-sourced product to be used, a locally available product will be provided 
by the Sponsor.  The EU-sourced Symbicort TBH must be used for the active control, and a 
locally available product cannot be substituted for the sponsor-provided Symbicort TBH. 
Subjects receiving the following respiratory medications must discontinue these medications 
at the initial Screening Visit (Visit 1).  The minimum cessation period must be met prior to 
returning for Visit 2.  These medications are not permitted during the study (Table 2). 

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Table 2.  
Other Respiratory/Nasal Medications and Required Washout 
Periods Prior to Visit 2 
Class of Medication 
Minimum Washout Period Prior to Visit 2 
Leukotriene antagonists (e.g., zafirlukast, 
montelukast and zilueton) 
7 days 
Cromoglycate 
7 days 
Nedocromil 
7 days 
Ketotifena 
7 days 
a 
Ketotifen eye drops are allowed 
 
5.4.4 
Other Prohibited Medications 
Table 3 lists certain non-COPD medications that can be used under the stated conditions 
during this study.  Each concomitant drug must be individually assessed against all exclusion 
criteria.  If in doubt, the Investigator should contact Pearl’s Medical Monitor before 
randomizing a subject or allowing a new medication to be started: 
Table 3.  
Non COPD Medications Allowed Under Certain Conditions 
Medications Allowed Under Certain 
Conditions 
Condition 
SSRIs or SNRIs or NaSSAs  
Treatment regimen has been stable for at least 4 
weeks prior to Visit 1 and not altered during the 
Screening Period, and does not exceed the 
maximum recommended dose 
Intranasal corticosteroids, intranasal 
antihistamines, or combination thereof 
Administered at constant dose and dosing 
regimen for at least 7 days prior to Screening 
(Visit 1) and during the Screening Period 
Abbreviations: COPD=chronic obstructive pulmonary disease; SNRI=serotonin–norepinephrine reuptake 
inhibitors; SSRI=selective serotonin reuptake inhibitors; NaSSAs=noradrenergic and specific serotonergic 
antidepressants 
Note: Use of cutaneous topical medications, including cutaneous topical corticosteroids, is permitted provided 
these medications are not applied to more than 20% of the subject’s body surface area. 
 
Subjects requiring medications presented in Table 4 are prohibited from participating in this 
study.  Subjects who recently discontinued use of these medications may be considered for 
study enrollment providing they have met the minimum Washout Period prior to Visit 1.  
These medications are prohibited throughout the course of the study, and should a subject 
require use of any of the listed medications, the subject should be discontinued from 
randomized treatment, resume the appropriate COPD maintenance therapy, and be 
encouraged to complete the remaining study visits. 

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Table 4.  
Prohibited Medications 
Prohibited Medications 
Minimum Cessation Period Prior to Screening 
(Visit 1) 
Any drug with potential to significantly prolong 
the QT interval 
14 days or 5 half-lives, whichever is longer 
Other investigational drugs 
30 days or 5 half-lives, whichever is longer  
Non-selective β-blocking agents a  
7 days 
Cardiac antiarrhythmics Class Ia, III 
7 days (amiodarone 3 months) 
Anticonvulsants for seizure disorder 
Allowed if stable dose for 12 months and free of 
seizures for 1 year  
Anticonvulsants for other indications b 
Allowed if stable dose for at least 3 months and 
free of seizures for 1 year 
Tricyclic antidepressants c 
14 days 
Monoamine oxidase inhibitors 
14 days  
Anti-tumor necrosis factor α antibodies 
(e.g., infliximab and any other members of this 
class of drugs) 
30 days or 5 half-lives, whichever is longer 
Monoclonal antibodies d 
30 days or 5 half-lives, whichever is longer 
Antipsychotic drugs c 
30 days 
Systemic calcineurin inhibitors, systemic 
antifungal agents, protease inhibitors, and 
cimetidine 
30 days 
Systemic anticholinergics e 
7 days 
Chinese complementary and alternative 
bronchodilatory medicines (CAM), ie, herbal 
therapies (eg, Astragalus membranaceus [huáng 
qí], Panax ginseng [ginseng products] and 
Cordyceps sinensis.  A.  membranaceus [ghost 
moth caterpillar fungus]) f 
10 days 
Note: Benzodiazepines are not exclusionary. 
a 
Carvedilol is allowed for the treatment of Class I/II congestive heart failure where use of this medication is 
appropriate 
b 
Anticonvulsants for conditions other than seizure disorders may be started and stopped at any time 
throughout the study 
c 
Antipsychotic agents and tricyclic antidepressants used for previously diagnosed underlying medical 
conditions are allowed if, in the opinion of the Investigator, there are no concerns regarding patient safety, 
and if the patient has been on a stable dose for at least 6 weeks prior to Visit 1  
d 
Investigators should contact the Medical Monitor to determine the appropriateness and safety of continuing 
study drug on a case by case basis (eg, XOLAIR® [omalizumab] will not be allowed, whereas a monoclonal 
antibody for another indication, such as osteoporosis, may be allowed after consultation with the Medical 
Monitor) 
e 
If systemic anticholinergics are used for treatment of overactive bladder and the treatment has been 
constant for at least 1 month prior to Visit 1, they are allowed. 
f 
Requires case-by-case review by the Investigator to determine appropriate wash-out period, if needed. 
 

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5.5 
Other Restrictions, Illicit Drugs, or Drugs of Abuse 
5.5.1 
Illicit Drugs 
Illicit drugs or drugs of abuse will not be allowed from the start of Screening (Visit 1) to the 
end of the Follow-up TC or to whenever the subject withdraws from the study.  If any illicit 
drugs or drugs of abuse are used by the subject during the study, the dates of use and the 
amount will be documented and the subject will be discontinued at the discretion of the 
investigator.  Medical marijuana is not an exclusionary drug if used for medical purposes, 
and there is no change in the dose or frequency of consumption. 
5.5.2 
Dietary Restrictions 
Subjects in the PK sub-study are encouraged to refrain from consuming grapefruits or 
grapefruit juice during the last 4 weeks of the study (i.e., between Visit 9 and Visit 10a).  
After the screening visit (Visit 1), subjects must not ingest xanthine and/or xanthine analogue 
(caffeine)-containing foods or beverages or caffeine containing medications, for at least 6 
hours prior to each study visit and for the duration of each study visit.  Examples of such 
products include coffee, tea, chocolate, and cola.  Decaffeinated beverages are acceptable. 
5.6 
Smoking Status 
Changes in a subject’s smoking status (i.e., stopping or re-starting smoking) may have an 
impact on the efficacy outcome measures.  At all visits, the subject will be asked about any 
recent change in their smoking status (i.e., whether a subject’s status has changed from 
smoker to non-smoker or vice versa).  Any change in smoking status during the Screening 
Period (Visit 1 to Visit 4) will result in a screen failure.  Smoking status changes during the 
24-week Treatment Period will be captured in the eCRF, but the subject will be permitted to 
continue in the study.  Subjects will be required to refrain from smoking (including medical 
marijuana and electronic cigarettes) for at least 4 hours prior to each study visit after the 
Screening Visit, and throughout the duration of each study visit.  Study participants may 
utilize various nicotine replacement treatments such as chewing gum and patches, as needed, 
in accordance with recommendations from the Investigator during the entire study visit. 
Note: For this study, the use of electronic cigarettes will be treated in the same manner as 
smoking. 
5.7 
Reasons for Treatment Discontinuation or Study Withdrawal 
5.7.1 
Reasons for Treatment Discontinuation 
The subject may voluntarily discontinue treatment at any time without prejudice to further 
treatment. 
If a subject experiences any of the changes of concern listed below, a repeat assessment 
should be obtained, and if confirmed, the subject should be discontinued from randomized 
treatment and continued in the study.  The changes of concern include: 

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• Calculated QTcF intervals >500 msec, and have increased by 60 msec or more over test 
day baseline value. 
• Hepatic impairment defined as abnormal liver function test of AST, ALT or total 
bilirubin ≥3 times upper limit of normal on repeat testing. 
 
If a subject experiences any of the changes of concern listed below, a repeat assessment 
should be obtained, and if confirmed, the Investigator or designee needs to make a 
determination as to the suitability of continuing the subject in the randomized treatment of 
the study.  The changes of concern include: 
• Following dosing, a heart rate increase of >40 bpm from the pre-dose value obtained on 
that specific test day and the measured value is also >120 bpm. 
• Following dosing, a systolic blood pressure increase of >40 mmHg from the pre dose 
value obtained on that specific test day and the measured value is also >160 mmHg. 
• Decrease in creatinine clearance to a value ≤30 mL/minute using CKD-EPI formula or a 
clinically relevant change from baseline as determined by the Investigator. 
 
If a subject requires any of the following prohibited medications, they should be discontinued 
from randomized treatment (see Section 8.7):  
• Initiation of maintenance therapy with any prohibited medications as listed in 
Section 5.4.3.   
• Initiation of maintenance therapy with a LABA (e.g., salmeterol, formoterol, indacaterol, 
vilanterol, olodaterol) administered alone or in combination with an ICS or a LAMA 
(e.g., tiotropium, aclidinium, glycopyrronium, umeclidinium). 
• Change inhaled maintenance therapy during the course of the study. 
 
NOTE: Subjects who suffer a COPD exacerbation (regardless of severity) will remain in the 
study and continue to take their assigned study drug unless the Investigator decides that it is 
in the best interest of the subject to discontinue randomized treatment and/or withdraw from 
the study (see Section 8).  
5.7.2 
Reasons for Study Withdrawal 
Subjects may be withdrawn from the study at any time at their own request, upon request of 
the Investigator, or by Pearl at any time or for any reason.  A subject who withdraws consent 
will always be asked about the reason(s) and the presence of any adverse events (AE).  For 
all subjects who withdraw from the study for any reason, they, their family or healthcare 
providers, will be contacted 24 weeks post randomization to determine vital status, and if 
applicable, cause of death (Section 8.10). 
If a female subject becomes pregnant during the course of the study, the subject will be 
withdrawn from the study and the pregnancy will be followed through delivery or final 
outcome (see Sections 7.2.4.4 and 7.5.12). 

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6 
LABELING, PACKAGING, STORAGE, DISPENSING, AND 
RETURN OF CLINICAL SUPPLIES 
6.1 
Subject Information 
Clinical supplies will be packaged to support enrollment of the study.  Study personnel will 
have access to an IWRS to allocate subjects, to assign drug to subjects and to manage the 
distribution of clinical supplies.  Clinical supplies will be packaged according to a component 
schedule generated by the Sponsor.  Each person accessing the IWRS must be assigned an 
individual unique personal identification number (PIN).  They must use only their assigned 
PIN to access the system and they must not share their assigned PIN with anyone. 
6.2 
Product Descriptions 
Investigational materials will be provided by Pearl as summarized in Table 5.   
Atrovent HFA and Ventolin HFA will be supplied as open-label MDIs.  Additionally, 
Symbicort TBH will also be supplied as open-label DPI. 
It is preferred that Atrovent and Ventolin be US-sourced products.  In cases where it is not 
possible for the US-sourced product to be used, a locally available product will be provided 
by the Sponsor.  The EU-sourced Symbicort TBH must be used for the active control, and a 
locally available product cannot be substituted for the sponsor-provided Symbicort TBH. 

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Table 5.  
Product Descriptions 
Product Name & Dose 
Product Strength 
Dosage Form/ Fill 
Count 
Administration 
Study Drug 
BGF MDI (PT010) 
320/14.4/9.6 µg 
ex-actuator 
160/7.2/4.8 µg per 
actuation 
MDI/ 
120 inhalations 
Taken as 2 inhalations 
BID 
GFF MDI (PT003) 
14.4/9.6 µg  
ex-actuator 
7.2/4.8 µg per actuation 
MDI/ 
120 inhalations 
Taken as 2 inhalations 
BID 
BFF MDI (PT009) 
320/9.6 µg  
ex-actuator 
160/4.8 µg per actuation 
MDI/ 
120 inhalations 
Taken as 2 inhalations 
BID 
Open-Label Products 
Budesonide and 
formoterol fumarate  
inhalation powder 
(Symbicort Turbuhaler)  
400/12 µga 
EU Source: Symbicort® 
Turbuhaler® 
200/6 µg per actuation 
Each metered dose 
contains: budesonide 
200 µg and formoterol 
fumarate dihydrate 6 µg 
per inhalation which 
corresponds to a 
delivered dose of 160 µg 
budesonide and 4.5 µg 
formoterol fumarate 
dihydrate per inhalation. 
DPI/ 
60 inhalations 
Taken as 2 inhalations 
BID 
Supplies are open-label 
Albuterol Sulfate  
inhalation aerosol 90 μgb 
ex-actuatorc 
US sourced: Ventolin® 
HFA 
HFA inhalation aerosol 
will be the US-supplied 
product.” Albuterol 
sulfate inhalation aerosol.  
Each inhalation contains 
108 μg corresponding to 
90 µg albuterol base from 
the mouthpiece 
MDI/ 
60 or 200 actuations 
Taken as directed 
Supplies are open-label 
Ipratropium bromide 
HFA inhalation aerosol 
34 μg  
ex-actuatore 
US sourced: Atrovent® 
HFA 
will be the US-supplied 
product.  Ipratropium 
bromide HFA Each 
inhalation contains 17 μg 
per actuation 
MDI/ 
200 actuations 
Taken as 2 inhalations 
QID during Screening 
Supplies are open-label  
BID=twice daily; BGF MDI=Budesonide, Glycopyrronium and Formoterol Fumarate Inhalation Aerosol;  
GFF MDI=Glycopyrronium and Formoterol Fumarate Inhalation Aerosol; BFF MDI=Budesonide and 
Formoterol Fumarate Inhalation Aerosol; HFA=Hydrofluroalkane; MDI=Metered Dose Inhaler; DPI=dry power 
inhalation;  
QID=4 times daily; EU=Europe; US=United States. 
a 
Active control.  Symbicort Turbuhaler is also known as Symbicort Turbohaler in some countries 

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Table 5.  
Product Descriptions 
Product Name & Dose 
Product Strength 
Dosage Form/ Fill 
Count 
Administration 
b 
Active control.  Albuterol sulfate is also known as salbutamol sulfate in some countries. 
c 
Reversibility testing at Visit 2, rescue medication during the study. 
d 
US-sourced products are the preferred product.  In cases where it is not possible for the US-sourced product 
to be used, a locally available product will be provided by Pearl. 
e 
Reversibility testing at Visit 3 and COPD maintenance therapy during Screening Period. 
Notes: All study drugs will be administered by oral inhalation.  Glycopyrronium 14.4 µg in GFF MDI is 
equivalent to 18 µg of glycopyrrolate (glycopyrronium bromide). 
Note: It is preferred that Atrovent and Ventolin be US-sourced products.  In cases where it is not possible for 
the US-sourced product to be used, a locally available product will be provided by the Sponsor.  The EU-
sourced Symbicort TBH must be used for the active control, and a locally available product cannot be 
substituted for the sponsor provided Symbicort TBH. 
 
Open-label Symbicort TBH DPIs will be provided from commercial supplies.  
Manufacturer’s instructions for study drug administration are provided in Appendix 3. 
Open-label Atrovent HFA MDIs will be provided from commercial supplies.  Manufacturer’s 
instructions for study drug administration are provided in Appendix 4. 
Open-label Ventolin HFA with dose counters will be provided from commercial supplies.  
Manufacturer’s instructions for study drug administration are provided in Appendix 5. 
6.3 
Primary Packaging and Labeling Information 
Investigational materials will be packaged by the Sponsor.  Symbicort TBH will be supplied 
as open-label DPI.  Atrovent HFA and Ventolin HFA will be supplied as open-label MDIs. 
Blinded Supplies: Each MDI will be labeled with a single label.  The MDI actuator will be 
labeled with a single label.  The foil pouch will be labeled with a single label.   
Open-label Supplies: Symbicort TBH will be supplied as open-label DPI.  The DPI actuator 
will be labeled with a single label.  Open-label Atrovent HFA and Ventolin HFA will be 
provided as individually-labeled MDIs.  Each MDI will contain a single label.  The MDI 
actuator will be labeled with a single label.  Labels will be printed with black ink and may 
include the following text: Labels will be printed with black ink and may include the 
following text: 
Lot # (Packaging Lot Trace ID) 
Space for entry of screening # 
Component ID # 
Space for entry of randomization # 
Fill Count & Dosage Form 
Visit # (Space for Entry of Interval ID) 
Storage Conditions 
Protocol # 
Country regulatory requirements 
Sponsor address Translation Key 
ID=identification; #=number 

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6.4 
Secondary Packaging and Labeling Information (Box) 
Blinded investigational drug and open-label supplies (Symbicort TBH, Atrovent HFA, 
Ventolin HFA, and locally-sourced products, as applicable) will be packaged in individual 
boxes as outlined in Table 6.  Box configuration is subject to change as a result of packaging 
constraints. 
Table 6.  
Description of Boxes 
Drug Supplies 
Individual Box Contents 
Blinded 
1 MDI 
Symbicort Turbuhaler  
1 DPI 
Atrovent (ipratropium bromide) HFAa 
1 MDI 
Ventolin (albuterol sulfate) HFAa  
1 MDI 
DPI=dry powder inhaler; HFA=Hydrofluoroalkane; MDI=metered dose inhaler 
a 
In cases where it is not possible for the US-sourced product to be used, a locally available product will be 
provided by the Sponsor. 
 
Each box will be labeled with a 2-part label printed with black ink and may include the 
following text: 
Packaging Lot ID # 
Space for entry of screening # 
Component ID # 
Space for entry of randomization # 
Kit Contents (1 MDI) 
Space for entry of Interval ID 
Re-evaluation/Expiration date (if applicable) 
Dosing Instructions (if applicable) 
Storage Conditions 
Compound ID - Protocol # 
Country regulatory requirements 
Sponsor address (if applicable) 
Translation Key (if applicable) 
ID=identification; #=number 
 
6.5 
Emergency Unblinding of Treatment Assignment 
The IWRS should be used in order to unblind subjects and to unmask drug identity.  When 
the Investigator contacts the system to unblind a subject, he/she must provide the requested 
subject identifying information and confirm the necessity to unblind the subject.  Pearl will 
not provide a disclosure envelope with the clinical supplies. 
The Investigator or treating physician may unblind a subject’s treatment assignment only in 
the case of an emergency, when knowledge of the study treatment is essential for the 
appropriate clinical management or welfare of the subject. 
Whenever possible, the Investigator must first discuss options with the Medical Monitor or 
appropriate study personnel before unblinding the subject’s treatment assignment.  If this is 
impractical, the Investigator must notify Pearl as soon as possible, but without revealing the 
treatment assignment of the unblinded subject, unless that information is important for the 

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safety of subjects currently in the study.  The date and reason for the unblinding must be 
recorded in the appropriate data collection tool. 
6.6 
Storage Requirements 
Blinded Supplies should be kept in a secured location.  BGF MDI, GFF MDI, and BFF MDI 
should be stored below 25° C (77° F) in a dry place.  Excursions permitted up to 30° C (86° 
F). 
Symbicort® Turbuhaler supplies: Do not store above 30°C (84° F).  Keep the container 
tightly closed, in order to protect from moisture. 
Ventolin® HFA supplies: Store between 15°C and 25°C (59°F and 77°F).  Store the inhaler 
with the mouthpiece down.  For best results, the inhaler should be at room temperature 
before use.  Do not use or store near heat or open flame.  Exposure to temperatures above 
120°F (49°C) may cause bursting.  Never throw into a fire or incinerator. 
Atrovent® HFA supplies: Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F 
to 86°F) [Refer to Unites States Pharmacopoeia Controlled Room Temperature].  For optimal 
results, the canister should be at room temperature before use.  Do not puncture.  Do not use 
or store near heat or open flame.  Exposure to temperatures above 120°F (49°C) may cause 
bursting.  Never throw the inhaler into a fire or incinerator. 
The clinical supplies storage area at the site must be monitored by the site staff for 
temperature consistency with the acceptable storage temperature range specified in 
accordance with the product label.  Documentation of temperature monitoring should be 
maintained. 
6.7 
Instructions for Preparation of Treatments for Administration and 
Dispensing 
6.7.1 
BGF MDI, GFF MDI, BFF MDI 
Individual BGF MDI, GFF MDI, and BFF MDI will be packaged in a foil pouch and 
contained in an individual visit treatment box.  Both the visit treatment box and the foil 
overwrap will have a label with a component ID number.  Confirm that the identifier given 
by IWRS and the component ID number written on the label are the same.  The visit 
treatment box is labeled with a 2 part label.  Write the subject number and treatment visit 
number on each of the 2-part labels.  The ‘tear-off’ part of the label is to be placed onto the 
IWRS confirmation report. 
All MDIs must be primed before the first use.  Priming involves releasing a certain number 
of sprays (4) into the air before the first use of the inhaler.  Shaking and priming the inhaler 
fills a chamber inside the canister with the correct dose and mix of medication so that the 
inhaler is ready to use. 

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The MDI must be primed in a separate room, away from the subject treatment area.  Each 
dose will consist of 2 puffs from the MDI.  Subjects will be dispensed the MDI and 
instructed to continue taking study medication twice daily, 2 puffs in the morning and 2 puffs 
in the evening approximately 12 hours apart, until subject returns to the clinic.  The MDI 
should be stored at room temperature by the subject, to avoid temperature extremes, and the 
products should not be stored in direct sunlight.  Refer to Appendix 2 for instructions on 
administration and cleaning of BGF MDI, GFF MDI, and BFF MDI. 
6.7.2 
Symbicort® Turbuhaler 
Refer to Appendix 3 for instructions on the administration and cleaning of Symbicort® 
Turbuhaler®. 
6.7.3 
Atrovent® HFA (Ipratropium Bromide) 
Refer to Appendix 4 for instructions on the administration of Atrovent® HFA. 
6.7.4 
Ventolin HFA® (Albuterol Sulfate) 
Refer to Appendix 5 for the manufacturer’s instructions on the administration and cleaning of 
Ventolin HFA. 
6.8 
Drug Accountability/Return of Clinical Supplies 
Under no circumstances will the Investigator(s) allow the study drug to be used other than as 
directed by this protocol. 
Investigational clinical supplies must be received by a designated person at the study site, 
handled and stored safely and properly, and kept in a secure location to which only the 
Investigator and designated assistants have access.  Storage conditions for the clinical 
supplies should be observed, monitored and documented.  Clinical supplies are to be 
dispensed only in accordance with the protocol.  The Investigator or designee is responsible 
for keeping accurate records of the clinical supplies received from Pearl, the amount 
dispensed to and returned by the subject, and the amount remaining at the conclusion of the 
study.  Study medication should be handled in accordance with Good Pharmacy Practices 
(i.e., gloves should always be worn by study personnel if directly handling tablets or capsules 
that are returned).  The Clinical Monitor should be contacted with any questions concerning 
investigational products where special or protective handling is indicated.  At the end of the 
study, all clinical supplies including partial and empty containers must be returned as 
directed by Pearl. 
Sites should check with the Pearl representative for appropriate documentation that needs to 
be completed for drug accountability. 
The Investigator or designated assistant should not open individual clinical supply containers 
until all pre-dose assessments have been completed and the subject is eligible to be 

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randomized/continue with the study.  Any deviation from this must be discussed with the 
Clinical Monitor. 
For each subject, all used study drug materials will be collected.  Used subject supplies will 
be kept at room temperature in a secure and locked cabinet until returned to Pearl or 
designee.   
Note: Used study drug will be stored separately from unused study drug. 
All product complaints (including device malfunctions) must be reported to Pearl using the 
Product Complaints Form provided in each site’s regulatory binder.  Pearl will contact the 
site to evaluate the nature of the complaint and determine what further action is needed. 

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7 
STUDY PROCEDURES 
A schedule of events is provided in Table 8.  Detailed schedules for pre-and post-dose 
procedures to be performed at Visit 4 through Visit 10a are provided in Table 9.  Detailed 
schedules for pre-and post-dose procedures at Visit 4 (Day 1) and Visit 10a (Week 24) for 
subjects participating in the HPA Axis sub-study and Visit 10a (Week 24) for subjects 
participating in the 12-hour PFT and Week 24 PK profile sub-studies are provided in 
Table 10. 
7.1 
Efficacy Assessments 
7.1.1 
Pulmonary Function Tests 
Forced expiratory spirometry maneuvers for derivation of FEV1, FVC, FEF25-75, and PEFR 
will be assessed using a spirometer that meets or exceeds minimum performance 
recommendations of the ATS (Refer to Appendix 6). 
The volume accuracy of the spirometer is to be checked daily using a 3 L syringe across 3 
flow ranges (i.e., low, medium and high flows), with temperature and barometric pressure 
correction.  The calibration syringe must meet ATS specifications and must not be used 
beyond the expiry date.  Required accuracy is ±3% (i.e., 3.09 L to 2.91 L) (ATS/ERS).  The 
results will be printed and maintained in a calibration log, which will be monitored for 
compliance during the monitoring visits (Refer to Appendix 7, Spirometry Assessment 
Criteria). 
All PFTs including FEV1, FVC, and PEFR as defined in ATS/ERS guidelines will be 
performed in accordance with ATS criteria (Miller, 2005). 
To standardize spirometry, all sites will be provided with identical spirometry systems 
 with customized, study-
specific software.  All study staff responsible for performing pulmonary function testing will 
receive standardized training at the Investigator meetings.  All technicians are required to 
demonstrate proficiency in the use of the equipment and the ability to perform technically 
acceptable PFTs (ATS criteria, Miller, 2005) prior to performing testing on study subjects.  
After each test is performed, the spirometry software will provide immediate feedback to the 
technician indicating whether the effort meets ATS acceptability and repeatability standards.  
All efforts will be stored electronically.  After completion of testing, the study staff will 
electronically transmit the spirometric measurements for centralized quality assurance review 
.  Feedback on the quality of the measurements 
will be provided to the investigational site and to Pearl or designee for central data 
management. 
At Visit 1, a single spirometry assessment will be conducted.   
Note: Spirometry must meet both acceptability and repeatability criteria.  (Refer to Exclusion 
Criteria, Section 5.2).   

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At Visit 2 and Visit 3, spirometry will be conducted 60 minutes and 30 minutes prior to 
bronchodilator administration and at 30 min post bronchodilator.   
Note: Spirometry must meet both acceptability and repeatability criteria.  (Refer to Exclusion 
Criteria, Section 5.2). 
Spirometry will be conducted 60 minutes and 30 minutes prior to study drug administration 
at Visit 4 through Visit 10a.  The mean of the 60 minutes and 30 minutes pre-dose spirometry 
assessments conducted at Visit 4 will be used to establish baseline FEV1, FVC, FEF25-75, and 
PEFR. 
At Visit 4 (Day 1) through Visit 10a (Week 24) spirometry will be obtained at 15 and 30 
minutes, and 1, 2 and 4 hours post-dosing of study drug.  Note: At Visit 4 (Day 1) only, a 5-
minute post-dose spirometry assessment will also be obtained. 
For subjects participating in the 12-hour PFT sub-study, at Visit 10a (Week 24), 
additional spirometry assessments will be obtained at 6, 8, 10, 11.5 and 12 hours after dosing. 
7.1.1.1 
Characterization of Reversibility 
Reversibility to Ventolin HFA will be evaluated at Visit 2 and reversibility to Atrovent HFA 
will be evaluated at Visit 3.  The procedures will be as follows: 
• Reversibility testing to Ventolin HFA (Visit 2 Only): 
- 
Perform pre-bronchodilator PFTs (-60 min and -30 min) prior to administration of 
Ventolin HFA 
- 
Administer 4 puffs of Ventolin HFA 
- 
Perform post-bronchodilator PFT 30 min after the administration of Ventolin HFA or 
locally available SABA. 
 
• Reversibility testing to Atrovent HFA (Visit 3 Only): 
- 
Perform pre-bronchodilator PFTs (-60 min and -30 min) prior to administration of 
Atrovent HFA. 
- 
Administer 4 puffs of Atrovent HFA  
- 
Perform post-bronchodilator PFT 30 minutes after the administration of Atrovent 
HFA or locally available short-acting anticholinergic 
 
Reversibility will be a comparison of the average best FEV1 effort obtained at -60 min 
and -30 min pre-bronchodilator to the best FEV1 effort obtained at 30 minutes post- 
bronchodilator.  A subject is determined to be reversible to Ventolin HFA or Atrovent HFA, 
if the improvement in FEV1 approximately 30 minutes following administration of 4 puffs of 
Ventolin HFA or Atrovent HFA, respectively, is ≥12% and ≥200 mL.  Reversibility to 
Ventolin HFA (obtained at Visit 2) will be used as a stratification variable at randomization 
to ensure an even distribution of reversibility across the treatment arms.  Reversibility to 
Atrovent HFA will be used to characterize the population. 

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7.1.1.2 
FEV1 Baseline Stability Criteria 
All comparisons will be made to the baseline (mean of 60 and 30 minutes prior to dosing) 
values obtained at Visit 4 (Randomization), it is important to ensure that the baseline FEV1 is 
stable and reflective of the subjects COPD severity prior to being randomized into the study.  
As such, the baseline FEV1 at Visit 4 must be within ±20% or 200 mL of the mean of the pre 
dose FEV1 obtained at the 2 preceding visits (average of pre-dose FEV1 obtained at Visit 2 
and Visit 3).  At Visit 4, if the pre-dose FEV1 average is outside of the ±20% or 200 mL 
range, but the -30 min assessment is within ±22% or 220 mL, then another assessment may 
be conducted 30 minutes later.  If the last 2 assessments meet the FEV1 baseline stability 
requirements (i.e., within ±20% or 200 mL), the initial 60 minute pre-dose assessment will 
not be used and the last 2 assessments will be used to establish the eligibility criteria.  If the 
test day FEV1 is not within ±20% or 200 mL, the subject will not be randomized and will be 
considered a screen failure. 
7.1.2 
Subject Electronic Diary Data Collection 
Subjects will be provided with an electronic Diary (eDiary) at screening to be completed 
twice daily to record time of study medication administration, daily symptoms using the 
Exacerbations of Chronic pulmonary disease Tool (EXACT) scale (see Section 7.1.4.5), and 
the use of rescue albuterol (Ventolin HFA) throughout their study participation.  The dose 
indicator reading will be recorded from Visit 4 onwards once daily for subject on blinded 
study drug.  Before issuing the eDiary to the subject, site personnel will be responsible for 
programming the eDiary and training the subject on its use. 
During the screening period (between Visit 1 and Visit 4), subjects will be required to 
demonstrate acceptable eDiary collections and compliance in order to be eligible for 
randomization.   
Electronic Diary Compliance Requirement: Subject participation may be terminated at any 
time during the study for the following reasons: 
• Chronic failure, in the judgment of the Investigator, to comply with diary compliance, 
despite documentation at the site of repeated efforts to reinforce compliance.  As defined 
for this study, compliance requires >70% subject completion of diary assessments.  Pearl 
may also instruct a site to discontinue a subject based on consistent noncompliance.   
• Subjects who are unable to meet the compliance requirement (>70% subject completion 
of diary assessments) in the last 7 days preceding the Randomization Visit (Visit 4) will 
be considered a screen failure. 
 
The eDiary data report will be available to site personnel through the vendor's server.  The 
eDiary data report should be reviewed by the study personnel at each visit.  The review 
should verify that morning and evening diary entries have been recorded by the subject for 
compliance requirements.  The EXACT responses will be reviewed at each visit as part of the 
subject diary review.  The subject should be reinstructed, as appropriate, on the importance 
of recording twice daily entries if missing entries are observed. 

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7.1.2.1 
Rescue Medication Usage 
The subject will record the total number of “puffs” of rescue medication (i.e., albuterol 
sulfate or locally available equivalent product) used on a daily basis in the eDiary.  The 
number of “puffs” of rescue product will be recorded as the number of actuations on the 
canister.  For example, when rescue product is required and 2 actuations are inhaled, this 
should be recorded as 2 “puffs.” In the event the subject requires 4 actuations, this should be 
recorded as 4 “puffs”.  Subjects requiring more than 8 puffs per day on 3 consecutive days 
with worsening symptoms should contact the site. 
7.1.2.2 
Medication Compliance 
Time of dosing with study medication will be recorded in the subject’s eDiary for each day 
of treatment (except the in-clinic dosing time).  Study medication compliance will be 
checked at all visits, and any issues identified will be documented in the appropriate study 
files. 
7.1.2.3 
Major/Minor Symptom Worsening Assessment and Alert System 
All major and minor symptoms of a worsening event will be captured once each morning for 
the purposes of a symptom worsening alert.  The purpose of this alert is to notify both the 
subject and the site of a potential symptom worsening event that warrants contact between 
the subject and site for further evaluation. 
All questions will have a 24-hour recall period.  Questions pertaining to the severity of 
symptoms versus their usual state will have 3 response options (e.g., How breathless have 
you been in the last 24 hours? Less breathlessness than usual, Usual level of breathlessness, 
More breathless than usual) whereas questions related to the presence or absence of a 
symptom will have a dichotomous response (e.g., Have you had a sore throat in the last 24 
hours? No, Yes, I had a sore throat). 
An alert will be triggered if 2 or more major symptoms (dyspnea, sputum volume, and 
sputum color) worsen for 2 consecutive days or if 1 major symptom and 1 minor symptom 
(sore throat, cold, fever without other cause, cough, and wheeze) worsen for at least 2 
consecutive days.  When either of these criteria is met, the subject will be alerted via the 
eDiary to contact the site as soon as possible for further evaluation.  Likewise, the study site 
will be alerted to contact the subject within approximately 24 to 72 hours if he/she has not 
yet contacted the study site for further evaluation. 
7.1.3 
COPD Exacerbations 
A COPD exacerbation will be defined as a change in the subject’s usual COPD symptoms 
that lasts 2 or more days, is beyond normal day-to-day variation, is acute in onset, and may 
warrant a change in regular medication.  The change in symptoms must include at least one 
major COPD symptom and at least one other major or minor symptom from the list below: 
• Major COPD symptoms: dyspnea, sputum volume, and sputum color  

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• Minor COPD symptoms: cough, wheeze, sore throat, cold symptoms (rhinorrhea or nasal 
congestion), and fever without other cause  
 
If symptoms are acute or have progressed rapidly and require treatment less than two days 
from onset of symptoms, the investigator will have to justify the decision for defining the 
event as an exacerbation and record it in the eCRF.   
If a subject’s symptoms and the overall clinical findings support the diagnosis of a COPD 
exacerbation, but the subject has not experienced a worsening of at least one major COPD 
symptom and at least one other major or minor symptom, the investigator will have to justify 
the decision for defining the event as an exacerbation and record it in the eCRF. 
7.1.3.1 
Severity of COPD Exacerbation 
COPD exacerbations will be classified as mild, moderate or severe based on the following 
criteria: 
Exacerbations will be considered moderate if they result in:  
• Use of systemic corticosteroids and/or antibiotics for at least 3 days; a single depot 
injectable dose of corticosteroids will be considered equivalent to a 3-day course of 
systemic corticosteroids 
 
Exacerbations will be considered severe if they result in:  
• An inpatient COPD-related hospitalization (documentation stating that the subject was 
hospitalized for the COPD exacerbation or a record of the subject being admitted for ≥24 
hours to an observation area, the emergency department, or other equivalent healthcare 
facility depending on the country and healthcare system). 
• COPD-related death 
 
Exacerbations will be considered mild if they do not meet the requirements to be classified as 
moderate or severe but otherwise fulfill the definition of COPD exacerbation. 
7.1.3.2 
Duration of COPD Exacerbation 
For moderate or severe exacerbations, the duration is defined by the length of prescribed 
treatment, whereas for mild exacerbations, the duration is defined by the length of symptoms. 
For moderate or severe COPD exacerbations, the start date will be defined as the start date of 
prescribed treatment with a systemic corticosteroid or systemic antibiotic and the stop date 
will be defined as the last day of prescribed treatment with a systemic corticosteroid or 
systemic antibiotic.  In order to ensure that the same event is not counted twice, concurrent 
moderate or severe COPD exacerbations with start and stop dates equal to or less than 7 days 
apart will be considered the same event and assigned the maximum severity between the two. 

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For mild COPD exacerbations, start date will be defined as the onset of worsened symptoms 
as recorded by the subject in the eDiary, and the stop date will be defined as the last day of 
worsened symptoms.  In order to ensure that the same event is not counted twice, mild COPD 
exacerbations with start and stop dates equal to or less than 7 days apart will be considered 
the same event. 
7.1.3.3 
Approach for Capturing COPD Exacerbations 
All moderate or severe COPD exacerbations must be captured using the COPD Exacerbation 
eCRF.  Mild COPD exacerbations will be captured based on symptoms as recorded by the 
subject in the eDiary.  COPD exacerbations of any severity will be considered expected study 
endpoints and will not be reported as adverse events (AEs) unless considered a serious AE 
(SAE). 
7.1.3.4 
Other Information 
Pearl Therapeutics will be using an electronic diary (eDiary) to capture daily symptom 
reporting.  If symptoms meet a specific threshold (i.e., one major COPD symptom and at 
least one other major or minor symptom for 2 consecutive days), the eDiary generates alerts 
to the subject and the clinical site.  This alert is intended to generate a contact between the 
subject and the clinical investigator.  The clinical investigator makes the decision to escalate 
or initiate treatment (steroids and/or antibiotics and/or hospitalizations). 
Circumstances will occur where symptoms are not captured in the eDiary (e.g.  technical 
difficulties, rapid deterioration, or sudden death).  In these cases, the investigator or designee 
will enter the information into the eCRF to capture the symptoms related to a COPD 
exacerbation. 
7.1.3.5 
Investigator-Judged COPD Exacerbations 
For events which do not meet the outlined symptom criteria and/or when symptoms have a 
shorter duration, the investigator can justify the decision for considering the event an 
exacerbation.  Exacerbations could be defined by an investigator when symptoms of COPD 
warranted urgent treatment due to rapid onset or rapidly progressive symptoms.  Such a 
situation does not allow enough time to strictly fulfill the criteria for symptom duration (≥2 
consecutive days).  In these cases, the investigator may define such an event as a COPD 
exacerbation.  As clinical presentations may vary among patients with COPD, exacerbations 
defined by an investigator can be supported by respiratory symptoms that may not strictly 
fulfill all symptom requirements defined above.  Since the investigator will need to document 
the symptoms that justify his or her decision to begin treatment defining a COPD 
exacerbation event, all exacerbations in the study will have documented symptoms justifying 
their clinical relevance. 
7.1.4 
Subject Questionnaires 
The following subject questionnaires will be completed by subjects using the study-supplied 
electronic questionnaire devices at specified visits throughout the study: CAT, SGRQ, and 

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EQ-5D-5L.  The BDI/TDI will be interviewer-administered to study subjects using the study-
supplied questionnaire (electronic version) at specified visits throughout the study.  The 
EXACT questionnaire will be captured via the subject eDiary (see Section 7.1.2).  When the 
BDI/TDI, SGRQ, and/or EQ-5D-5L are obtained at the same visit, it is recommended that the 
BDI/TDI be collected first, followed immediately by the SGRQ and then the EQ-5D-5L.   
7.1.4.1 
Chronic Obstructive Pulmonary Disease Assessment Test (CAT) 
The CAT is a self administered questionnaire designed to assess the condition of subjects and 
overall impact of COPD [Jones, 2009].  It has been proven that the CAT has good 
repeatability and discriminative properties, which suggest that it is sensitive to treatment 
effects at a group level.  Since the CAT is designed to assess the impact of COPD on the 
subject by measuring overall impairment, it has moderate correlations with other instruments, 
such as the Modified Medical Research Council Dyspnea Scale, SGRQ, and the 6 minute 
walk test.   
Subjects will complete the CAT (Refer to Appendix 8) at Visit 2.  The CAT score will 
describe the burden and symptomatic impact of COPD in subjects enrolled in the Study and 
will be used to determine subject eligibility to participate in the study. 
7.1.4.2 
Baseline and Transition Dyspnea Indices 
Dyspnea is the primary symptom of COPD and its relief is an important goal of therapy.  In 
the evaluation of pharmacotherapy for COPD, several instruments are available to provide a 
discriminative and evaluative assessment of dyspnea.  Among these are the BDI and TDI 
indices, which assess breathlessness in components related to functional impairment, 
magnitude of task and magnitude of effort.  The reliability and validity of the BDI have been 
reported (Mahler, 1984).  The validity of the BDI/TDI based on its association with other 
related measures has also been demonstrated (Witek, 2003).  The BDI/TDI questionnaire 
should always be completed before any other assessments are made to avoid influencing the 
responses.  The Interviewer-administered rating of severity of dyspnea at a single state 
provides a multidimensional measurement of dyspnea based on 3 components that evoke 
dyspnea in activities of daily living, in symptomatic individuals.  The BDI score ranges from 
0 (very severe impairment) to 4 (no impairment) for each domain and are summed to 
determine the BDI focal score (0 to 12) (i.e., the lower the score, the worse the severity of 
dyspnea).  The appropriate language version of the questionnaires will be used.  The 
questionnaire can be found in Appendix 9.   
The TDI measures changes in dyspnea severity from the baseline as established by the BDI.  
TDI components are: Change in Functional Impairment, Change in Magnitude of Task, and 
Change in Magnitude of Effort.  The TDI score ranges from -3 (major deterioration) to +3 
(major improvement) for each component.  The sum of all components yields the TDI focal 
score (-9 to +9) (i.e., the lower the score, the more deterioration in severity of dyspnea).  The 
BDI will be completed at Visit 4 (Day 1, prior to study drug administration).  The TDI will 
be completed at each post-randomization visit including the Treatment 
Discontinuation/Withdrawal Visit. 

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The BDI/TDI should be completed prior to study drug administration and before 
administration of SGRQ Questionnaire. 
7.1.4.3 
St.  George Respiratory Questionnaire 
The SGRQ 4-week recall tool will be used to provide the health status/health-related quality- 
of-life measurements in this study (Refer to Appendix 10).  The appropriate language version 
of the questionnaires will be available in each participating country.  The subject should 
complete the questionnaires in a quiet area and be allowed to ask questions; however site 
staff should take care not to influence the subject’s responses.  The subject will be instructed 
to provide the most accurate and best individualized response about how they felt regarding 
their health status/health-related Quality of Life in the last 4 weeks from the study visit day.  
The questionnaire will be checked for completeness and collected before the subject leaves 
the study site.  At later visits, subjects are not allowed to review their previous responses.   
The SGRQ contains 50 items divided into 3 domains: "Symptoms" concerned with 
respiratory symptoms, their frequency and severity; "Activity" concerned with activities that 
cause or are limited by breathlessness; and "Impacts" which covers a range of aspects 
concerned with social functioning and psychological disturbances resulting from airway 
disease.  A “Total” score combining each domain will be calculated.  In each case the lowest 
possible value is zero and the highest is 100.  Higher values correspond to greater impairment 
of quality of life.  Completed questionnaires will be reviewed and examined by the 
Investigator or designee, before the clinical examination, for responses which may indicate 
potential AEs or SAEs.  The Investigator should review not only the responses to the 
questions in the questionnaire but also for any unsolicited comments written by the subject.  
Investigators should not encourage the subjects to change the responses reported in the 
questionnaire. 
The SGRQ will be completed by the subject prior to study drug administration at Visit 4 
(Day 1) and at each post-randomization visit including the Treatment 
Discontinuation/Withdrawal Visit. 
7.1.4.4 
European Quality-of-Life-5 Dimension Questionnaire 
The EQ-5D-5L is a standardized instrument for use as a measure of health outcome.  
Applicable to a wide range of health conditions and treatments, it provides a simple 
descriptive profile and a single index value for health status [EuroQol, 2014].  The EQ-5D-
5L consists of 2 assessments, a descriptive system and a visual analogue scale (VAS).  The 
descriptive system comprises of the following 5 dimensions: mobility, self-care, usual 
activities, pain/discomfort, and anxiety/depression.  Each dimension has 5 severity levels: no 
problems, slight problems, moderate problems, severe problems, and extreme problems.   
The VAS records the respondent’s self-rated health on a 20 cm, 0-100 vertical scale with 
endpoints labeled “the best health you can imagine” and “the worst health you can imagine”, 
with higher scores corresponding to a better health state.  This information is used as a 
quantitative measure of health as judged by the individual respondents.   

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The EQ-5D-5L (see Appendix 11) will be completed by the subject prior to study drug 
administration at Visit 4 (Day 1; Randomization) and at each post-randomization visit 
including the Treatment Discontinuation/Withdrawal Visit. 
7.1.4.5 
Exacerbations of Chronic Pulmonary Disease Tool (EXACT) 
The EXACT is a 14-item patient-reported outcome (PRO) instrument developed to assess the 
frequency, severity and duration of COPD exacerbations (Jones, 2011).  The instrument was 
developed for daily, at home, administration using a handheld electronic device.  
Respondents are instructed to complete the diary each evening just prior to bedtime and to 
answer the questions while considering their experiences “today”.  The instrument includes 
assessments of breathlessness (5 items), cough and sputum (2 items), chest symptoms (3 
items), and 4 additional items (difficulty with sputum, tired or weak, sleep disturbance, and 
psychological state).   
The daily EXACT total score is computed across the 14 items and has a range of 0-100 with 
higher scores indicative of greater severity.  Total score changes are used to identify the onset 
and recovery from an EXACT-defined exacerbation event.  In identifying event onset and 
recovery, the EXACT can provide information on event frequency and duration as well as 
event severity. 
The E-RS is an 11-item sub-set of the 14- question EXACT to evaluate the severity of 
respiratory symptoms of COPD (Jones, 2011).  The E-RS was designed to be captured as part 
of the daily EXACT assessment.  On 07 March 2016, the EXACT-Respiratory Symptoms 
Scale was renamed the Evaluating Respiratory Symptoms (E-RS) measure. When referring 
specifically to its use in COPD, the proposed context of use for qualification, the full name is 
now “Evaluating Respiratory Symptoms in COPD (E-RS™: COPD).  Summation of E-RS 
item responses produces a total score ranging from 0 to 40, with higher scores indicating 
greater severity.  In addition to the total score, symptom domain scores can be calculated for 
breathlessness (5 items; score range: 0–17), cough and sputum (3 items; score range: 0–11) 
and chest symptoms (3 items; score range: 0–11) by summing the responses of items within a 
respective domain.  As with the total score, higher domain scores indicate greater severity. 
The EXACT (see Appendix 12) will be completed daily by the subject as part of the eDiary 
assessments. 
7.2 
Safety Assessments 
The safety assessments include physical examination findings, vital signs, ECGs, and clinical 
laboratory tests in addition to recording of AEs. 
7.2.1 
Medical/Surgical History and Physical Examination 
Medical history, including specific cardiovascular history details, will be collected at Visit 1 
(Screening) and updated during the Screening Period (Visit 1 to Visit 4).  The number of 
COPD exacerbations requiring oral steroids and/or oral antibiotics, or hospitalization within 
12 months of Visit 1 (Screening) will be collected.  A complete physical examination will be 

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performed at Visit 1 (Screening) and at Visit 10a or Treatment Discontinuation/Withdrawal 
Visit.  A complete physical examination will include evaluation of the following: general 
appearance, skin, head, eyes, ears, nose, throat, neck (including thyroid), lymph nodes, chest, 
heart, abdomen, extremities, and nervous system.  Weight, assessed in ordinary indoor 
clothing with shoes removed will be recorded at Visit 1 (Screening) and Visit 10a or 
Treatment Discontinuation/Withdrawal Visit only.  Height will be recorded at Visit 1 
(Screening) only. 
7.2.2 
Vital Sign Measurements 
Vital signs, including Heart rate (HR) and systolic and diastolic blood pressure (DBP), and 
temperature will be assessed as outlined below; assessments may be obtained while the 
subject is resting for 5 minutes in either the supine or seated position. 
A single set of vital signs will be obtained at Visit 1 (Screening) and the Treatment 
Discontinuation/Withdrawal Visit. 
Vital signs will be obtained at Visit 2 and Visit 3 within 60 minutes pre-bronchodilator and at 
30 minutes post-bronchodilator.   
At Visit 4 (Randomization) only, pre-dose vital signs will be obtained two times at least 5 
minutes apart within 1 hour prior to dosing.  Post-dose vital signs will be obtained 30 
minutes and 2 hours post study drug dosing.   
Note: Temperature will be obtained at Visit 1 (Screening) and pre dose at all visits and will 
not be repeated post dose at subsequent time points unless clinically indicated.   
At Visits 5 through 10a:  
• Pre-dose vital signs will be obtained once within 1 hour prior to dosing. 
• Post-dose vital signs will be obtained at 30 minutes and 2 hours post study drug dosing at 
all treatment visits. 
 
For subjects participating in the 12-hour PFT and PK sub-studies at Visit 10a 
(Week 24), additional vital signs will be obtained at 12 hours post study drug dosing. 
7.2.3 
12-Lead Electrocardiogram 
• A single ECG will be obtained at Visit 1 (Screening) and the Treatment 
Discontinuation/Withdrawal Visit.   
 
Timed ECGs will be obtained as follows: 
• Visit 2 and Visit 3 within 60 minutes pre-bronchodilator and at 30 minutes post-
bronchodilator.   

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7.2.4 
Clinical Laboratory Tests 
Clinical safety laboratory tests will be analyzed by a central laboratory according to 
standardized, validated assays.  The laboratory will supply detailed instructions and all 
containers for blood and urine investigations.  Blood sample volumes will meet the 
laboratory’s specification.  All clinical laboratory tests will be obtained at Visit 1 (Screening) 
and prior to dosing at Visit 4 (Day 1), Visit 5 (Week 4), Visit 7 (Week 12) and Visit 10a 
(Week 24) and the Treatment Discontinuation/Withdrawal Visit. 
A Basic Metabolic Panel (BMP) will be obtained at 30 minutes and 2 hours post-dosing at 
Visit 4 (Day 1), Visit 5 (Week 4), Visit 10a (Week 24). 
7.2.4.1 
Hematology 
Hemoglobin, hematocrit, red blood cell count, white blood cell count with differential, and 
platelet count will be measured at Visit 1 (Screening) and prior to dosing at Visit 4 (Day 1), 
Visit 5 (Week 4), Visit 7 (Week 12) and Visit 10a (Week 24), or the Treatment 
Discontinuation/Withdrawal Visit. 
7.2.4.2 
Clinical Chemistry 
Albumin, alkaline phosphatase, total bilirubin, blood urea nitrogen (BUN), calcium, total 
cholesterol, magnesium, phosphate, sodium, potassium, chloride, creatinine, gamma-
glutamyl transferase, blood glucose, total protein, triglycerides, bicarbonate, aspartate 
aminotransferase (AST), and alanine aminotransferase (ALT) will be measured at Visit 1 
(Screening) and prior to dosing at Visit 4 (Day 1), Visit 5 (Week 4), Visit 7 (Week 12) and 
Visit 10a (Week 24), or the Treatment Discontinuation/Withdrawal Visit. 
Refer to Table 7 for a list of study-associated laboratory tests.  The central laboratory will 
supply procedures for the preparation and collection of these samples. 
Table 7.  
Clinical Laboratory Tests 
Hematology 
 
Hemoglobin  
Mean corpuscular hemoglobin  
Hematocrit  
Mean corpuscular hemoglobin concentration  
White blood cell count with differential  
Mean corpuscular volume  
Red blood cell count  
Eosinophils 
Platelet count  
 
Clinical Blood Chemistry 
 
Liver Enzyme and Other Liver Function Tests 
Other Clinical Blood Chemistry 
Alanine aminotransferase  
Albumin 
Aspartate aminotransferase  
Blood Urea Nitrogen (BUN) 
Alkaline phosphatase  
Calciuma 
Bilirubin, total  
Chloridea 
Gamma-glutamyl transferase  
Cholesterol  

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Table 7.  
Clinical Laboratory Tests 
 
Bicarbonate 
 
Creatininea 
 
Glucosea 
 
Magnesium  
 
Potassiuma 
 
Phosphate 
 
Protein, total  
 
Sodiuma 
 
Triglycerides  
Urinalysis 
Macroscopic examination including specific gravity, pH, protein, glucose, ketones, blood, and  
urobilinogen. 
Other Tests: 
Pregnancy test (women of childbearing potential only): serum hCG at Visit 1 (Screening), and Final 
Visit (Visit 10a) or  
Treatment Discontinuation Visit; urine hCG at Visit 7 (Week 12). 
Creatinine clearance will be estimated by the CKD-EPI formula [Levey, 2009]. 
Abbreviations: CKD EPI=Chronic Kidney Disease Epidemiology Collaboration; hCG=human chorionic 
gonadotropin 
a 
Parameters included in the Basic Metabolic Panel. 
 
7.2.4.3 
Urinalysis 
Routine macroscopic urinalysis for specific gravity, pH, protein, glucose, ketones, blood, and 
urobilinogen will be measured.  A microscopic examination will be performed if warranted 
based on macroscopic results. 
Urinalysis will be measured at Visit 1 (Screening) and prior to dosing at Visit 4 (Day 1), 
Visit 5 (Week 4), Visit 7 (Week 12) and Visit 10a (Week 24) or the Treatment 
Discontinuation/Withdrawal Visit. 
7.2.4.4 
Pregnancy Test 
A serum pregnancy test will be performed at the central laboratory in pre-menopausal 
women who are not surgically sterile at Visit 1 (Screening) and Visit 10a (Week 24), or the 
Treatment Discontinuation/Withdrawal Visit.  A urine pregnancy test will be performed on-
site at Visit 7 (Week 12). 
7.3 
Pharmacokinetic Sub-Study Assessments 
Pharmacokinetic assessments will be obtained in a subset of PFT sub-study subjects 
randomized to each treatment arm (BGF MDI:BFF MDI:GFF MDI) at Visit 10a (Week 24).  
Sample collections will be scheduled for the nominal time point and actual collection times 
will be recorded in the source documents (Refer to Table 8). 

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7.3.1 
Procedure for Blood Sample Collection and Schedule 
Pre-Dose Administration Sample Collection - Week 24 (Visit 10a): Approximately 10 mL of 
whole blood will be collected within 30 minutes before administration of study drug. 
Post-Dose Administration - Week 24 (Visit 10a): Approximately 10 mL of whole blood will 
be collected at 2, 5, and 20 minutes, and at 1, 2, 4, 8, 10, and 12 hours post-dose. 
Blood will be collected by direct venipuncture or may be obtained from an indwelling 
intravenous cannula (per the study site’s Standard Operating Procedure [SOP] after review 
by Pearl’s Medical Monitor or designee) using a vacuum collection tube (e.g., Vacutainer™ 
plasma collection tube) containing ethylenediaminetetraacetic acid (EDTA) tripotassium.  
Refer to the Laboratory Manual for details of plasma collection, storage, and handling. 
7.3.1.1 
Procedure for Shipping Blood Samples 
Samples are to be shipped frozen by overnight courier to the central laboratory for analysis.  
Plasma levels of budesonide, glycopyrrolate (the bromide salt of glycopyrronium), and 
formoterol will be determined using a validated High Performance Liquid Chromatography 
tandem Mass Spectrometry methodology.  Instructions for sample handling, storage, and 
shipping will be provided in the Laboratory Manual. 
7.4 
HPA Axis Sub-Study Assessments 
Blood samples to measure serum cortisol will be obtained in a subset of PFT sub-study 
subjects over 24 hours between Visits 3 and 4 prior to dosing at Randomization and Visit 10a 
(Week 24).  It is recommended that subjects provide samples starting 24 hours prior to 
Randomization.  However, the subject can complete the 24-hour blood draws any day 
between Visits 3 and 4. 
Samples will be collected at the following time points: 30 minutes pre-dose, and 1, 2, 4, 8, 
10, 12, 14, 16, 20, 22, and 24 hours post-dose.  Samples will be sent to the central laboratory 
and analyzed for cortisol levels.  These data will also be categorized as normal/abnormal. 
Those subjects participating in the HPA Axis sub-study will also participate in the Week 24 
PK profile sub-study (see Section 7.3). 
7.5 
Adverse Events 
7.5.1 
Performing Adverse Event Assessments 
The Investigator is responsible for promptly documenting and reporting all AEs observed 
during the study in the subject’s case report form and on the AE Reporting Form.  If the AE 
is “alarming,” the Investigator must report the AE immediately to Pearl.  In addition, certain 
AEs (as described in Section 7.5.10) are classified as "serious" and must be reported no later 
than 24 hours after the Investigator recognizes/classifies the event as an SAE to Pearl or its 
designee. 

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In the case of SAEs, after discussing the details of the AE, the Investigator and the Medical 
Monitor may discontinue the subject from treatment prematurely. 
7.5.2 
Adverse Event Definitions 
The following definitions of terms are guided by the International Conference on 
Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human 
Use (ICH), the US Code of Federal Regulations (21 CFR 312.32) and EU Directive 
2001/83/EC and are included herein. 
An AE is any untoward medical occurrence associated with the use of a drug in humans, 
whether or not considered drug related.  An AE (also referred to as an adverse experience) 
can be any unfavorable and unintended sign (e.g., an abnormal laboratory finding), symptom, 
or disease temporally associated with the use of a drug, without any judgment about 
causality.  An AE can arise from any use of the drug (e.g., off-label use, use in combination 
with another drug) and from any route of administration, formulation, or dose, including an 
overdose. 
Adverse events include, but are not limited to: 
• Any symptom or condition not previously reported by the subject (medical history). 
• An exacerbation of a pre-existing symptom or condition. 
• A significant increase in frequency or intensity of a pre-existing episodic event or 
condition. 
• A drug interaction. 
• A condition first detected or diagnosed after study drug administration even though it 
may have been present prior to the start of the study. 
 
An AE does not include: 
• Medical or surgical procedures (e.g., surgery, endoscopy, tooth extraction, blood 
transfusion); the condition that leads to the procedure is an AE (e.g., bleeding esophageal 
varices, dental caries) 
• Overdose of either study drug or concurrent medication without any clinical signs or 
symptoms 
• Non-clinically significant abnormal laboratory values.  (If accompanied by 
signs/symptoms, the signs or symptoms are considered an AE.) 
 
7.5.3 
Pre-Randomization Adverse Events 
Adverse events that occur between the time subject signs the ICF for the study and the time 
when that subject is randomized will be summarized as medical history and not as an adverse 
event unless the event meets the definition of an SAE as defined in Section 7.5.10. 

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7.5.4 
Severity 
The Investigator must categorize the severity of each AE according to the following 
guidelines: 
Mild: Associated with no limitation of usual activities or only slight discomfort; generally not 
requiring alteration or cessation of study drug administration; and/or not needing therapeutic 
intervention. 
Moderate: Associated with limitation of usual activities or significant discomfort; generally 
requiring alteration or cessation of study drug administration; and/or requiring therapeutic 
intervention. 
Severe: Associated with inability of subject to carry out usual activities or very marked 
discomfort; considered to be life-threatening; resulting in significant disability or incapacity; 
and requiring therapeutic intervention. 
7.5.5 
Relationship 
The relationship of each AE to the study drug administration will be assessed by the 
Investigator after careful consideration, and according to the following guidelines: 
Definitely: A reaction that follows a reasonable temporal sequence from administration of 
study drug; that follows a known or expected response pattern to the study drug; it disappears 
or decreases on cessation or reduction in study drug dose; and/or it reappears or worsens 
when the study drug is administered. 
Probably: A reaction that follows a reasonable temporal sequence from administration of 
study drug; that follows a known or expected response pattern to the study drug; and/or that 
could not be reasonably explained by other factors such as underlying disease, complications, 
concomitant drugs, or concurrent treatments. 
Possibly: A reaction that follows a reasonable temporal sequence from administration of 
study drug; that follows a known or expected response pattern to the study drug, but that 
could reasonably have been produced by a number of other factors including 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 drug. 
7.5.6 
Chronic Obstructive Pulmonary Disease Exacerbations 
All moderate or severe COPD exacerbations must be captured using the COPD Exacerbation 
eCRF.  Mild COPD exacerbations will be captured based on symptoms as recorded by the 
subject in the eDiary.  COPD exacerbations of any severity will be considered expected study 
endpoints and will not be reported as adverse events (AEs) unless considered a serious AE 
(SAE).   

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Exacerbation(s) of COPD is expected to occur as a progression of disease despite 
standardized drug treatment, or treatment(s) with combination therapies.  As a result, the 
Sponsor has classified this event as a protocol specified criteria expected event.  Any 
individual case safety reports received related to exacerbation of COPD will not be submitted 
on an expedited basis as a Suspected Unexpected Serious Adverse Reaction (SUSAR) unless 
otherwise required as per the Sponsor’s medical assessment. 
7.5.7 
Adverse Events of Special Interest 
Certain AEs have been identified as adverse events of special interest (AESIs) due to the 
class of drugs being studied.  These adverse events will be captured through spontaneous 
reporting and the reporting of these AESIs will be described in the SAP.  Some events are 
described below but this is not a comprehensive list of all AESIs. 
7.5.7.1 
LABA and LAMA Effects 
Known effects of LAMAs and LABAs include cardiovascular effects, ocular disorders, 
urinary retention, gastrointestinal disorders, and anticholinergic effects for LAMAs and 
cardiovascular and tremor effects for LABAs. 
7.5.7.2 
Local Steroid Effects 
Local steroid effects include oral candidiasis, hoarseness candidiasis, oropharyngeal 
candidiasis, dysphonia, and throat irritation. 
7.5.7.3 
Pneumonia 
In order to adequately assess and characterize the risk of pneumonia in patients in a non-
biased manner, an external, independent Clinical Endpoint Committee (CEC), as described in 
the Pneumonia Clinical Endpoint Adjudication Charter, will review all adverse events 
reported as pneumonia to ensure appropriate pre-defined and clinically consistent pneumonia 
criteria are met. 
To standardize the diagnosis of pneumonia a clinically consistent definition of pneumonia 
will be implemented, which will require the following:  
1. Clinical diagnosis of pneumonia by the Investigator 
2. Documentation of chest imaging obtained within 14 days of the diagnosis of pneumonia 
that is compatible with the diagnosis of pneumonia 
3. Treatment with antibiotics (and/or if appropriate antiviral and/or antifungal agents) 
4. At least 2 of the following clinical signs, symptoms, or laboratory findings: 
• Increased cough  
• Increased sputum purulence or production  
• Adventitious breath sounds on auscultation  
• Dyspnea or tachypnea 
• Fever 

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• Elevated white blood cell counts 
• Hypoxemia 
 
The CEC will be empowered to request any additional information, including copies of chest 
X-rays or CT scans if needed, to confirm the pneumonia diagnosis.   
Radiographs will be evaluated locally and the results (infiltrate compatible with pneumonia 
(yes/no) will be entered in the eCRF.  If the Investigator becomes aware that a diagnosis of 
pneumonia was made without a chest image having been performed, he or she should obtain 
a chest image (frontal and lateral) up to 10 to 14 days after the date of pneumonia diagnosis. 
7.5.7.4 
Paradoxical Bronchospasm 
Monitoring for paradoxical bronchospasm will occur at each visit during the Treatment 
Period (Visits 4 through 10a) at 15 and 30 minutes post-dose.  In this study, paradoxical 
bronchospasm is defined as a reduction in FEV1 of >20% from baseline (i.e., the mean FEV1 
values obtained 60 and 30 minutes prior to study drug administration) that occurs within 30 
minutes post-dosing with associated symptoms of wheezing, shortness of breath, or cough. 
7.5.8 
Major Adverse Cardiovascular Events 
Due to the prevalence of cardiovascular diseases in patients with COPD, MACE will be 
evaluated according to pre-defined criteria as described in the Cardiovascular and 
Cerebrovascular Clinical Endpoint Adjudication Charter.  The CEC will review potential 
clinical endpoints to determine if the events meet the following MACE criteria: 
• Cardiovascular death 
• Non-fatal myocardial infarction (MI) 
• Non-fatal stroke 
 
The Clinical Endpoint Adjudication Charters will be established to govern these processes as 
described in Section 7.5.16 Clinical Endpoint Committee. 
7.5.9 
Clinical Laboratory Adverse Events 
Many laboratory abnormalities observed during the course of a study will be included under 
a reported AE describing a clinical syndrome (e.g., elevated BUN and creatinine in the 
setting of an AE of renal failure, or decreased hemoglobin in a case of bleeding esophageal 
varices).  Isolated laboratory abnormalities should be reported as AEs if they are considered 
to be clinically significant by the Investigator. 
Criteria for a "clinically significant" laboratory abnormality are: 
• A laboratory abnormality that leads to a dose-limiting toxicity (e.g., an abnormality that 
results in study drug dose reduction, suspension, or discontinuation) 

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• A laboratory abnormality that results in any therapeutic intervention (i.e., concomitant 
medication or therapy) 
• Other laboratory abnormality judged by the Investigator to be of any particular clinical 
concern (e.g., significant fall in hemoglobin not requiring transfusion) 
 
For laboratory abnormalities that do not meet the above criteria but are outside of normal 
range (e.g., < or > normal reference range), the Investigator should indicate whether the 
value is clinically significant or not clinically significant for the subject. 
7.5.10 
Serious Adverse Events 
An AE is considered “serious” if, in the view of the Investigator or Sponsor, it results in any 
of the following outcomes: 
• Death 
• A life-threatening AE 
• In patient hospitalization or prolongation of existing hospitalization  
• A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
• A congenital anomaly/birth defect. 
 
Important medical events that may not result in death, be life threatening, or require 
hospitalization may be considered serious when, based upon appropriate judgment, they may 
jeopardize the subject or subject and may require medical or surgical intervention to prevent 
one of the outcomes listed in the definition.  Examples of such medical events include 
allergic bronchospasm requiring intensive treatment in an emergency room or at home, blood 
dyscrasias or convulsions that do not result in subject hospitalization, or the development of 
drug dependency or drug abuse. 
Hospitalization for a pre-existing condition, including elective procedures, which has not 
worsened, does not constitute an SAE. 
An AE or suspected adverse reaction is considered “life-threatening’ if, in the view of the 
Investigator or Sponsor, its occurrence places the subject or subject at immediate risk of 
death.  It does not include an adverse reaction or suspected adverse reaction that, had it 
occurred in a more severe form, might have caused death. 
An AE or suspected adverse reaction is considered unexpected if it is not listed in the current 
Investigator brochure or is not listed at the specificity or severity that has been observed. 
7.5.10.1 
Reporting of Serious Adverse Events 
In agreeing to the provisions of this protocol, the Investigator accepts all legal responsibilities 
for AE identification, documentation, grading, assignment of causality, and prompt 
notification of SAEs to Pearl Pharmacovigilance or designee.  All SAEs must be reported to 

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Pearl Therapeutics no later than 24 hours after the Investigator recognizes/classifies the event 
as an SAE.  At a minimum, a description of the event and the Investigator’s judgment of 
causality must be provided at the time of the initial report using the appropriate form (e.g., 
SAE Report Form).  After the initial report, as necessary, the Investigator must provide any 
additional information on a SAE to Pearl Pharmacovigilance within 2 working days after 
he/she receives that information.  This follow-up information will be a detailed written report 
that may include copies of hospital records, case reports, and autopsy reports, and other 
pertinent documents. 
Post-study SAEs following the last dose of study drug must be reported to Pearl as described 
in Section 7.5.10.3. 
The Investigator is responsible for continuing to report any new or relevant follow-up 
information that he/she learns about the SAE. 
7.5.10.2 
Supplemental Investigations of SAEs 
The Investigator and supporting personnel responsible for subject care should discuss with 
the Medical Monitor any need for supplemental investigations of SAEs.  The results of these 
additional assessments conducted must be reported to Pearl.  If a subject dies during 
participation in the study and a post-mortem examination is performed, a copy of the autopsy 
report must be submitted to Pearl. 
7.5.10.3 
Post-Study Follow-Up of Adverse Events 
Any AEs that are unresolved at the subject’s last AE assessment in the study are followed up 
by the Investigator for as long as medically indicated, but without further recording in the 
eCRF.  Pearl retains the right to request additional information for any subject with ongoing 
AE(s)/SAE(s) at the end of the study, if judged necessary. 
7.5.10.4 
Notification of Post-Study Serious Adverse Events 
Investigators are not obligated to actively follow subjects after the completion of the study.  
However, if the Investigation becomes aware of a post-study SAEs occurring up to 14 days 
following the last dose of study drug must be reported to Pearl, whether or not the event is 
attributable to study drug.  All SAEs must be reported to Pearl no later than 24 hours after the 
Investigator recognizes/classifies the event as an SAE. 
7.5.10.5 
Investigational Research Board/Independent Ethics Committee Notification of 
Serious Adverse Events 
The Investigator is responsible for promptly notifying her/his Investigational Research 
Board/Independent Ethics Committee (IRB/IEC) of all SAEs, including any follow-up 
information, occurring at her/his site and any SAE regulatory report, including any follow-up 
reports that he/she receives from Pearl.  Documentation of the submission to the IRB/IEC 
must be retained for each safety report.  The Investigator is also responsible for notifying 

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Pearl if their IRB/IEC requires revisions to the ICF or other measures based on its review of 
an SAE report. 
7.5.10.6 
Health Authority Safety Reports 
Pearl or its representatives will submit a safety report to the Food and Drug Administration 
(FDA) and/or any other appropriate regulatory agencies, for any suspected adverse reaction 
that is both serious and unexpected within the appropriate time frame. 
Pearl or its representatives will send copies of each safety report submitted to the FDA and/or 
other regulatory agencies to the Investigators who are actively participating in Pearl-
sponsored clinical studies.  Safety reports must be submitted to the appropriate IRB/IEC as 
soon as possible.  Documentation of the submission to the IRB/IEC must be retained for each 
safety report. 
7.5.11 
Overdose 
An overdose is defined as a dose greater than the high dose level evaluated in this study as 
described in Section 6.2 (Product Descriptions) that results in clinical signs and symptoms.  
In the event of an overdose of study medication, the Investigator should use clinical 
judgment in treating the overdose and contact the study Medical Monitor.  The Investigator 
should refer to the relevant document(s) for detailed information regarding warnings, 
precautions, contraindications, AEs, and other significant data pertaining to the study drug(s) 
being used in this study.  Such document may include, but not be limited to, the 
Investigator’s Brochure for BGF MDI, BFF MDI, GFF MDI, and approved product labeling 
for open-label products. 
7.5.12 
Pregnancy 
To ensure subject safety, each pregnancy in a female subject from Visit 1 (Screening) until 
study completion must be reported to Pearl within 24 hours of learning of its occurrence.  
The pregnancy should be followed up to determine outcome, including spontaneous or 
voluntary termination, details of the birth, and the presence or absence of any birth defects, 
congenital abnormalities, or maternal and/or newborn complications.  Pregnancy should be 
recorded on a Paper Pregnancy Report Form and reported by the Investigator to Pearl 
Pharmacovigilance or designee.  Pregnancy follow-up should be recorded on the same form 
and should include an assessment of the possible relationship to the Pearl study drug of any 
pregnancy outcome.  Any SAE experienced during pregnancy must be reported on the SAE 
Report Form. 
7.5.13 
Paternal Exposure 
Male subjects who are sexually active must agree to use a double barrier method of 
contraception (condom with spermicide) from the first dose of randomized treatment until 2 
weeks after their last dose, and must not donate sperm during their study participation period.  
If a male subject's partner becomes pregnant during the course of the study, it must be 
reported to the Sponsor within 24 hours of the investigator learning of its occurrence. 

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7.5.14 
Hy’s Law 
Cases where a subject shows an AST or ALT ≥ 3x Upper Limit of Normal (ULN) and Total 
Bilirubin (TBL) ≥ 2x ULN may need to be reported as SAEs.  Please refer to Appendix 13 
for further instructions in cases of combined increase of aminotransferase and TBL. 
7.5.15 
Use of Steroids During the Study 
At each visit, subjects will be asked whether they have been administered oral, intramuscular, 
or intravenous corticosteroids since the last visit.  Use of oral, intramuscular, or intravenous 
corticosteroids for the management of COPD exacerbations or other condition is not a reason 
for early treatment discontinuation or study withdrawal.  Use of corticosteroids should be 
documented.  Subjects who are being treated for a COPD exacerbation with oral 
corticosteroids or have been treated for a COPD exacerbation with oral corticosteroids within 
14 days of the scheduled visit will be allowed to perform PFTs under close medical 
supervision.  The Investigator can decide to stop PFTs if subject safety is at risk or symptoms 
make it difficult for the subject to continue. 
Subjects treated with oral, intramuscular, or intravenous corticosteroids for other indications 
will follow their visit schedule.  If a subject requires intraocular corticosteroids, this should 
be fully documented and the Investigator should make a determination as to the suitability of 
the subject continuing on randomized treatment. 
7.5.16 
Clinical Endpoint Committee 
An external CEC will be established for this study.  The committee will provide systematic 
and unbiased assessment of pre-defined, Investigator reported adverse events.  The 
committee will consist of experts who will provide a centralized review functioning 
independently of Pearl.  Three Clinical Endpoint Adjudication Charters will outline the 
clinical endpoints for adjudication.   
• Cardiovascular and Cerebrovascular (CCV) Clinical Endpoint Adjudication Charter 
• Cause-Specific Mortality Clinical Endpoint Adjudication Charter 
• Pneumonia Clinical Endpoint Adjudication Charter 
 
Further details are provided in the Adjudication Committee Charters. 
7.5.16.1 
Cardiovascular and Cerebrovascular Clinical Endpoint Adjudication Charter 
A Cardiovascular and Cerebrovascular Clinical Endpoint Adjudication Charter will be 
referenced for the review and assessment of non-fatal serious CCV events and classification 
of Major Adverse Cardiovascular Event (MACE).  The CEC will review potential clinical 
endpoints to determine if the event meets MACE criteria. 

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7.5.16.2 
Cause-Specific Mortality Clinical Endpoint Adjudication Charter 
A Cause-Specific Mortality Clinical Endpoint Adjudication Charter will be referenced for the 
review and assessment of the cause of deaths.  The CEC will review fatal reports to 
determine if the event meets MACE criteria.  Cardiovascular deaths will be classified as 
MACE. 
7.5.16.3 
Pneumonia Clinical Endpoint Adjudication Charter 
A Pneumonia Clinical Endpoint Adjudication Charter will be referenced for the review and 
assessment of all pneumonia-related events to ensure appropriate pre-defined and clinically 
consistent pneumonia criteria are met. 
7.5.17 
Data Monitoring Committee 
An external Data Monitoring Committee (DMC) will be set up to provide systematic and 
unbiased assessment of safety for Study PT010006.  Members of the DMC will review data 
at predetermined intervals.  If significant safety issues arise in between scheduled meetings, 
ad hoc meetings will be scheduled to review the data.  Based on the safety implications of the 
data, the DMC may recommend modification or termination of the study. 
7.6 
Health Care Resource Utilization 
The number of days missed from work, days that primary caregivers of subjects missed work 
as a result of the subject’s COPD, telephone calls to health care providers or general 
practitioners (GPs), visits to health care providers or GPs, Emergency Room (ER) visits, days 
in the hospital, days in Intensive Care Units (ICU), days in Coronary Care Units (CCU), and 
use of ambulance transport will be assessed at Visit 5 (Week 4), Visit 6 (Week 8), Visit 7 
(Week 12), Visit 8 (Week 16), Visit 9 (Week 20), Visit 10a (Week 24), and the telephone 
follow up call or Treatment Discontinuation/Withdrawal Visit. 
7.7 
Termination of the Study 
An Investigator may choose to discontinue study participation at any time with sufficient 
notice by the Investigator for any reason as per the terms of the contract with Pearl.   
Pearl reserves the right to discontinue the study at any time for clinical or administrative 
reasons.  Such a termination must be implemented by the Investigator, if instructed to do so 
by Pearl, in a time frame that is compatible with the subjects’ wellbeing. 

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8 
STUDY ACTIVITIES 
A schedule of events is provided in Table 8.  Detailed schedules for pre-and post-dose 
procedures to be performed at Visit 4 through Visit 10a are provided in Table 9.  Detailed 
schedules for pre-and post-dose procedures at Visit 4 (Day 1) and Visit 10a (Week 24) for 
subjects participating in the HPA Axis sub-study and Visit 10a (Week 24) for subjects 
participating in the 12-hour PFT and Week 24 PK profile sub-studies are provided in 
Table 10. 
 

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Table 8.  
Schedule of Events 
Study Day/Weeka 
Screening Period 
Treatment Period 
Follow-
Up TC 
Visit 1 
Visit 2 
Visit 3 
Visit 4 
Visit 5 
Visit 6 
Visit 7 
Visit 8 
Visit 9 
Visit 
10a  
14 days  
Post-
Dose 
Day 
-28 to -
9 
Day 
-21 to -
2 
Day 
-19 to -
1 
Day 
1 
Week 4 
±2 
Daysa 
Week 8 
±2 
Daysa 
Week 
12 
±2 
Daysa 
Week 
16 
±2 
Daysa 
Week 
20 
±2 
Daysa 
Week 
24 
±2 
Daysa 
 
Procedures 
 
 
 
 
 
 
 
 
 
 
 
Obtain Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
Review Incl/Excl Criteria 
X 
X 
X 
X 
 
 
 
 
 
 
 
Verify Continued Eligibility 
 
 
 
 
X 
X 
X 
X 
X 
X 
 
Reversibilityb 
 
X 
X 
 
 
 
 
 
 
 
 
Demographics & Medical/Surgical History 
X 
 
 
 
 
 
 
 
 
 
 
Smoking Status 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
CATc 
 
X 
 
 
 
 
 
 
 
 
 
Prior/Concomitant Medicationsd 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Xs 
X 
Spirometrye 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Xs 
 
Physical Examinationf 
X 
 
 
 
 
 
 
 
 
Xs 
 
Vital Signsg 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Xs 
 
12-Lead ECGh 
X 
X 
X 
X 
X 
 
X 
 
 
Xs 
 
Pregnancy Testi 
X 
 
 
 
 
 
X 
 
 
Xs 
 
Clinical Laboratory Testingi 
X 
 
 
X 
X 
 
X 
 
 
Xs 
 
Chest Image or MRIj 
X 
 
 
 
 
 
 
 
 
 
 
Adjust COPD Medicationsk 
X 
 
 
 
 
 
 
 
 
Xs 
 
Adverse Events/COPD Exacerbations 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Xs 
X 
Inhalation Device and Dose Indicator Training 
X 
X 
X 
X 
 
 
 
 
 
 
 
Study Drug Dispensing/Collection 
Xl 
 
 
X 
X 
X 
X 
X 
X 
Xs 
 
Study Drug Administration 
 
 
 
X 
X 
X 
X 
X 
X 
X 
 
BDI/TDIm 
 
 
 
X 
X 
X 
X 
X 
X 
Xs 
 

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Table 8.  
Schedule of Events 
Study Day/Weeka 
Screening Period 
Treatment Period 
Follow-
Up TC 
Visit 1 
Visit 2 
Visit 3 
Visit 4 
Visit 5 
Visit 6 
Visit 7 
Visit 8 
Visit 9 
Visit 
10a  
14 days  
Post-
Dose 
Day 
-28 to -
9 
Day 
-21 to -
2 
Day 
-19 to -
1 
Day 
1 
Week 4 
±2 
Daysa 
Week 8 
±2 
Daysa 
Week 
12 
±2 
Daysa 
Week 
16 
±2 
Daysa 
Week 
20 
±2 
Daysa 
Week 
24 
±2 
Daysa 
 
SGRQm 
 
 
 
X 
X 
X 
X 
X 
X 
Xs 
 
EQ-5D-5L Questionnairem 
 
 
 
X 
X 
X 
X 
X 
X 
Xs 
 
12-hr PFTs (sub-study) 
 
 
 
 
 
 
 
 
 
X 
 
PK Profile (sub-study) 
 
 
 
 
 
 
 
 
 
X 
 
HPA Axis (sub-study)n 
 
 
X 
 
 
 
 
 
 
X 
 
eDiary Dispense/Collecto 
X 
 
 
 
 
 
 
 
 
Xs 
 
Review of eDiaryp 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
HCRU 
 
 
 
 
X 
X 
X 
X 
X 
Xs 
 
Telephone Contactq 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
Vital Status Checkr 
 
 
 
 
 
 
 
 
 
X 
 
BDI/TDI=Baseline Dyspnea Index/Transition Dyspnea Index; CAT=COPD Assessment Test; COPD=Chronic obstructive pulmonary disease; eDiary=electronic diary; 
ECG=electrocardiogram; EQ-5D-5L=European Quality-of-Life-5 Dimensions EXACT=Exacerbations of Chronic Pulmonary Disease Tool – Patient Reported Outcomes; 
HCRU=Healthcare Resource Utilization; HFA=Hydrofluoroalkane ; HPA Axis=hypothalamic-pituitary-adrenal axis; Inc/Exc=Inclusion/Exclusion; LABA=long acting β2 agonist; 
MDI=metered dose inhaler; MRI=Magnetic resonance imaging; PFTs=pulmonary function tests; PK=pharmacokinetic; Rand=randomization; SGRQ=St.  George Respiratory 
Questionnaire; TC=Telephone call 
Note: When data collection time points are concurrent, it is recommended that variables be collected in the following order: BDI/TDI, SGRQ, EQ-5D-5L, vital signs, ECG, clinical 
laboratory assessments, PK, and spirometry. 
a 
Scheduling Visits: The maximum Screening Period is 28 days; the earliest a subject can be randomized from Visit 1 date is 9 days (7 days for LABA 
washout plus 1 day between Visit 2 and 3 plus 1 day between Visit 3 and Visit 4) or 16 days if subject is washing off of tiotropium; Site should make every 
effort to maintain subjects within the scheduled visit window.  Subjects who fall outside the visit window will be placed in the appropriate visit window at 
the next scheduled visit. 
b 
Subjects will be tested for reversibility to albuterol (Ventolin HFA) at Visit 2 and reversibility to Atrovent HFA at Visit 3; Refer to Section 7.1.1.1 for 
additional details 
c 
Subjects will complete the CAT (see Appendix 8) at Visit 2 as an entry criterion.   

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d 
At all visits beyond Visit 1 (Screening), note time of last dose of short-acting bronchodilator and other COPD medications (if <6 hours, visit should be 
rescheduled). 
e 
Refer to Section 7.1.1 and Table 9 for spirometry assessments and specific time points for these assessments to be performed at each treatment visit. 
f 
Includes evaluation of weight at Visit 1 (Screening) and Visit 10a and evaluation of height at Visit 1 (Screening) only. 
g 
Refer to Section 7.2.2 and Table 9 for vital signs assessments and specific time points for these assessments to be performed at each treatment visit.   
h 
Refer to Section 7.2.3 and Table 9 for ECG assessments and specific time points for these assessments to be performed at each treatment visit. 
i 
Refer to Section 7.2.4 and Table 9 for clinical laboratory assessments (hematology, chemistry and urinalysis) and specific time points for these assessments 
to be performed at each treatment visit.  Serum pregnancy test will be performed at Visit 1 (Screening) and at Visit 10a (Week 24) or at the Treatment 
Discontinuation/Withdrawal Visit.  At Visit 7 (Week 12), a urine pregnancy test will be performed.  Note: A Basic Metabolic Panel (BMP) will be obtained 
at 30 minutes and 2 hours post-dosing at Visit 4 (Day 1), Visit 5 (Week 4), Visit 10a (Week 24) 
j 
Obtain a new chest x-ray (frontal and lateral) at Visit 1 if a chest x-ray or CT performed within the 6 months prior to Visit 1 (Screening) is not available, 
except in countries with restrictive radiology assessment practice, where only subjects who have had a chest x-ray or CT scan (thorax) performed outside of 
the study in the last 6 months are allowed to be enrolled.  Alternatively, in these countries, an MRI should be used instead of a CT scan or chest x-ray as per 
local practice assessment. 
k 
At Visit 1 (Screening), stop prohibited COPD medications and change COPD medications as specified in Section 5.4.1 (i.e., Sponsor provided Atrovent 
HFA with or without ICS).  At the end of Visit 10a, return subject to pre-study or other appropriate inhaled maintenance COPD. 
l 
Sponsor-provided Atrovent HFA or Ventolin HFA is dispensed only after a subject is determined to be eligible to proceed to Visit 2 (i.e., only if a subject 
meets COPD definition following spirometry assessments at Screening). 
m 
When BDI/TDI and SGRQ are obtained at the same visit, it is recommended that the BDI/TDI should be collected first, followed immediately by the SGRQ 
and then the EQ-5D-5L.  The BDI/TDI, SGRQ, and EQ-5D-5L should be completed by the subject prior to any other visit procedures. 
n 
It is recommended that subjects provide these samples 1 day prior to Randomization (see Section 7.4) 
o 
Issue and train subjects on eDiary use, only after a subject is determined to qualify to proceed to Visit 2.  Retraining will be done if necessary at Visits 2 and 
3. 
p 
Refer to Section 7.1.2 for details on eDiary review.  Subjects will be asked to maintain a daily record of their study drug dosing and rescue medication use.  
EXACT will be reviewed at each visit as part of the e Diary review.   
q 
It is recommended that sites call the subject on the day before a scheduled visit and remind the subject of the expectations for the upcoming visit (e.g., 
Dosing appropriately the day before the visit, withholding COPD medications the morning of the scheduled visit, bring all study drug and eDiary to the 
visit). 
r 
Vital status check for all subjects.  For subjects that discontinue, the vital status check will be conducted 24 weeks after randomization. 
s 
These are the minimum procedures that should be completed at a Treatment Discontinuation/Withdrawal Visit. 
 

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Table 9.  
Timed Assessments at Each Treatment Visit (Visit 4 to Visit 10a) 
Clinical Variablea 
Pre-dosing 
Post-dosing 
-60 minutes 
-30 minutes 
5 minutes 
15 minutes 
30 minutes 
1 hour 
2 hours 
4 hours 
BDI/TDIb 
X 
 
 
 
 
 
 
 
SGRQb 
X 
 
 
 
 
 
 
 
EQ-5D-5L Questionnaireb 
X 
 
 
 
 
 
 
 
Review of eDiaryb 
X 
 
 
 
 
 
 
 
Vital Signsc 
X 
 
 
 
X 
 
X 
 
12-Lead ECGd 
X 
 
 
 
X 
 
X 
 
Clinical Laboratory Testinge 
X 
 
 
 
Xf 
 
Xf 
 
Spirometry (FEV1, FVC, FEF25-
75,PEFR) g 
X 
X 
Xh 
X 
X 
X 
X 
X 
Study Drug Collectioni 
X 
 
 
 
 
 
 
 
Study Drug Dispensing 
 
X 
 
 
 
 
 
 
BDI/TDI=Baseline Dyspnea Index/Transition Dyspnea Index; eDiary=electronic diary; ECG=electrocardiogram; EQ-5D-5L=European Quality-of-Life-5 Dimensions 
EXACT=Exacerbations of Chronic Pulmonary Disease Tool; FEF25-75=Forced expiratory flow from 25% to 75%; FEV1=forced expiratory volume in 1 second; FVC=Forced vital 
capacity; HFA=Hydrofluoroalkane; PEFR=Peak expiratory flow rate; SGRQ=St.  George Respiratory Questionnaire 
Note: When data collection time points are concurrent, it is recommended that variables be collected in the following order: BDI/TDI, SGRQ, EQ-5D-5L, vital signs, ECG, 
clinical laboratory assessments, PK, and spirometry. 
a 
In-clinic dosing time is recorded as time of the second puff.  Safety assessments ( vital signs and ECG) should be started approximately 5 to 10 minutes ahead of the specified 
time point to ensure that spirometry assessments for FEV1, FVC, and PEFR will be conducted as close to the specified time points as possible (i.e., FEV1, FVC, and PEFR 
assessments need to be conducted within ±15 minutes of specified time prior to study drug administration; ±5 minutes of specified time point for the first 60 minutes post 
study drug administration; ±15 minutes of specified time point for assessments obtained thereafter). 
b 
This is not a timed assessment.  Sites should plan to perform these activities so as not to interfere with collection of timed assessments such as spirometry. 
c 
At Visit 4 only, pre-dose vital signs will be collected twice, at least 5 minutes apart within 1 hour prior to dosing.  Vital signs will be obtained within 1 hour pre-dosing and at 
30 minutes and 2 hours post-dose at all treatment visits.  Temperature will be obtained pre-dose; no further temperature assessments are required unless clinically indicated. 
d 
At Visit 4 only, pre-dose ECGs will be collected twice, at least 5 minutes apart.  An ECG will be obtained pre-dose and at 30 minutes and 2 hours post-dose Visit 4 (Day 1), 
Visit 5 (Week 4), Visit 7 (Week 12) and Visit 10a (Week 24). 
e 
Clinical laboratory tests ((hematology, chemistry and urinalysis) will be obtained prior to dosing at Visit 4 (Day 1), Visit 5 (Week 4), Visit 7 (Week 12), and Visit 10a (Week 
24) only.  Serum pregnancy test will be performed at Visit 10a (Week 24) and a urine pregnancy test will be performed at Visit 7 (Week 12).   
f 
A Basic Metabolic Panel (BMP) will be obtained at 30 minutes and 2 hours post-dosing at Visit 4 (Day 1), Visit 5 (Week 4), Visit 10a (Week 24). 
g 
The baseline FEV1 at Visit 4 must be within ±20% or 200 mL of the mean of the pre dose FEV1 obtained at the 2 preceding visits (average of pre-dose FEV1 obtained at Visit 
2 and Visit 3).  At Visit 4, if the pre-dose FEV1 average is outside of the ±20% or 200 mL range, but the 30 min assessment is within ±22% or 220 mL, then another 

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assessment may be conducted 30 minutes later.  If the last 2 assessments meet the FEV1 baseline stability requirements (i.e., within ±20% or 200 mL), the initial 60 minute 
pre-dose assessment will not be used and the last 2 assessments will be used to establish the eligibility criteria.  If the test day FEV1 is not within ±20% or 200 mL, the subject 
will not be randomized and will be considered a screen failure. 
h 
5-minute spirometry assessment post-dose at ONLY Visit 4 (Day1) 
i 
At the start of each treatment visit, subject must have withheld all COPD medications, including study medication, and rescue Ventolin HFA, for at least 6 hours prior to start 
of the test day procedures. 

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Table 10.  
Timed Assessments at Visit 10a (Week 24) for 12-hour PFT, PK-Profile and HPA Axis Sub-studies 
 
Pre-dosing 
Post-dosing 
 
Minutes 
Minutes 
Hours 
Clinical Variablea 
-60 
-30 
2 
5 
15 
20 
30 
1 
2 
4 
6 
8 
10 
11.5 
12 
14 
16 
20 
22 
24 
Vital Signs 
X 
 
 
 
 
 
X 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
12-Lead ECG 
X 
 
 
 
 
 
X 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
Spirometry (FEV1, FVC, 
FEF25-75, PEFR) 
X 
X 
 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
PK Sample Collection 
 
X 
X 
X 
 
X 
 
X 
X 
X 
 
X 
X 
 
X 
 
 
 
 
 
HPA Axis 
 
X 
 
 
 
 
 
X 
X 
X 
 
X 
X 
 
X 
X 
X 
X 
X 
X 
Study Drug Collection 
Xb 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ECG=electrocardiograph; FEF25-75=forced expiratory flow from 25% to 75%; FEV1=Forced expiratory volume in 1 second; FVC=Forced vital capacity; PEFR=Peak expiratory 
flow rate; PK=pharmacokinetic 
Note: At the start of Visit 10a, subject must have withheld all COPD medications, including study medication and rescue Ventolin HFA for at least 6 hours prior to start of the test 
day procedures. 
Note: When data collection time points are concurrent, it is recommended that variables be collected in the following order: BDI/TDI, SGRQ, EQ-5D-5L, vital signs, ECG, 
clinical laboratory assessments, PK, and spirometry. 
a 
In-clinic dosing time is recorded as time of the second puff.  Safety assessments ( vital signs and ECG) should be started approximately 5 to 10 minutes ahead of the specified 
time point to ensure that spirometry assessments for FEV1, FVC, and PEFR will be conducted as close to the specified time points as possible (i.e., FEV1, FVC, and PEFR 
assessments need to be conducted within ±15 minutes of specified time prior to study drug administration; ±5 minutes of specified time point for the first 60 minutes post 
study drug administration; ±15 minutes of specified time point for assessments obtained thereafter). 
b 
This is not a timed assessment.  Sites should plan to perform these activities so as not to interfere with collection of timed assessments such as spirometry. 
 
 

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8.1 
Visit 1 (Screening Period) 
• Obtain informed consent prior to conducting any study procedure. 
• Register subject in IWRS to obtain subject screening number.   
• Obtain demographic data, including age, race, smoking history, medical/surgical history 
(including cardiovascular risk factors and history), and age of onset of COPD. 
• Review inclusion/exclusion criteria. 
• Obtain medication history, including prior concomitant and COPD medications. 
• Conduct a complete physical examination (general appearance, skin, head, eyes, ears, 
nose, throat, neck [including thyroid], lymph nodes, chest, heart, abdomen, extremities, 
and nervous system). 
• Record COPD exacerbations and AEs (if any).   
Note: Adverse events that occur during the Screening Period (Visit 1 to Visit 4, before 
study drug dosing) will be summarized as medical history and not as a study AE, unless 
the event meets the definition of an SAE.   
• Obtain height, weight, and vital signs (heart rate and blood pressure after being supine or 
seated for 5 minutes, and oral or tympanic temperature). 
• Obtain a 12-lead ECG. 
• Conduct a serum pregnancy test for all female subjects, unless it is documented in the 
medical history that the subject has been irreversibly surgically sterilized (hysterectomy, 
oophorectomy, or bilateral tubal ligation) or they are at least 2 years post-menopausal. 
• For those subjects participating in a sub-study (12-hour PFT, Week 24 PK profile, and/or 
HPA Axis) provide consent, as applicable. 
• Conduct spirometry assessments. 
• Confirm subject’s ability to use MDI correctly (provide training as needed). 
• If the subject qualifies to continue to Visit 2 perform the following: 
- 
Obtain laboratory samples (hematology, chemistry and urinalysis) 
- 
Chest x-ray or computed tomography (CT) scan of the chest/lungs within 6 months 
prior to Visit 1 must be acceptable to the Investigator.  Subjects who have a chest x-
ray that reveals clinically significant abnormalities not believed to be due to the 
presence of COPD should not be included.  A chest x-ray must be conducted if the 
most recent chest x-ray or CT scan are more than 6 months old at the time of Visit 1, 
except in countries with restrictive radiology assessment practice (e.g., Germany) 
where only subjects who have had a chest x-ray or CT scan (thorax) performed 
outside of the study in the last 6 months are allowed to be enrolled.  Alternatively, in 
these countries an MRI may be used instead of a CT scan or chest x-ray, as per local 
practice assessment. 
- 
Stop prohibited COPD medications and change concurrent COPD medications, as 
specified in protocol (refer to Section 5.4.3). 
- 
Obtain subject assignment information of Atrovent HFA and Ventolin HFA from 
IWRS. 
- 
Dispense and train subject on eDiary use. 

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• In order to allow for adequate washout of previous maintenance medications, subjects 
will undergo a Washout Period of at least 1 week (at least 2 weeks if taking Spiriva), but 
not greater than 26 days in duration prior to returning to the clinic for Visit 2. 
• Schedule Visit 2. 
• It is recommended that sites call subjects on the day before their scheduled Visit 2 and 
remind them of these expectations for the upcoming visit. 
- 
Subjects will be instructed to bring their eDiary, Sponsor-provided Ventolin HFA and 
Atrovent HFA to the next scheduled clinic visit. 
 
8.2 
Visit 2 (Screening Period) 
• Review smoking status 
• Review subject eDiary entries and retrain subject if he/she has not met the eDiary 
compliance requirement of >70% subject completion of eDiary assessments.   
- 
Review EXACT for completion as part of the eDiary review. 
• Determine time of last dose of short-acting bronchodilator and other COPD medications 
(if <6 hours, Visit 2 must be rescheduled). 
• Review inclusion/exclusion criteria and confirm subject’s eligibility to continue. 
• If not previously reviewed, review clinical laboratory results from Visit 1.  Please note 
whether the results are clinically significant and include comments where applicable. 
• Record COPD exacerbations and AEs (if any).   
Note: Adverse events that occur during the Screening Period (Visit 1 to Visit 4, before 
study drug dosing) will be summarized as medical history and not as a study AE, unless 
the event meets the definition of an SAE. 
• Have the subject complete the CAT questionnaire 
• Review all prior medications and ensure adherence to COPD regimen. 
• Obtain vital signs and 12-lead ECG 60 minutes pre-bronchodilator and 30 minutes post-
bronchodilator administration 
• Conduct spirometry 60 and 30 minutes prior to bronchodilator administration and at 30 
minutes post-bronchodilator administration 
• Perform reversibility test to Ventolin HFA (refer to Section 7.1.1.1 for instructions) and 
confirm subject continues to meet entry criteria based on pre- and post dose spirometry 
quality (refer to Exclusion Criterion 3 in Section 5.2), and post dose spirometry values. 
• Schedule Visit 3. 
Note: Visit 3 can be scheduled a minimum of 1 day after Visit 2 and no later than 27 days 
after Visit 1 (Screening).   
• Ensure subject has adequate supply of Sponsor-provided Atrovent HFA and Sponsor 
provided rescue Ventolin HFA. 
• It is recommended that sites call subjects on the day before their scheduled Visit 3 and 
remind them of these expectations for the upcoming visit 

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- 
Subjects will be instructed to bring their eDiary, Sponsor-provided Atrovent HFA, 
and Sponsor-provided Ventolin HFA to the next scheduled clinic visit. 
 
8.3 
Visit 3 (Screening Period) 
• Review inclusion/exclusion criteria and confirm subject’s eligibility to continue 
• Review smoking status 
• Review subject diary entries and retrain subject if subject has not met the eDiary 
compliance requirement of >70% subject completion of diary assessments. 
- 
Review EXACT for completion as part of the eDiary review. 
• Determine time of last dose of short-acting bronchodilator and other COPD medications 
(if <6 hours, Visit 3 must be rescheduled). 
• Record COPD exacerbations and AEs (if any).   
Note: Adverse events that occur during the Screening Period (Visit 1 to Visit 4, before 
study drug dosing) will be summarized as medical history and not as a study AE, unless 
the event meets the definition of an SAE. 
• Review all prior medications and ensure adherence to COPD regimen. 
• Obtain vital signs and 12-lead ECG 60 minutes pre-bronchodilator and 30 minutes post-
bronchodilator administration. 
• Conduct spirometry 60 and 30 minutes pre- bronchodilator and 30 minutes post-
bronchodilator administration 
• Perform reversibility test to Sponsor-provided Atrovent HFA (refer to Section 7.1.1.1 for 
instructions). 
• If participating in HPA Axis sub-study, obtain serum sample over 24 hours between 
Visits 3 and 4 prior to dosing at Randomization (Visit 4).  Refer to Section 7.4 and 
Table 10 for sample collection schedule and details. 
Note: It is recommended that subjects provide the samples starting 24 hours prior to 
Randomization.  However, he/she can do the 24-hour blood draws any day between 
Visits 3 and 4. 
• Schedule Visit 4 (Randomization Visit, Day 1). 
Note: Visit 4 (Randomization Visit, Day 1) can be scheduled at minimum 1 day after 
Visit 3 and no later than 28 days after Visit 1 (Screening). 
• Ensure subject has adequate supply of Sponsor-provided Atrovent HFA and Sponsor 
provided rescue Ventolin HFA. 
• It is recommended that sites call subjects on the day before their scheduled Visit 4 and 
remind them of these expectations for the upcoming visit 
- 
Subjects will be instructed to bring their eDiary, Sponsor-provided Atrovent HFA, 
and Sponsor provided Ventolin HFA to the next scheduled clinic visit. 
 
8.4 
Visit 4 (Randomization) 
• Review inclusion/exclusion criteria and confirm subject’s eligibility to continue. 

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• Review smoking status 
• Review subject diary entries and screen fail subject if subject has not met the diary 
compliance requirement of >70% subject completion of diary assessments. 
- 
Review EXACT for completion as part of the eDiary review. 
• Determine time of last dose of short-acting bronchodilator and other COPD medications 
(if <6 hours, Visit 4 must be rescheduled). 
• Complete BDI questionnaire followed by SGRQ questionnaire before any other study 
procedures are performed. 
• Have the subject complete the EQ-5D-5L. 
• Record COPD exacerbations and AEs (if any). 
• Review all concomitant medications and ensure adherence to COPD regimen. 
• Collect Sponsor-provided Atrovent HFA and Sponsor-provided Ventolin HFA dispensed 
during the Screening Period. 
• Subjects treated with an ICS during screening must discontinue ICS use prior to 
randomization and throughout the study. 
• Perform all pre-dose assessments (refer to Table 9) 
- 
Obtain vital signs and 12-lead ECG two times each at least 5 minutes apart 1 hour 
prior to dosing 
- 
Obtain clinical laboratory samples  
- 
Spirometry to be conducted 60 and 30 minutes pre-dose 
• To be randomized, all subjects must meet the FEV1 baseline stability criteria.  Refer to 
Section 7.1.1.2 for additional details.  If the FEV1 baseline stability entry criteria are not 
met at Visit 4 (Randomization) the subject will not be eligible to be randomized and will 
be screen failed. 
• Obtain subject randomization number and treatment assignment information from IWRS. 
Note: The subject is to be considered randomized after receiving a randomization 
number. 
• To allow for proper preparation of study drug, it is recommended that the seal around the 
study day treatment box is opened 15 to 30 minutes prior to dosing and the instructions 
for administration of study drug followed: 
- 
Refer to Appendix 2 for detailed instructions for preparation of treatments for 
administration.  These instructions are to be adhered to and are relevant to all study 
treatment visits. 
- 
Record/document the dose indicator reading.  The dose indicator count recorded by 
the site staff will be the dose indicator count observed after priming but prior to 
subject dosing.  For new MDIs, the recorded count will be the count following the 
priming of the device but before the subject dose.  Refer to Appendix 1 for more 
details. 
• Subject will administer first dose of newly assigned study drug at the clinic. 
• Perform all post-dosing assessments (Refer to Table 9)  
- 
Conduct spirometry 5, 15 and 30 minutes and 1, 2, and 4 hours post-dose. 
- 
Obtain vital signs, ECG, and BMP 30 minutes and 2 hours post-dose 

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• Return eDiary to subjects and provide retraining if appropriate. 
• Subjects will be instructed to track study drug dosing in their eDiary between study clinic 
visits. 
• Schedule Visit 5 and ensure subject has adequate supply of study drug including a 
replacement MDI kit and rescue Ventolin HFA 
• It is recommended that sites call subjects on the day before their scheduled Visit 5 and 
remind them of these expectations for the upcoming visit. 
- 
Subjects will be instructed to bring their eDiary and all study medication (including 
used study drug, replacement MDI kit and rescue Ventolin HFA) to the next 
scheduled clinic visit. 
 
8.5 
Visits 5 to 9 (Treatment Period) 
• Confirm subject eligibility to continue.   
• Review subject diary and EXACT questionnaire for data collection compliance. 
• Review smoking status 
• Determine time of last dose of short-acting bronchodilator and other COPD medications 
(if <6 hours, the visit must be rescheduled). 
• Confirm the subject took their last dose of randomized study medication as scheduled the 
prior evening.  If the time of dosing was not in accordance with the protocol, then the 
visit must be rescheduled.   
• Complete TDI questionnaire (Visits 5 to 9) followed by SGRQ questionnaire before any 
other study procedures are performed. 
• Have the subject complete the EQ-5D-5L  
• Collect HCRU information. 
• Record COPD exacerbations and AEs (if any). 
• Review all concomitant medications and ensure adherence to COPD regimen. 
• Perform all pre-dose assessments (Refer to Table 9) 
- 
Conduct spirometry 60 and 30 minutes pre-dose. 
- 
Obtain vital signs once within 1 hour of dosing. 
- 
Obtain a 12-lead ECG within 1 hour of dosing at Visit 5 and Visit 7. 
- 
Obtain clinical laboratory samples at Visit 5 and Visit 7. 
- 
Perform a urine pregnancy test at Visit 7. 
• Prior to dosing, site personnel will use IWRS to assign subjects a new kit of study drug 
for in-clinic dosing and to continue dosing at home until the next scheduled visit. 
• Refer to Appendix 2 for detailed instructions for preparation of treatments for 
administration.  These instructions are to be adhered to and are relevant to all study 
treatment visits. 
• Perform all post-dose assessments (Refer to Table 9) 
- 
Obtain vital signs 30 minutes post-dose and 2 hours post-dose. 

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- 
Obtain a 12-lead ECG 30 minutes and 2 hours post-dose at Visit 5 and Visit 7. 
- 
Obtain BMP samples 30 minutes and 2 hours post-dose at Visit 5. 
- 
Obtain spirometry 15 and 30 minutes, and 1, 2, and 4 hours post-dose. 
• Subjects will be instructed to track study drug dosing in their eDiary between study clinic 
visits. 
• Return eDiary to subjects and provide retraining if appropriate. 
• Subjects assigned to blinded study drug will be instructed to dose while at home from the 
site-primed MDI only, unless all of the following replacement conditions are met: 
- 
Dose indicator is in the red zone (Refer to Appendix 1 for dose indicator reading 
instructions) 
- 
The dose indicator registers ≤10 puffs remaining, and  
- 
Their next scheduled study clinic visit is not the following day. 
• If these replacement conditions are met, subjects will be instructed to open their 
replacement kit, prime the MDI and start using for at-home dosing until the next 
scheduled study clinic visit. 
• Schedule next visit and ensure subject has adequate supply of study drug including a 
replacement MDI kit and Sponsor-provided rescue Ventolin HFA. 
• It is recommended that sites call subjects on the day before their scheduled visit and 
remind them of these expectations for the upcoming visit. 
- 
Subjects will be instructed to bring their eDiary and all study medication (including 
used study drug, replacement MDI kit and Sponsor-provided rescue Ventolin HFA) to 
the next scheduled clinic visit. 
 
8.6 
Visit 10a (Week 24; Final Visit) 
• Review subject eDiary and EXACT questionnaire for data collection compliance. 
• Perform physical examination (including weight) and review smoking status 
• Determine time of last dose of short-acting bronchodilator and other COPD medications 
(if <6 hours, the visit must be rescheduled). 
• Confirm the subject took their last dose of randomized study medication as scheduled the 
prior evening.  If the time of dosing was not in accordance with the protocol, then the 
visit must be rescheduled.   
• Have subject complete TDI questionnaire followed by SGRQ questionnaire before any 
other study procedures are performed. 
• Have subject complete the EQ-5D-5L. 
• Collect HCRU information. 
• Record COPD exacerbations and AEs (if any). 
• Review all concomitant medications and ensure adherence to COPD regimen. 
• Perform all pre-dose assessments (Refer to Table 9) 
- 
Obtain vital signs and 12-lead ECG 1 hour prior to study dosing 
- 
Obtain central laboratory samples and conduct a serum pregnancy test (as applicable). 

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- 
Obtain spirometry 60 and 30 minutes pre-dose 
• If subjects are participating in the PK and/or 12-hour PFT sub-studies, perform 
additional assessments at Visit 10a (refer to Table 10). 
• If subjects are participating in the HPA Axis sub-study, perform additional 
assessments at Visit 10a (refer to Table 10) 
• Prior to dosing, site personnel will use IWRS to assign subjects a new kit of study drug 
for in-clinic dosing. 
• Refer to the appendices for detailed instructions for preparation of treatments for 
administration.  These instructions are to be adhered to and are relevant to all study 
treatment visits. 
• Record/document the dose indicator readings of the used MDI and the replacement MDI. 
- 
For the new MDI, the recorded count will be the count following the priming of the 
device but before the subject doses.   
• Administer in-clinic study drug dose from the new kit assigned at the visit.   
• Perform all post-dose assessments (Refer to Table 9) 
- 
Obtain spirometry 15 and 30 minutes and 1, 2, and 4 hours post-dose 
- 
Obtain vital signs and 12-lead ECG 30 minutes and 2 hours post dose 
- 
Obtain BMP samples 30 minutes and 2 hours post-dose. 
• Collect subject eDiary. 
• Collect all study medication including Sponsor-provided Ventolin HFA and Atrovent 
HFA 
 
Subjects not participating in the Extension Study (All Subjects): 
• At completion of all assessments at Visit 10a, return subject to appropriate maintenance 
COPD medications. 
• Inform subject about reporting all SAEs up to 14 days following the last dose of study 
drug. 
• Schedule the follow-up telephone call at least 14 days from Visit 10a. 
 
Subjects who choose to participate in the extension study (Subjects in Japan only): 
• Subjects who volunteer to participate in the 28-week extension study will complete Visit 
10a procedures and be scheduled for the first study visit in the extension study (Visit 
10b). 
 
8.7 
Procedures for Treatment Discontinuation and Study Withdrawal 
Subjects 
Subjects who discontinue study treatment prior to Week 24 (Visit 10a) will be encouraged to 
remain in the study to complete all remaining study visits during the 24 week treatment 
period.  Subjects who agree to continue to be followed post treatment discontinuation will 

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sign an ICF addendum.  All subjects who agree to continue study participation beyond 
treatment discontinuation will complete a Treatment Discontinuation/Withdrawal Visit (refer 
to Table 8) prior to transitioning back to regularly scheduled study visits.  Subjects 
participating in a sub-study who choose to discontinue from treatment will only complete 
regular scheduled visits and not complete any remaining sub-study assessments.  Treatment 
discontinuation subjects will return to appropriate maintenance COPD medications, per the 
investigators discretion.  For subjects recorded as Treatment Discontinuations that do not 
complete at least one post-treatment data collection a telephone follow-up call is required at 
least 14 days after last study drug dose.   
If a subject chooses not to continue with study assessments, at a minimum the subject will 
complete the Treatment Discontinuation/Withdrawal Visit (refer to Table 8).  These subjects 
will return to appropriate maintenance COPD medications, per the investigators discretion.  
A follow-up telephone call will be performed at least 14 days after the last study drug dose.  
In the event the Treatment Discontinuation/Withdrawal Visit is performed >14 days post last 
study drug dosing, a follow-up TC will not be required.  These subjects will be followed for 
vital status at 24 weeks post randomization in accordance with the informed consent. 
8.8 
Unscheduled Visit and Treatment Discontinuation/Withdrawal Visit 
Repeat assessments, if needed, will be captured in unscheduled visits. 
Treatment Discontinuation/Withdrawal Visits will be captured as unscheduled visits.  The 
following minimum procedures will be completed for these types of visits: 
• Complete TDI questionnaire first; followed by SGRQ questionnaire before any other 
study procedures are performed. 
• Have subject complete the EQ-5D-5L. 
• Collect HCRU information. 
• Record COPD exacerbations and AEs (if any). 
• Review concomitant medications. 
• Conduct a physical examination, including vital signs. 
• Perform spirometry assessment (subject should have withheld all COPD medications, 
including study medication and rescue Ventolin HFA, for at least 6 hours prior to the start 
of procedures) 
• Perform ECG and collect blood samples for hematology, chemistry and urinalysis. 
• Collect a blood sample for pregnancy test for women of child-bearing potential. 
• Collect subject eDiary. 
• Collect all study drugs, including rescue medications.   
• Return subject to pre-study or appropriate maintenance COPD medications. 
• Inform subject about reporting all SAEs up to 14 days following the last dose of study 
drug. 
• Capture the reason for subject discontinuation. 

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8.9 
Telephone Follow-up 
Subjects will be followed-up within 14 days after the last study drug dosing.  The following 
information will be requested: 
• Review previously on-going COPD exacerbations and AEs/SAEs (if any) 
• Review concomitant medications 
 
Note: For subjects who withdraw consent, schedule a follow-up TC at least 14 days after the 
last study drug dosing unless the visit is performed >14 days post last study drug dosing, a 
follow-up TC will not be required.  For Treatment Discontinuation Subjects, a telephone 
follow-up call is not required as long as at least one post treatment study visit is completed. 
8.10 24-Week Post-Randomization Vital Status Confirmation 
All subjects who discontinue study treatment prior to 24 weeks post- randomization will have 
their vital status confirmed at 24 weeks post-randomization. 
To confirm the vital status and cause of death, if appropriate, the following attempts will be 
made: 
• The first and second attempts may be conducted as telephone follow-up call to the subject 
within 2 weeks after 24 weeks post-randomization  
• The third attempt will be by certified mail to the subject’s address provided at the time of 
informed consent within 3 weeks after 24 weeks post-randomization. 
• The fourth attempt will be made as a telephone follow-up call to the next of 
kin/emergency contact provided at the time of informed consent within 4 weeks after 24 
weeks post-randomization 
• A fifth attempt will be made through a certified letter to the next of kin/emergency 
contact provided at the time of informed consent within 5weeks after 24 weeks post-
randomization 
• After the fifth attempt, the study site will contact the national death registries (if available 
in that country) to confirm date and cause of death. 
 
8.11 Completion of Study 
The Investigator will document the completion or the reason for a subject’s early withdrawal 
from the study in the eCRF.  The following categories should be used to describe these 
events in the eCRF: 
• Subject discretion (document reason) 
• Investigator considers it to be in the best interest of the subject 
• Adverse events(s) 
• Administrative reasons (e.g., early termination of the study) 

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• Subject lost-to-follow-up 
• Lack of efficacy 
• Major protocol deviation 
• Death 
• Completion of the study 
• Protocol-specified criteria (Refer to Section 5). 
 

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9 
PLANNED STATISTICAL METHODS 
9.1 
Introduction 
This study will be conducted as a double-blind, active-control (open-label), and parallel-
group study evaluating the following treatments in approximately 1800 subjects: 
• BGF MDI (320/14.4/9.6 μg BID) 
• GFF MDI (14.4/9.6 μg BID) 
• BFF MDI (320/9.6 μg BID) 
• Symbicort Turbuhaler (400/12 μg BID) 
 
Approximately 1800 subjects with moderate to very severe COPD will be randomized to 
provide approximately 1600 subjects to complete the study.   
The primary objective of this study is to compare the effects of treatment with BGF MDI 
relative to GFF MDI, BFF MDI, and Symbicort TBH on lung function in subjects with 
moderate to very severe COPD.   
This study will include a 24 week Treatment Period, preceded by a Screening Period and 
followed by either enrollment into a 28-week extension study or a 2-week follow-up 
telephone call. 
The primary endpoints, comparisons of interest, and time frames for analyses may differ by 
country or region due to local regulatory agency requirements.  The 3 different registration 
approaches will be called: (1) Japan/China, (2) EU/Canada, and (3) US.  Countries not 
specifically mentioned will be decided by regulatory requirements and included in one of the 
three defined registration approaches. The impact of these approaches is delineated in each of 
the relevant sections below.  Where not specified, a common approach will be used for all 
regions.   
The registration requirements also impact controls for multiplicity; these multiplicity controls 
will be delineated by approach. 
9.2 
Protocol Variables 
9.2.1 
Efficacy Endpoints 
All efficacy assessments are relative to pre-dose baseline obtained at or prior to Visit 4 
(Section 3). 

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9.2.2 
Safety Endpoints 
• Adverse events (AEs) 
• 12-lead electrocardiograms (ECG) 
• Clinical laboratory testing 
• Vital sign measurements 
 
9.3 
Study Populations 
The following analysis populations are defined in this study: 
• The Intent-To-Treat Population is defined as all subjects who are randomized to 
treatment and used any amount of the study treatment.  Subjects will be analyzed 
according to the treatment they were assigned to at randomization.  Data obtained after 
discontinuation of treatment, but prior to withdrawal from the study, will be included 
• The Modified Intent-to-Treat (mITT) Population is a subset of the ITT Population, 
defined as all subjects with post randomization data obtained prior to discontinuation 
from treatment.  Any data collected after completion of or discontinuation from 
randomized study medication will be excluded from the mITT analysis but will still be 
included in the ITT analysis. Subjects will be analyzed according to randomized 
treatment group. (Note that a subject who used a study treatment, but took less than one 
full dose of treatment will qualify for this population). Data obtained after treatment 
discontinuation will be excluded. The mITT Population will be the primary population 
for all efficacy analyses except for the non-inferiority analyses. Note: The knowledge that 
a subject did not have a COPD exacerbation constitutes an efficacy assessment. 
• The Rescue Ventolin User Population is defined as all subjects in the ITT Population 
with mean baseline rescue Ventolin use of ≥1.0 puff/day. 
• The Per-Protocol (PP) Population is a subset of the ITT Population, defined as all 
subjects with post-randomization data obtained prior to any major protocol deviations.  
Data obtained after any major protocol deviation or discontinuation from treatment will 
be excluded.  Since receiving the wrong treatment will be a major protocol deviation, 
subjects in the PP population will be analyzed as randomized (which for this population if 
identical to analysis by the actual treatment received).  Any evaluability criteria with a 
potential impact on efficacy results will be identified in a blinded fashion from review of 
data listings prior to unblinding.  Major protocol deviations (protocol violations), 
therefore, can result in exclusion of all data from a particular subject from the PP 
population or require exclusion of data from a specific time point and/or subsequent time 
points for an endpoint. 
• The Safety Population is similar to the ITT Population (all subjects who are randomized 
to treatment and receive at least one dose of the study treatment).  However, subjects will 
be analyzed according to treatment received rather than randomized.  If a subject received 
more than 1 randomized treatment, they will be analyzed and included in summaries 
according to the treatment they received the most.  Subjects receiving no study treatment 

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will be excluded, as will subjects who have no post-dose safety assessments.  (Note that a 
subject who used a study treatment, but took less than 1 full dose of treatment will 
qualify for this population).  Note: The statement that a subject had no AEs also 
constitutes a safety assessment 
• The PK Population is defined as all randomized and treated subjects who have sufficient 
data to reliably calculate at least 1 PK parameter.  Subjects will be analyzed according to 
treatment received rather than randomized. 
• The HPA Axis Population consists of subjects who participated in the HPA axis sub-
study and is a subset of the ITT Population without protocol deviations which could 
affect the serum cortisol endpoint and whose serum samples did not have confounding 
factors that would affect the interpretation of the results 
 
Analyses will be performed as follows: 
Demographics will be summarized for the mITT, PP, Safety, and Non-randomized 
Populations.  Extent of exposure will be summarized for the Safety Population.  The Safety 
Population will be used to summarize safety.  Efficacy Analyses will be performed for the 
ITT, mITT, and PP Populations.  The mITT Population using only on-treatment data will be 
considered the primary population for these analyses, with the ITT and PP populations being 
considered supportive.  
9.4 
Efficacy Analyses 
9.4.1 
Estimands 
The primary estimand of interest is called the efficacy estimand and is the effect of the 
randomized treatments in all subjects assuming continuation of randomized treatments for 
the duration of the study regardless of actual compliance. There are three additional 
estimands of interest. One is called the attributable estimand and is the effect of treatment in 
subjects attributable to the randomized treatment. For this estimand, discontinuation of 
randomized medication for reasons such as tolerability or lack of efficacy is considered a bad 
outcome. Another estimand of interest is called the treatment policy estimand. This estimand 
is the effect of randomized treatment over the study period regardless of whether randomized 
treatment is continued. The final estimand of interest is called the per protocol estimand. This 
estimand is the effect of treatment on subjects who are compliant with the protocol (i.e. no 
major protocol deviations), including the use of randomized medication. 
The primary analysis for the efficacy estimand will be conducted using the mITT Population 
where only data obtained prior to subjects discontinuing from randomized treatment will be 
utilized. This assumes that efficacy observed on treatment is reflective of what would have 
occurred after discontinuation of randomized treatment had they remained on treatment.  
The second estimand of interest is the attributable estimand. Analyses of the attributable 
estimand will be conducted in the mITT Population, but data that are missing due to 
treatment discontinuation will be imputed based on the 95th percentile of the reference arms’ 
distribution if the reason is reasonably attributable to tolerability or lack of efficacy. The 95th 

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percentile applies to an endpoint for which a higher value is a worse outcome; however, the 
5th percentile applies to an endpoint for which a higher value is a better outcome. More 
detail about the computation of the attributable estimand will be provided in the SAP. 
The third estimand of interest is the treatment policy estimand. Analyses of the treatment 
policy estimand will be conducted in the ITT Population, in which all observed data will be 
utilized regardless of whether subjects remain on randomized treatment. The treatment policy 
estimand will be provided as a supporting analysis for all primary and secondary endpoints. 
Finally, the last estimand of interest is the per protocol estimand. Analysis of this estimand 
will use the PP Population. This estimand will serve as primary for the non-inferiority 
comparison of BFF MDI to Symbicort TBH. It will be supportive for all other comparisons 
of interest. 
9.4.2 
Primary Efficacy Analyses 
For the primary comparisons, the null hypothesis for each pair-wise comparison will be that 
the mean treatment difference is zero (mean treatment effects are equal).  The alternative 
hypothesis is that the mean treatment difference is greater (less than) zero (mean treatment 
effects are not equal).   
All comparisons will be for superiority except that the comparison of BFF MDI to Symbicort 
TBH will be for non-inferiority and will use margins (δ’s) of 50 mL for trough FEV1 and 75 
mL for post-dose FEV1 measures.  P-values will be reported as 2-sided.  
9.4.2.1 
Change from Baseline in Morning Pre-dose Trough FEV1 
The primary analysis will be conducted using the efficacy estimand.  The change from 
baseline in morning pre-dose trough FEV1 will be analyzed using a linear model with 
repeated measures (RM).  The model will include treatment, visit, treatment, treatment by 
visit interaction, and ICS use at Screening as categorical covariates and baseline FEV1, 
percent reversibility to Ventolin HFA, and baseline eosinophil counts as continuous 
covariates.  Baseline FEV1 is defined as the average of the non-missing 60 minute and 30 
minute values obtained prior to dosing at Visit 4, and baseline eosinophil count is defined as 
the average of non-missing eosinophil counts prior to treatment.  An unstructured covariance 
matrix will be used to model correlation within a subject.  If this model fails to converge, a 
first-order autoregressive structure will be used instead; for this model, subject will be 
included as a random effect.  Contrasts will be used to obtain estimates of the treatment 
differences over 24 weeks (primary for EU/Canada; secondary for Japan/China; secondary 
for the US), over Weeks 12 to 24 (primary for Japan/China), and at Week 24 (primary for 
US).  Two-sided p values and point estimates with 2-sided 95% CIs will be produced for 
each treatment difference.  The primary analysis will be for the efficacy estimand.  
Secondary analyses will be produced for the attributable estimand.  The non-inferiority 
comparison of BFF MDI to Symbicort TBH will be based on the per-protocol estimand.  
Supportive analyses will: 

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• repeat the above analysis using the treatment policy estimand  
• provide estimates of the change from baseline at individual time points from the primary 
RM model 
 
Subgroup analyses for morning pre-dose trough FEV1 will be performed for the Japanese 
region versus the remaining regions combined.  Additional subgroup analyses may be 
defined in the Statistical Analysis Plan (SAP) as appropriate.   
Sensitivity analyses to evaluate the robustness of the primary analyses to the nature of the 
missing data are discussed in Section 9.15. 
9.4.2.2 
FEV1 AUC0-4 
Change from baseline in FEV1 AUC0-4 over 24 weeks will be analyzed in a similar manner as 
for morning pre-dose trough FEV1.  Area under the curve will be calculated using the 
trapezoidal rule and will be normalized by dividing by the time in hours from dosing to the 
last measurement included (typically 4 hours).  Only 1 non-missing, post dose value is 
required for the calculation of AUC.  Actual time from dosing will be used if available; 
otherwise scheduled time will be used. 
9.4.3 
Analysis of Secondary Endpoints 
The following variables appear as secondary for 1 or more registration approaches: peak 
FEV1, TDI focal score over 24 weeks, rescue Ventolin HFA usage over 24 weeks, SGRQ 
total score over 24 weeks, percentage of subjects achieving an MCID of 4 units or more in 
SGRQ total score at Week 24, RS-total score over 24 weeks, time to CID, the rate of 
moderate or severe COPD exacerbations, and time to onset. Multiplicity will be controlled 
for the secondary variables as described in Section 9.4.5.  The main analysis for secondary 
endpoints and other endpoints will use the efficacy estimand. The attributable estimand and 
treatment policy estimand will be estimated as sensitivity analyses for the secondary 
endpoints with the exception of time of onset on Day 1. The attributable estimand will 
impute missing data due to lack of efficacy and tolerability punitively, whereas all other 
missing data will be imputed using the observed data model. Details of imputation will be 
described in the SAP. The treatment policy estimand will include all post-treatment 
discontinuation data. 
9.4.3.1 
Transition Dyspnea Index 
Assessments of dyspnea will be obtained using the BDI/TDI.  The BDI/TDI questionnaire is 
presented in Appendix 9. 
At Visit 4, the severity of dyspnea at baseline will be assessed using the BDI.  At subsequent 
visits (as per Schedule of Events, Table 8) change from baseline will be assessed using the 
TDI.  The difference between treatment groups in TDI focal score over 24 weeks will be 
evaluated using a similar RM approach as for the primary endpoint, but using BDI instead of 
baseline FEV1 in the model, and adding baseline post-bronchodilator percent predicted FEV1 

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as a continuous covariate.  Scoring and handling of missing items will be conducted in 
accordance with the user’s guide for the TDI score.  Two-sided p values and point estimates 
with 2-sided 95% CIs will be produced for each treatment difference.  The comparison of 
BFF MDI to Symbicort TBH will be for non inferiority rather than superiority and will use a 
margin of 0.75. 
The above analyses of the TDI focal score will be repeated over Weeks 12 to 24 as secondary 
efficacy for Japan/China.   
The difference between treatments at each of the individual visits will be evaluated and 
summarized, both for the focal score as well as for the individual components of the TDI: 
functional impairment, magnitude of task, and magnitude of effort.  Responder analyses will 
be performed, where responders are defined as a response of 1.0 point or more 
(corresponding to at least a minor improvement) on average over 24 weeks, and separately 
over Weeks 12 to 24.  Logistic regression will be used to compare the treatment groups with 
BDI, baseline eosinophil count, post-bronchodilator percent predicted FEV1, and percent 
reversibility to Ventolin HFA as continuous covariates, and treatment, and ICS use at 
Screening as categorical covariates.  P-values and odds ratios with 95% CIs will be produced 
for each treatment comparison. 
9.4.3.2 
Peak FEV1 
The peak change from baseline in FEV1 within 2 hours post-dosing over 24 weeks, over 
Weeks 12 to 24, and at Week 24 will be analyzed in a similar way to morning pre-dose 
trough FEV1. 
9.4.3.3 
St. George Respiratory Questionnaire 
The SGRQ is presented in Appendix 10.  The difference between treatment groups in the 
change from baseline in SGRQ over 24 weeks and over Weeks 12 to 24 will be evaluated 
using a similar RM approach as for the TDI focal score, but adding country as a covariate, 
and with baseline SGRQ replacing BDI in the model.  Scoring and handling of missing items 
will be conducted in accordance with the user’s guide for the SGRQ.  Each response is to be 
given a unique empirically derived weight between 0 and 100, the weights of all responses 
are then summed up and divided by the maximum possible score and expressed as a 
percentage.  Missing data of the SGRQ total score will not be imputed.  Two-sided p-values 
and point estimates with 2-sided 95% CIs will be produced for each treatment difference. 
As supportive analyses, the difference between treatments at each of the individual visits will 
be evaluated and summarized.  Individual domains of the SGRQ also will be analyzed in a 
similar fashion as the overall score.  A responder analysis will be performed where 
responders are defined as an improvement of 4.0 points or more on average at 24 weeks, over 
24 weeks, over Weeks 12-24, and at each post-randomization assessment time-point.  
Logistic regression will be used to compare the treatment groups with baseline SGRQ using a 
similar approach as the TDI responder analyses - with baseline eosinophil count, baseline 
post-bronchodilator percent predicted FEV1, and reversibility to Ventolin HFA as continuous 

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covariates, and treatment, country, and ICS use at Screening as categorical covariates.  P-
values and odds ratios with 95% CIs will be produced for each treatment comparison. 
9.4.3.4 
Rescue Ventolin HFA Use 
The number of puffs of rescue Ventolin HFA taken in the previous 12 hours will be recorded 
in the subject diary in the morning and evening.  The mean daily number of puffs of rescue 
Ventolin HFA will be calculated overall and for each of the 4-week intervals during the 
Treatment Period.  Diary data recorded during the last 7 days of the Screening Period will be 
used to calculate the baseline.  For every interval of time over which the mean number of 
puffs of rescue will be calculated for both overall as well as 4-week intervals, records with 
missing values will be ignored in both the numerator and denominator.  As such, the 
denominator will be adjusted based on the number of days (including half days) with non-
missing values.   
The difference between treatment groups in the change from baseline in rescue Ventolin 
HFA usage over 24 weeks will be evaluated using a similar RM approach as for the TDI.  
Instead of visit, the number of the relevant 4-week interval (Interval 1 to Interval 6) will be 
used as a categorical covariate in the model.  As supportive analyses, the treatment difference 
for each 4 week interval and over Weeks 12 to 24 will be evaluated and summarized.  
Additionally as supportive analyses, daytime rescue Ventolin HFA use and night-time rescue 
Ventolin HFA usage will be evaluated and summarized in a similar fashion.  Two sided p 
values and point estimates with 2-sided 95% CIs will be produced for each treatment 
difference. 
9.4.3.5 
RS-Total Score 
The EXACT is a 14-item PRO daily diary which will be used to measure the effect of 
treatment on exacerbations, and on the severity of respiratory symptoms.  The RS-total 
utilizes the 11 respiratory symptom items contained in the 14-item EXACT. The RS-Total 
score represents respiratory symptom severity, overall.  The mean change from baseline in: 
the RS-Total Score will be calculated over each 4-week interval of the 24-week Treatment 
Period.  The last 7 days of the Screening Period will be used to calculate the baseline.  The 
mean change from baseline in the RS-Total Score will be analyzed using a similar model 
as for the TDI to estimate treatment effects over 24 weeks, but using the baseline mean score 
instead of the BDI as a covariate, and baseline post-bronchodilator percent predicted FEV1 as 
a continuous covariate.  Instead of visit, the number of the relevant 4-week interval (Interval 
1 to Interval 6) will be used as a categorical covariate in the model.  This analysis will be 
secondary for the EU only. 
9.4.3.6 
COPD Exacerbations 
Secondary Endpoint Analysis: 
The rate of moderate or severe COPD exacerbations will be analyzed using negative 
binomial regression.  Chronic obstructive pulmonary disease exacerbations will be 
considered separate events provided that 7 or more days are between the recorded stop date 

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of the earlier event and start date of the latter.  Time at risk of experiencing an exacerbation 
will be used as an offset variable in the model.  Time during an exacerbation or in the 7 days 
following an exacerbation will not be included in the calculation of time at risk.  For 
moderate or severe COPD exacerbations, the start date is be defined as the start date of 
prescribed treatment with a systemic corticosteroid or systemic antibiotic and the stop date 
will be defined as the last day of prescribed treatment with a systemic corticosteroid or 
systemic antibiotic.  Treatments will be compared adjusting for country, baseline post-
bronchodilator percent predicted FEV1, baseline COPD exacerbation history, baseline 
eosinophil count, and ICS use at Screening. 
Other endpoints: 
The rate of COPD exacerbations of any severity and the rate of severe COPD exacerbations 
will be analyzed in a similar manner. 
The time to first moderate or severe COPD exacerbation, the time to the first COPD 
exacerbation of any severity, and the time to the first severe COPD exacerbation will each be 
analyzed using Cox regression model.  The model will include treatment; baseline percent 
predicted FEV1, baseline COPD exacerbation history, baseline eosinophil count, and ICS use 
at Screening.  Estimated adjusted hazard ratios relative to the comparator will be displayed 
along with the associated Wald 2-sided 95% CIs and p-values.  Time to first moderate or 
severe COPD exacerbation as well as the time to first COPD exacerbation of any severity 
will be displayed graphically for each treatment group using a Kaplan-Meier curve.  Subjects 
who did not experience a COPD exacerbation will be censored at the Week 24 visit.  
Subjects who withdrew from the study without experiencing a COPD exacerbation will be 
censored at the date of withdrawal. 
Duration of COPD Exacerbation 
For moderate or severe exacerbations, the duration is defined by the length of prescribed 
treatment, whereas for mild exacerbations, the duration is defined by the length of symptoms. 
For moderate or severe COPD exacerbations, the start date will be defined as the start date of 
prescribed treatment with a systemic corticosteroid or systemic antibiotic and the stop date 
will be defined as the last day of prescribed treatment with a systemic corticosteroid or 
systemic antibiotic.  In order to ensure that the same event is not counted twice, concurrent 
moderate or severe COPD exacerbations with start and stop dates equal to or less than 7 days 
apart will be considered the same event and assigned the maximum severity between the two.   
For mild COPD exacerbations, start date will be defined as the onset of worsened symptoms 
as recorded by the subject in the eDiary, and the stop date will be defined as the last day of 
worsened symptoms.  In order to ensure that the same event is not counted twice, mild COPD 
exacerbations with start and stop dates equal to or less than 7 days apart will be considered 
the same event.   
In addition, in order to not double count exacerbations that are moderate or severe, eDiary 
data from dates within 7 days of a moderate or severe exacerbation will not be included as 

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additional mild COPD exacerbations.  This implies that continuing worsened symptoms that 
meet the definition of a mild exacerbation would need to be present at least 2 days prior to 
the 7-day period immediately preceding the start date of a moderate or severe COPD 
exacerbation in order to be considered a separate event.  Similarly, worsened symptoms 
would need to be present for at least 2 days after the 7-day period immediately following a 
moderate or severe COPD exacerbation to be considered a separate event.   
Analyses of each severity of exacerbation will account for the time that subjects are at risk of 
having an exacerbation of that severity or greater.  Time during or immediately following an 
exacerbation will not be considered as part of the time that the subject was at risk.  However, 
time during or immediately following an exacerbation of lower severity will be included 
since, for example, a subject experiencing a mild exacerbation is still at risk of the event 
increasing in severity and becoming a moderate exacerbation. 
9.4.3.7 
Time to Clinically Important Deterioration 
CID is defined as a ≥ 100 mL decrease (from baseline) in trough FEV1, or ≥ 4 points increase 
(from baseline) in SGRQ total score, or a TDI focal score of -1 point or less, or treatment-
emergent moderate-or-severe COPD exacerbation occurring up to Week 24. Sustained CID is 
defined as ≥ 100 mL decrease (from baseline) in trough FEV1, or ≥ 4 points increase (from 
baseline) in SGRQ total score, or a TDI focal score of -1 point or less, any of which is 
occurring on two consecutive analysis visits or for ≥ 50% of all available subsequent analysis 
visits, or a treatment emergent moderate-or-severe COPD exacerbation occurring up to Week 
24.  
Time to CID analysis will be performed using the Cox regression model. The model will 
include baseline post-bronchodilator percent predicted FEV1, baseline eosinophil count, 
baseline COPD exacerbation history (0, 1, ≥2), country, and ICS use at Screening (yes/no). 
Time to a CID event will be based on the component event which occurs first. Subjects who 
do not have a CID event will be censored at the earliest day among the component censoring 
times. COPD exacerbations happening after Week 24 will not be counted as CID events. 
Estimated adjusted hazard ratios will be displayed along with associated 95% CI and p-
values. Time to CID will be displayed for each treatment group using a Kaplan-Meier curve. 
Time to CID will be presented for the efficacy, the attributable, the treatment policy, and per-
protocol estimands.  
The analyses will be repeated for time to sustained CID as an ‘other’ endpoint for the 
efficacy estimand. 
9.4.3.8 
Time to Onset of Action 
The onset of action will be determined for each treatment using the post dosing FEV1 
assessments from Day 1.  The onset of action for each product (BGF MDI, GFF MDI, and 
BFF MDI) will be defined as the first time point where the mean change from baseline 
exceeds 100 mL.  Supportive analyses may be conducted using alternatively definitions of 
onset of action. 

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9.4.4 
Analysis of Other Endpoints 
All exploratory endpoints will be presented for the efficacy estimand only. These will not be 
presented for the attributable, treatment policy, or per-protocol estimands.  
9.4.4.1 
Other Spirometry Endpoints 
The analysis of the other between-treatment comparisons for changes in morning pre-dose 
trough FEV1 at each post-dose time point has already been described in Section 9.4.2.1.  
Treatment differences in the change from baseline in FEV1, morning pre-dose trough FVC, 
PEFR, and FEF25-75 will be evaluated in a similar manner to the primary endpoint. 
9.4.4.2 
12-Hour Pulmonary Function Tests 
FEV1 AUC0-12 will be measured in a subset of subjects at the 12 week visit.  Area under the 
curve will be calculated using the trapezoidal rule and transformed into a weighted average 
by dividing by the time in hours from dosing of the last measurement included (typically 12 
hours).  Only 1 non-missing post dose value is required for the calculation of AUC.  The per 
protocol estimand is primary for the non-inferiority comparison of BFF vs. Symbicort. 
Actual time from dosing will be used if available; otherwise scheduled time will be used.  
The differences between treatment groups in FEV1 AUC0-12 at Week 12 will be evaluated 
using an ANCOVA with baseline FEV1, baseline eosinophil count, and percent reversibility 
to Ventolin HFA as continuous covariates, and treatment, and ICS use at Screening as 
categorical covariates.  Two-sided p-values and point estimates with 2-sided 95% CIs will be 
produced for each treatment difference.  The comparison of BFF MDI to Symbicort TBH 
will be for non-inferiority rather than superiority and will use a margin of 75 mL. 
As additional supportive analyses, FEV1 AUC0-4, FEV1 AUC0-6, FEV1 AUC6-12, FVC 
AUC0-4, FVC AUC0-4, PEFR AUC0-12, PEFR AUC0-4, and FEF25-75 AUC0-12, FEF25-75 AUC0-4 
will be calculated and analyzed for the efficacy estimand only, in a similar fashion as the 
efficacy estimand for FEV1 AUC0-12. 
9.4.4.3 
Percentage of Days with No Rescue Ventolin HFA Use over the Treatment 
Period 
As a supportive analysis, the percentage of days with ‘no rescue Ventolin HFA use’ over 24 
weeks will be analyzed.  A ‘day with no rescue use’ is defined as any day where the subject 
reported zero puffs of rescue Ventolin HFA.  The rescue Ventolin HFA usage diary data 
from days where rescue Ventolin HFA usage data is non-missing will be used to ascertain the 
days with “no rescue Ventolin HFA use”.  The percentage of days with ‘no rescue Ventolin 
HFA use’ will be summarized by treatment and analyzed using ANCOVA with baseline 
average daily rescue Ventolin HFA use instead of baseline FEV1 as a covariate, and baseline 
post-bronchodilator percent predicted FEV1 as a continuous covariate.  

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9.4.4.4 
Time to Treatment Discontinuation 
Treatment discontinuation will be defined as a moderate or severe COPD exacerbation or 
discontinuation from treatment for any reason.  The time to treatment discontinuation will be 
analyzed using a Cox regression model.  The model will include treatment, baseline post-
bronchodilator percent predicted FEV1, baseline eosinophil count, baseline COPD 
exacerbation history, and ICS use at Screening.  Estimated adjusted hazard ratios will be 
displayed along with associated 95% CIs and p-values.  Time to treatment discontinuation 
will be displayed graphically for each treatment group using a Kaplan-Meier curve.  Subjects 
who did not experience a treatment discontinuation will be censored at Week 24. 
9.4.4.5 
Exacerbations of Chronic Pulmonary Disease Tool 
The EXACT (please note new name Section 7.1.4.5) is a 14-item PRO daily diary which will 
be used to measure the effect of treatment on exacerbations, and on the severity of respiratory 
symptoms.  The severity of respiratory systems will be measured using the E-RS:COPD, 
which is an 11-item subset of the EXACT.  The analysis of the RS-Total score is already 
described under secondary endpoints.  Mean change from baseline in: the daily EXACT 
Total Score, and the 3 subscale scores of the E-RS:COPD (i.e. RS-Breathlessness, RS-Cough 
and Sputum, and RS-Chest Symptoms) will be calculated over each 4-week interval of the 
24-week Treatment Period and analyzed using a similar approach as the RS-Total score.  The 
last 7 days of the Screening Period will be used to calculate the baseline. 
9.4.4.6 
European Quality-of-Life-5 Dimension-5 Level Questionnaire 
The European Quality-of-Life-5 Dimension-5 Level Questionnaire (EQ-5D-5L) data will be 
weighted to calculate an index score based upon subjects responses to the 5 dimensions.  The 
visual analogue scale will be scored from 0 (worst imaginable health state) through 100 (best 
imaginable health state) to represent the subject’s self-report concerning how bad or how 
good their health was during that day.  The percentage of subjects’ categorical responses to 
each of the 5-dimensions will be summarized.  Descriptive statistics for the index score and 
VAS will be presented by treatment group.  VAS scores over 24 weeks may be analyzed 
using a similar RM model as is used for the TDI, but using baseline EQ-5D-5L VAS score as 
a covariate instead of BDI. 
The compliance of completing the EQ-5D-5L questionnaires will be described at each 
assessment time-point, by the number and percentage of subjects who filled out a 
questionnaire (per subject, at least 1 question answered). 
9.4.5 
Control of Type I Error 
There are 3 separate plans for control of Type I error, corresponding to each of the 3 
registration approaches for Japan/China, EU/Canada, and US.  Each of the plans will test the 
primary endpoint (s) using the efficacy estimand first for superiority comparisons, followed 
by the attributable estimand as the first secondary.  Additional secondary endpoints will only 
be tested using the efficacy estimand for Type I error control.  Non-inferiority comparisons 
will be made using the per-protocol estimand.  Additional details, including non-inferiority 

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margins, will be described in detail in the SAP.  All secondary endpoints with the exception 
of time to onset are included in the Type I error control plans described below. 
9.4.5.1 
Japan/China Approach:  
The comparisons of interest for the Japan/China approach are BGF MDI versus BFF MDI 
and BGF MDI versus GFF MDI, both for superiority, and BFF MDI versus Symbicort TBH 
for non-inferiority. 
Strong control of the Type I error rate will be maintained at the 2-sided 0.05 level for the 
primary endpoint across key treatment comparisons using a sequential approach across 
comparisons, and then for the secondary measures.  Type I error control will be maintained 
within comparison using a combination of sequential and simultaneous approaches as 
detailed below.  Based on positive dependence of the test statistics (Sarkar, 2008; Sarkar and 
Chang 1997), simultaneous control of Type I error for the relevant secondary measures will 
be achieved using the Hochberg procedure (Hochberg, 1988).   
The following 3 between-treatment comparisons will be conducted, in the order stated, for 
morning pre-dose trough FEV1 over Weeks 12 to 24: BGF MDI versus BFF MDI, BGF MDI 
versus GFF MDI, using the efficacy estimand, and BFF MDI versus Symbicort TBH (non-
inferiority) using the per-protocol estimand.  Each comparison will be made only if the 
preceding comparison in the sequence is statistically significant.   
If the comparisons for BGF MDI versus BFF MDI and BGF MDI versus GFF MDI are both 
statistically significant at a 2-sided alpha level of 0.05, testing will proceed to comparison of 
the respective attributable estimands in the same order. If the comparisons of the attributable 
estimands are also significant, then the remaining secondary measures within each 
comparison will be tested using the efficacy estimand.  Type I error will be controlled at 0.05 
within each comparison (BGF MDI versus BFF MDI, BGF MDI versus GFF MDI) for the 
secondary endpoints through simultaneous testing under the Hochberg procedure with a 2-
sided alpha of 0.05. 
If non-inferiority is established for the comparison of trough FEV1 between BFF MDI and 
Symbicort TBH, then tests of the additional secondary measures for this comparison will be 
interpreted without any additional control of Type I error. 
9.4.5.2 
EU/Canada Approach 
The comparisons of interest for the EU/Canada approach are: BGF MDI versus GFF MDI, 
BGF MDI versus BFF MDI, and BGF MDI versus Symbicort TBH, all for superiority, and 
the comparison of BFF MDI vs. Symbicort for non-inferiority.  All comparisons are 
evaluated over 24 weeks unless stated otherwise. 
Strong control of the Type I error rate will be maintained at the 2-sided 0.05 level for the key 
comparisons using a sequential approach for the primary endpoints and then for the 
secondary measures Type I error control will be maintained within comparison using a 
combination of sequential and simultaneous approaches as detailed below. 

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The following 4 comparisons will be conducted first, in the order they appear below: 
• FEV1 AUC0-4 for BGF MDI versus BFF MDI using the efficacy estimand 
• Trough FEV1 for BGF MDI versus GFF MDI using the efficacy estimand 
• FEV1 AUC0-4 for BGF MDI versus BFF MDI using the attributable estimand 
• Trough FEV1 for BGF MDI versus GFF MDI using the attributable estimand 
 
All subsequent comparisons below will use only the efficacy estimand. 
If the comparison of FEV1 AUC0-4 between BGF MDI and BFF MDI using the attributable 
estimand above is statistically significant, testing will proceed to the secondary comparison 
of BGF MDI versus BFF MDI for change in morning pre-dose trough FEV1 using a 2-sided 
0.05 level test.  If this test is also significant, testing will proceed to the remaining secondary 
endpoints.  BGF MDI versus BFF MDI will be simultaneously compared among these 
secondary endpoints using the Hochberg procedure with a 2-sided alpha of 0.05.  
If the comparison of BGF MDI versus GFF MDI for change in morning pre-dose trough 
FEV1 using the attributable estimand is statistically significant, testing will proceed to the 
remaining secondary endpoints for BGF MDI vs. GFF MDI using the efficacy estimand.  
BGF MDI versus GFF MDI will be simultaneously compared among the secondary 
endpoints using the Hochberg procedure with a 2-sided alpha of 0.05. 
If the comparison of FEV1 AUC0-4 for BGF MDI versus BFF MDI is statistically significant 
using the attributable estimand, testing will also proceed to a comparison of BGF MDI versus 
Symbicort TBH for of FEV1 AUC0-4 using the efficacy estimand.  If statistically significant, 
the remaining secondary endpoints for BGF MDI versus Symbicort TBH will be 
simultaneously compared among the secondary endpoints using the Hochberg procedure with 
a 2-sided alpha of 0.05. 
Finally, if the comparison of FEV1 AUC0-4 over 24 weeks for BGF MDI versus BFF MDI is 
statistically significant, testing will proceed to the non-inferiority comparisons of BFF MDI 
versus Symbicort TBH.  If non-inferiority is established, tests of the additional secondary 
measures for this comparison will be interpreted without any additional control of Type I 
error. 
9.4.5.3 
US Approach  
The comparisons of interest for the US approach are: BGF MDI versus GFF MDI and BGF 
MDI versus BFF MDI, both for superiority, and at Week 24 unless stated otherwise. 
Statistical significance for nominal comparisons will be at alpha=0.05. 
Strong control of the Type I error rate will be maintained at the 2-sided 0.05 level for the key 
comparisons using a sequential approach for the primary endpoints and then for the 
secondary measures Type I error control will be maintained within comparison using a 
combination of sequential and simultaneous approaches as detailed below . 

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The following 4 comparisons will be conducted first, in the order they appear below: 
• FEV1 AUC0-4 for BGF MDI versus BFF MDI using the efficacy estimand 
• Trough FEV1 for BGF MDI versus GFF MDI using the efficacy estimand 
• FEV1 AUC0-4 for BGF MDI versus BFF MDI using the attributable estimand 
• Trough FEV1 for BGF MDI versus GFF MDI using the attributable estimand 
 
If the comparison of FEV1 AUC0-4 between BGF MDI versus BFF MDI using the 
attributable estimand is statistically significant, the secondary endpoints for BGF MDI versus 
BFF MDI will be compared simultaneously using the efficacy estimand, and using the 
Hochberg procedure with a 2-sided alpha of 0.05. 
If the comparison of trough FEV1 AUC0-4 between BGF MDI versus GFF MDI for the 
attributable estimand is statistically significant, the remaining secondary endpoints for BGF 
MDI versus GFF MDI will be simultaneously compared using the Hochberg procedure with 
a 2-sided alpha of 0.05. 
9.5 
Subgroup Analyses 
Subgroup analyses for primary and secondary endpoints will be performed for the Japanese 
region versus the remaining regions combined as well as for Chinese and Asian subgroups.  
Additional subgroup analyses will be defined in the SAP as appropriate. 
9.6 
Safety Analyses 
9.6.1 
Adverse Events 
The version of the Medical Dictionary for Regulatory Activities (MedDRA) that is current at 
the time of database lock will be used to code verbatim terms for AEs for final analysis of the 
data.  The number and incidence of adverse events, serious adverse events, adverse events of 
special interest by category, confirmed AEs of pneumonia, and study drug discontinuations 
due to adverse events will be summarized by treatment group.  They will be tabulated at the 
level of the Medical Dictionary for Regulatory Activities (MedDRA) preferred term and the 
MedDRA system organ class.  Tabulations will be broken down by severity, by relationship 
to study drug, and AEs leading to treatment discontinuation.  No hypothesis tests will be 
performed. 
9.6.2 
Cardio- and Cerebrovascular Events Determined by Clinical Endpoint 
Committee 
The CEC will review and adjudicate serious CCV events as MACE.  MACE events are 
defined as the following: 
• Cardiovascular death 
• Non-fatal myocardial infarction (MI) 

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• Non-fatal stroke  
 
The CEC will review and assess these non-fatal serious CCV events and all deaths as to 
whether or not they fulfill criteria (based on CEC working practices) for MACE. 
MACE events will be summarized by treatment group. 
9.6.3 
Pneumonia Events Determined by Clinical Endpoint Committee 
All AEs/SAEs with preferred terms that could relate to pneumonia will be adjudicated to 
provide a more complete assessment of all physician-reported pneumonias.  The assessment 
of pneumonia events will include the overall rates of pneumonia. 
In order to account for specific patient risk factors, time to first pneumonia will be compared 
between treatments using Cox proportional hazards.  Specific patient risk factors that have 
will be evaluated for inclusion. 
9.6.4 
Clinical Laboratory Measurements 
Summary statistics (n, mean, median, standard deviation, minimum, and maximum) for the 
baseline assessment (Day 1) and for the pre-dose value and change from baseline at pre dose 
value of post-baseline visits with scheduled lab assessments of continuous laboratory 
variables, including serum potassium and glucose will be tabulated. 
Shift tables relative to the normal reference ranges will be produced using the categories 
defined by the CTCAE Version 4.03 grades.  For these shift tables, for each treatment, the 
subject’s pre-dose grade will be cross-tabulated by the subject’s maximum post baseline 
grade during the treatment; also, the subject’s maximum post-baseline grade during treatment 
will be tabulated for all baseline grades combined. 
The number and percent of subjects with potentially clinically significant (PCS) lab values 
will be summarized.  Potentially clinically significant values for serum potassium are <3.0 
mmol/L or >6.0 mmol/L, and for blood glucose <2.2 mmol/L or >13.9 mmol/L.  Potentially 
clinically significant values for additional labs will be defined in the SAP.  No hypothesis 
tests will be performed. 
9.6.5 
Vital Signs 
Summary statistics (mean, median, standard deviation and range) for absolute values and 
change from baseline values will be tabulated for each treatment and assessment time.  For 
vital signs, baseline values will be defined as the average of the values prior to dosing at the 
randomization visit (Visit 4).  Potentially clinically significant values for vital signs will be 
defined in the SAP and the percentage of subjects with PCS values will be summarized.  No 
hypothesis tests will be performed. 

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9.6.6 
Electrocardiograms 
Summary statistics (mean, median, standard deviation and range) for raw values and change 
from baseline values in Heart Rate, PR Interval, QRS Axis, QRS Interval, QT Interval and 
QTcF interval will be calculated, where baseline is defined as the average of the pre-dose 
measurements taken prior to the start of treatment at the randomization visit (Visit 4).  The 
QTcF (Fridericia Corrected QT) is defined as (QT/[RR1/3]).  Heart rate (bpm) is estimated as 
60,000/RR.  These assessments will be tabulated for each treatment and assessment time.  
Potentially clinically significant values for ECG parameters will be defined in the SAP, and 
the percentage and number of subjects with PCS ECG values will be tabulated.  No 
hypothesis tests will be performed. 
9.6.7 
Exposure 
The duration of exposure to study medication (in days), the person-years of exposure, the 
mean number of doses, and number and percentage of subjects who are compliant will be 
summarized by treatment group.  All exposure summaries will be generated for the safety 
population by actual treatment received. 
9.7 
Pharmacokinetic Analyses 
Non-compartmental parameter estimates for budesonide, glycopyrronium, and formoterol 
AUC0-12 and Cmax will be natural-log transformed and analyzed using mixed effect models.  
Additional analyses will estimate bioavailability of BGF MDI relative to GFF MDI, BFF 
MDI, or Symbicort TBH.  Separate mixed models with fixed effects for treatment, visit and 
treatment-by-visit interaction and a random effect for subject will be fit for each analyte. 
9.8 
HPA Axis 
The primary analysis will performed on the log transformed ratio from baseline of the serum 
cortisol weighted mean (0-24 h) for subjects in the HPA Axis Population.  Baseline was 
defined as the weighted mean 0-24 h from Day -1/1.  An analysis of covariance (ANCOVA) 
model was fitted with baseline (log transformed), gender, age, and treatment group as terms 
in the model and the following comparisons will be made: BGF MDI versus GFF MDI, BGF 
MDI versus BFF MDI, and Symbicort TBH versus GFF MDI.  The change from Screening 
(Visit 3) to Visit 10a (Week 24) in the 0- to 24-hour weighted mean SC at Week 24 will also 
be summarized by treatment group.  Serum cortisol profiles over 24 hours will be graphically 
presented by treatment group using box plots over time, at baseline and at Week 24. 
The percentage of subjects observing a 30% or greater reduction from baseline in the 0-24 
hour weighted mean SC will be summarized. 
9.9 
Health Care Resource Utilization 
COPD-related and non-COPD-related HCRU will be summarized by treatment group. 

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9.10 Randomization 
Subjects will be randomized in a 2:2:1:1 scheme.  Approximately 600 subjects each will be 
randomized to the BGF MDI and GFF MDI treatment groups, and 300 subjects each will be 
randomized to the BFF MDI and Symbicort TBH treatment groups.  Randomization will be 
stratified by reversibility (yes/no) to Ventolin HFA, country, and disease severity as 
determined by post-bronchodilator percent predicted FEV1 (≥50%=moderate versus 
<50%=severe or very severe) to ensure even distribution of treatment arms within each 
stratum. 
9.11 Experimental Design 
This study is a multi-center, double-blind, parallel-group, active-controlled (open-label 
Symbicort TBH) design. 
9.12 Sample Size 
It is estimated that a sample size of 1800 subjects (600 per arm in the BGF MDI and GFF 
MDI groups and 300 per arm in the BFF MDI and Symbicort TBH groups) will provide the 
following power estimates, all assuming Type I error control at a 2-sided alpha level of 0.05 
unless specified otherwise: 99% power to detect a difference of 75 mL between BGF MDI 
and BFF MDI in FEV1 AUC0-4 over 24 weeks; 96% power to detect a difference of 35 mL 
between BGF MDI and GFF MDI in morning pre-dose trough FEV1 over 24 weeks and 
approximately 92% power over Weeks 12 to 24; 97% power to detect a difference of 50 mL 
between BGF MDI and BFF MDI in morning pre-dose trough FEV1 over Weeks 12 to 24; 
and 96% power to demonstrate non-inferiority of BFF MDI to Symbicort TBH in morning 
pre-dose trough FEV1 over 24 weeks and approximately 92% power over Weeks 12 to 24 
based on a margin of 50 mL (one-sided, alpha=0.025) assuming no true difference.   
Assumptions regarding variability for the primary endpoint are based on Pearl’s experience 
with Phase IIb and III clinical studies.  A composite value standard deviation (SD) of 200 mL 
for the change from baseline at each visit has been assumed for trough FEV1 and 220 mL for 
FEV1 AUC0-4.  Dropout is anticipated to be approximately 12% by the end of the study.  
Based on the repeated measures analysis, an effective SD for the change over 24 weeks of 
157 mL and 173 mL for trough FEV1 and FEV1 AUC0-4, respectively, is assumed.  For 
Weeks 12 to 24, an effective SD for trough FEV1 of 171 mL is assumed. 
9.13 Data Validation and Transformation 
In general the distribution of spirometry measures is well-approximated by a normal 
distribution.  Under some circumstances, however, (for example during a COPD 
exacerbation, unrelated to treatment) extreme and atypical values can arise.  Such values 
have high influence on estimation of variance parameters and on standard errors of fixed 
effect estimates.  The distribution and potential influence of outliers will be evaluated and 
additional sensitivity analyses will be conducted if warranted to demonstrate the robustness 
of the primary and secondary results. 

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9.14 Analysis Plan 
All analyses will be specified in a detailed SAP that will be accompanied by table and data 
listing shells with mock graphical representations.  The analysis plan will be approved by 
signature before database lock and unblinding.  
9.15 Handling of Missing Data 
All observed values will be included in the treatment policy estimand.  All observed values 
recorded prior to treatment discontinuation will be included in the efficacy estimand.  As a 
maximum likelihood method, RM is valid for missing-at-random (MAR) data (Little and 
Rubin, 2002).  Additional sensitivity analyses will be performed using multiple imputations 
under varying assumptions about treatment effects in the unobserved data to explore the 
impact of missing data.  Further details are provided in the SAP. 
Change from baseline in morning pre-dose trough FEV1 at each visit is defined as the 
average of the 60 and 30 minute pre-dose values minus baseline.  In subjects missing either 
of these pre-dose assessments, the value will be calculated from the single measurement.  In 
subjects missing both pre-dose values, morning pre-dose trough FEV1 at that visit will not be 
calculated. 
Peak FEV1 and FEV1 AUC0-4 will be included in the efficacy, attributable, treatment policy, 
and per-protocol estimands as long as there is at least 1 non-missing post-dose value during 
the first 4 hours post-dose. 
For the subset of subjects included in the 12-hour spirometry assessment at Visit 10a (Week 
24), the efficacy estimand will use all available data with the trapezoidal rule to calculate 
AUC0-12 (AUC0-6 and AUC6-12) using change from baseline values.  The determination of 
peak change from baseline in FEV1 requires at least 1 non-missing FEV1 value during the 
first 2 hours post-dose. 
9.16 Statistical Software 
Data processing, statistical screening, descriptive reporting and analysis of the efficacy and 
safety data will be performed using SAS (Version 9.2 or higher).  Graphs may also be 
produced using R (R Development, 2003). 

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10 ADMINISTRATIVE CONSIDERATIONS 
10.1 Regulatory Authority Approval 
Pearl will obtain approval to conduct the study from the appropriate regulatory agency in 
accordance with any applicable country-specific regulatory requirements prior to a site 
initiating the study in that country. 
10.2 Ethical Conduct of the Study and Institutional Review Board or 
Independent Ethics Committee Approval 
The study will be conducted in accordance with Good Clinical Practice (GCP).  These 
standards respect the following guidelines: 
• Guideline for Good Clinical Practice E6 (R1): Consolidated Guideline (International 
Conference on Harmonization of Technical Requirements for the Registration of 
Pharmaceuticals for Human Use, May 1996). 
• US CFR dealing with clinical studies (21 CFR parts 50, 54, 56, and 312). 
• Declaration of Helsinki, concerning medical research in humans (Ethical Principles for 
Medical Research Involving Human Subjects) 
[http://www.wma.net/en/10home/index.html]. 
• Any additional regulatory requirements. 
 
The Investigator (or Pearl, where applicable) is responsible for ensuring that this protocol, 
the site’s ICF, and any other information that will be presented to potential subjects (eg, 
advertisements or information that supports or supplements the ICF) are reviewed and 
approved by the appropriate IRB/IEC.  The Investigator agrees to allow the IRB/IEC direct 
access to all relevant documents.  The IRB/IEC must be constituted in accordance with all 
applicable regulatory requirements.   
Pearl will provide the Investigator with relevant document(s)/data that are needed for 
IRB/IEC review and approval of the study.  If the protocol, the ICF, or any other information 
that the IRB/IEC has approved for presentation to potential subjects is amended during the 
study, the Investigator is responsible for ensuring the IRB/IEC reviews and approves, where 
applicable, these amended documents.  The Investigator must follow all applicable regulatory 
requirements pertaining to the use of an amended ICF including obtaining IRB/IEC approval 
of the amended form before new subjects consent to take part in the study using this version 
of the form.  The IRB/IEC approval of the amended ICF/other information and the approved 
amended ICF/other information must be forwarded to Pearl promptly. 
10.3 Subject Information and Consent 
The study will be conducted in accordance with applicable subject privacy requirements.  
The proposed ICF, which must be in compliance with applicable regulations, must be 
reviewed and approved by the IRB/IEC and Pearl prior to initiation of the study.   

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The Investigator will be responsible for obtaining written informed consent from potential 
subjects prior to any study-specific screening and entry into the study.  A copy of the signed 
ICF will be provided to the subject.  The original will be retained by the Investigator. 
10.4 Laboratory Accreditation 
Any laboratory facility intended to be used for analysis of clinical laboratory samples 
required by this protocol must provide evidence of adequate licensure or accreditation 
according to the prevailing regulations in that state and/or country.  Reference values and/or 
normal ranges for the test results must be provided to Pearl.  Pearl must be notified promptly 
in writing of any changes occurring in reference values during the course of the study. 
10.5 Confidentiality 
10.5.1 
Confidentiality of Data 
By signing this protocol, the Investigator affirms to Pearl that information furnished to the 
Investigator by Pearl will be maintained in confidence and such information will be divulged 
to the IRB/IEC, or similar or expert committee; affiliated institution; and employees only 
under an appropriate understanding of confidentiality with such board or committee, 
affiliated institution and employees.  Data generated by this study will be considered 
confidential by the Investigator, except to the extent that it is included in a publication. 
10.5.2 
Confidentiality of Subject/Patient Records 
By signing this protocol, the Investigator agrees that Pearl (or representative), IRB/IEC, or 
Regulatory Agency representatives may consult and/or copy study documents in order to 
verify worksheet/case report form data.  By signing the consent form, the subject/patient 
agrees to this process.  If study documents will be photocopied during the process of 
verifying worksheet/case report form information, the subject/patient will be identified by 
unique code only; full names/initials will be masked prior to transmission to Pearl.  In 
addition, the Investigator agrees to treat all subject data used and disclosed in connection 
with this study in accordance with all applicable laws (i.e., Health Insurance Portability and 
Accountability Act), rules and regulations. 
10.6 Quality Control and Assurance 
Pearl is responsible for implementing and maintaining quality control and quality assurance 
systems with written SOPs to ensure that Studies are conducted and data are generated, 
documented, and reported in compliance with the protocol, accepted standards of GCP, and 
all applicable federal, state, and local laws, rules and regulations relating to the conduct of 
the clinical study. 
10.7 Data Management 
Data management procedures and information for this protocol will be provided by Pearl or 
their designee. 

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10.8 Study Monitoring 
In accordance with applicable regulations, GCP, and Pearl procedures, clinical monitors will 
contact the site prior to subject enrollment to review the protocol and data collection 
procedures with site staff.  In addition, the monitor will periodically contact the site, 
including conducting on-site visits.  The extent, nature, and frequency of on-site visits will be 
based on such considerations as the study objective and/or endpoints, the purpose of the 
study, study design complexity, and enrollment rate. 
During these contacts, the monitor will: 
• Check the progress of the study. 
• Review study data collected.   
• Conduct source document verification. 
• Identify any issues and address their resolution. 
 
This will be done in order to verify that the: 
• Data are authentic, accurate, and complete. 
• Safety and rights of subjects are being protected. 
• Study is conducted in accordance with the currently approved protocol (and any 
amendments), GCP, and all applicable regulatory requirements. 
 
The Investigator agrees to allow the monitor direct access to all relevant documents and to 
allocate his/her time and the time of his/her staff to the monitor to discuss findings and any 
relevant issues. 
Upon completion of the study, the monitor will conduct the following activities in 
conjunction with the Investigator or site staff, as appropriate: 
• Return of all study data to Pearl  
• Data queries  
• Accountability, reconciliation, and arrangements for unused investigational product(s) 
• Review of site study records for completeness 
 
After the final review of the study files, the files should be secured for the appropriate time 
period as specified in Section 10.9.  The Investigator will also permit inspection of the study 
files by Pearl’s Quality Assurance auditors, and authorized representatives of the FDA or 
other applicable regulatory agencies. 
10.9 Retention of Data 
Documents that individually and collectively permit evaluation of the conduct of the study 
and the quality of the data produced must be maintained for review by Pearl’s quality 

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assurance auditors and by all applicable regulatory authorities.  The period of time these 
documents must be maintained is governed by applicable regulations.  Pearl or its designee 
will inform the Investigator when these documents may be destroyed.  Pearl or its designee 
must be notified in writing at least 6 months prior to the intended date of disposal of any 
study record related to this protocol to allow Pearl to make alternate storage arrangements. 
10.10 Financial Disclosure 
The Principal Investigator or sub-Investigators named on the FDA Form 1572 or the locally 
accepted alternate Investigator Statement form, will need to complete a financial disclosure 
form prior to study initiation, at any time during the study execution if new information 
needs to be disclosed, and for 1 year after study completion.  Investigators should make the 
IRB/IEC aware of any financial interests that the Investigator has in the investigational 
product. 
10.11 Investigator’s Final Report 
Shortly after completion of the Investigator's participation in the study, the Investigator will 
submit a written report to Pearl. 
10.12 Publication Policy 
Pearl intends to publish the results of all of the clinical studies that it sponsors in compliance 
with the Declaration of Helsinki (http://www.wma.net/en/10home/index.html).  Consistent 
with the recommendations of the editors of several leading medical journals, the International 
Committee of Medical Journal Editors (ICMJE), authorship of publications resulting from 
Pearl -sponsored studies should fairly recognize the activities of those that have made a 
significant contribution to the study.  Thus, it is anticipated that authorship will reflect the 
contribution made by Pearl personnel, the Investigators and others involved, such as 
statisticians. 
In recent years, issues about conflicts of interest and accuracy of the study data have been 
raised in the medical press.  Accordingly, Pearl has developed publication guidelines as 
described below: 
1. Responsibility: Each Principal Investigator is responsible for the accuracy and 
completeness of all data from their site.  Pearl (or its representatives) is responsible for 
the accuracy of the data entered into the study databases and for the accuracy of the 
analyses conducted. 
2. Authorship and Publication Committee: The Sponsor, in collaboration with the 
Investigators, will establish the appropriate authorship and responsibility for drafting 
study documents in accordance with the principles of the ICMJE and the International 
Society for Medical Publication Professionals. It is anticipated that a publication 
committee will be formed to assume oversight of these activities. All manuscripts will be 
reviewed and agreed upon before submission for publication by all authors. 
3. Sponsor Review of External Manuscripts: Consistent with the previous bullet point, 
drafts of any and all publications or presentations that may arise from this study must be 

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submitted at least 30 days prior to submission for publication or presentation to Pearl for 
review, approval, and to ensure consistency with the policy in this protocol.  Pearl will 
have the right to request appropriate modification to correct facts and to represent its 
opinions, or the opinions of the publication committee, if these differ with the proposed 
publication. 
4. Confidentiality: Investigators will conduct all interactions with Pearl and with third 
parties consistent with the executed confidentiality agreements.  While publication, by 
intention, presents the critical scientific data in a public forum, some information (such as 
future plans, results of nonclinical studies, or chemical formulae) may still need to remain 
confidential. 
5. Medical Journal Review: Consistent with the intention of Pearl to publish the study in a 
fair and accurate manner, Pearl supports diligence in the publication review process of 
medical journals.  Accordingly, upon request, all pertinent study data and information 
will be made available as supplemental information for journal editors and reviewers to 
evaluate and audit, e.g., protocol and amendments, data tabulations.  The journal and 
reviewers will need to make arrangements to maintain the confidentiality of such 
supplemental information, where relevant, and Pearl will make suitable arrangements to 
ensure that the identity of journal reviewers is kept confidential.  Records will be 
maintained of reviewers and the respective documents and datasets that were reviewed by 
each of them. 
6. Reporting of Clinical Trial Results: To provide transparency in the conduct and 
reporting of randomized clinical trials, Pearl reports clinical findings based on the 
guidance of The CONSORT (Consolidated Standards of Reporting Trials) Statement 
(CONSORT, 2010) and a 25 item checklist which is intended to improve the reporting of 
a randomized controlled Study, and to facilitate reader understanding of the Study design, 
conduct, analysis and interpretation, and to support their ability to assess the validity of 
its results. 
7. Internet Clinical Trial Listing: In addition, also consistent with the recommendations of 
the ICMJE, Pearl will make available appropriate information regarding the study via the 
internet.  This will include registration and listing of the study on www.clinicaltrials.gov, 
the US National Institutes of Health listing of clinical trials, and other clinical trial 
listings as appropriate (e.g., EUdraCT; https://eudract.ema.europa.eu).  Per AstraZeneca 
policy, Pearl posts clinical study protocols for public viewing when a manuscript is 
published in a medical journal.  Prior to being made public, the protocol is reviewed by 
AstraZeneca Intellectual Property. 
 

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11 REFERENCE LIST 
Atrovent Prescribing Information (US), Boehringer Ingelheim, 2012. 
Casaburi R, Kukafka D, Cooper CB, et al.  Improvement in exercise tolerance with the 
combination of tiotropium and pulmonary rehabilitation in patients with COPD.  Chest.  
2005;127:809-817. 
Celli B, MaNee W, Agusti A, et al.  Standards for the diagnosis and treatment of subjects 
with COPD: a summary of the ATS/ERS position paper.  Eur Respir J 2004; 23:932-946. 
Chang C, Zhu H, Shen N, Han X, Chen y, He B.  Utility of the combination of serum highly-
sensitive C-reactive protein level at discharge and a risk index in predicting readmission for 
acute exacerbation of COPD.  J Bras Pneumol 2014;140(5):495-503. 
Consolidated Standards of Reporting Trials (CONSORT) Statement 2010.  Available online 
at: http://www.consort-statement.org/consort-2010. 
European Respiratory Journal 2005;26(2):319-338. 
EuroQol Group.  EQ-5D-5L.  Accessed at http://www.euroqol.org/about-eq-5d/how-to-use-
eq-5d.html (November, 2014). 
Global Strategy for the Diagnosis, Management, and Prevention of COPD.  Global Initiative 
for Chronic Obstructive Lung Disease (GOLD) 2016.  Available online at: 
http://www.goldcopd.org 
Global Strategy for the Diagnosis, Management, and Prevention of COPD.  Global Initiative 
for Chronic Obstructive Lung Disease (GOLD) 2014.  Available online at: 
http://www.goldcopd.org.   
Hoiseth AD, Neukamm A, Hagve TA, Omland T, Brekke PH, Soyseth V.  The clinical value 
of serial measurement of high-sensitivity cardia troponin T in Acute exacerbations of chronic 
obstructive pulmonary disease.  Open Heart, 2014 Jan 15(1) 
Japanese Respiratory Society (JRS).  Guidelines for the Diagnosis and Treatment of COPD, 
4th edition, 2013. 
Jones PW, Chen WH, Wilcox TK, Sethi S, Leidy NK; EXACT-PRO Study Group.  
Characterizing and quantifying the symptomatic features of COPD exacerbations.  CHEST.  
2011;139(6):1388–1394. 
Lee MH, Chang CL, Davies AR, Davis M, Hancox RJ.  Cardiac dysfunction and N-terminal 
Pro-B type natriuretic peptide in exacerbations of chronic obstructive pulmonary disease.  
Inter Med J 2013;43(5):595-8. 

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Levey AS, Stevens LA, Schmid CH et al.  A new equation to estimate glomerular filtration 
rate.  Annals of Internal Medicine.  2009;150 (9):604–12. 
Li CI, Li TC, Liu CS, Lin Wy, Chen CC, Yang SY et al.  Extreme values of hemoglobin A1c 
are associated with increased risks of chronic obstructive pulmonary disease in patients with 
Type 2 diabetes: A competing risk analysis in National cohort of Taiwan Diabetes Study.  
Medicine (Baltimore) 2015;Jan 94(1):e367. 
Little RJA, Rubin DB.  Statistical Analysis with Missing Data.  Second Edition.  Wiley-
Interscience.  2002. 
Mahler DA, Weinberg DH, Wells CK, Feinstein AR.  The measurement of dyspnea.  
Contents, interobserver agreement, and physiologic correlates of two new clinical indexes.  
Chest.  1984;85(6):751 758. 
Miller MR, Hankinson J, Brusasco V, et al.  Standardisation of spirometry.  Eur Respir J.  
2005;26(2):319 338. 
National Health and Nutrition Examination Survey (NHANES III), 2011.  Accessed on 14 
July 2014.  Available online at: http://www.cdc.gov/niosh/topics/spirometry/nhanes.html. 
Niewoehner DE, Rice K, Cote C, et al.  Prevention of exacerbations of chronic obstructive 
pulmonary disease with tiotropium, a once-daily inhaled anticholinergic bronchodilator: a 
randomized trial.  Ann Intern Med.  2005;143:317-326. 
New York Heart Association NYHA 2011 NYHA Classification, the Stages of Heart Failure.  
Accessed on 29 September 2014.  Available online at Heart Failure Society of America: 
http://www.abouthf.org/questions_stages.htm 
R Development Core Team, 2003] R Development Core Team (2003).  R: A language and 
environment for statistical computing.  R Foundation for Statistical Computing, Vienna, 
Austria. 
http://www.renal.org/information-resources/the-uk-eckd-guide/ckd-
stages#sthash.u0MhYkto.dpbs 
Rennard SI, Tashkin DP, McElhattan J, et al.  Efficacy and tolerability of 
budesonide/formoterol in one HFA pressurized metered-dose inhaler in patients with chronic 
obstructive pulmonary disease: results from a 1-year randomized controlled clinical trial.  
Drugs.  2009;69(5):549-65. 
Robinul and Robinul Forte US Product Information, Shionogi Inc., 2011. 
Symbicort Inhalation Aerosol US Prescribing Information, Astra Zenenca, 2012. 
Tashkin DP, Rennard SI, Martin P, et al.  Efficacy and safety of budesonide and formoterol 
in one pressurized metered-dose inhaler in patients with moderate to very severe chronic 

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obstructive pulmonary disease: results of a 6-month randomized clinical trial.  Drugs.  2008; 
68(14):1975 2000.   
Ventolin (albuterol sulfate) inhalation aerosol HFA.  Highlights of Prescribing Information 
(2012).  Accessed on 15 July 2014.  Available online at: 
https://www.gsksource.com/gskprm/htdocs/documents/VENTOLIN-HFA-PI-PIL.PDF. 
Witek TJ Jr, Mahler DA.  Minimal important difference of the transition dyspnoea index in a 
multinational clinical trial.  Eur Respir J.  2003;21(2):267 272. 
 
 
 
 

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12 APPENDICES 

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Appendix 1 
Dose Indicator Reading 
For the purposes of this study, when recording the dose indicator display value, review the 
indicator display at the top of the MDI and record the number of inhalations remaining that 
matches the chart below: 
130 Count (Actuation) Version Shown 
 
If your dose 
indicator 
display looks 
like this record 
120+  
 
If your dose 
indicator 
display looks 
like this record 
120 
 
If your dose 
indicator 
display looks 
like this record 
110 
 
If your dose 
indicator 
display looks 
like this record 
100 
 
If your dose 
indicator 
display looks 
like this record 
90 
 
If your dose 
indicator 
display looks 
like this record  
80 
 
If your dose 
indicator 
display looks 
like this record  
70 
 
If your dose 
indicator 
display looks 
like this record  
60 
 
If your dose 
indicator 
display looks 
like this record 
50 
 
If your dose 
indicator 
display looks 
like this record 
40 
 
If your dose 
indicator 
display looks 
like this record  
30 
 
If your dose 
indicator 
display looks 
like this record  
20 
 
If your dose 
indicator 
display looks 
like this record  
10 
 
If your dose 
indicator 
display looks 
like this record  
0  
 
 

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Appendix 2 
Subject Instructions for Use of  BGF MDI, GFF MDI, 
and BFF MDI 
How do I store the inhaler? 
• The inhaler should be stored below 25°C (77°F) in a dry place.  Excursions permitted up 
to 30°C (86°F).   
• The contents of the canister are under pressure.  Do not puncture or throw the canister 
into a fire or incinerator.  Do not use or store it near heat or open flame.  Storage above 
120ºF may cause the canister to burst. 
• Keep the product and all medicines out of the reach of children. 
 
For Oral Inhalation Only 
Parts of the Inhaler: 
• The parts of your inhaler are seen in Figure 1. 
 
Figure 1 
 
 
• The Dose indicator lets you know about how many puffs are left in your inhaler and is 
the part of the inhaler that is pressed to dispense a puff of medication.  See Figure 1. 
• The Dose indicator should be pointing just to the right of 120 when your inhaler is new.  
See Figure 1. 
• The Dose indicator has numbers for every 20 puffs.  The Dose indicator display will 
move after every tenth puff.   

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• For example, if the Dose indicator is pointing to 120 (see Figure 2a) and you take 10 
puffs it will move between 120 and 100.  This means that there are 110 puffs of medicine 
left (see Figure 2b).  After 10 more puffs are used, the Dose indicator pointer will move 
to the number 100.  This means that there are 100 puffs of medicine left (see Figure 2c). 
• The Dose indicator number will continue to change after every 20 puffs. 
• When the number in the Dose indicator window changes to 20 and the color behind the 
number changes to red, this means that there are only 20 puffs left in your inhaler.  See 
Figure 2d. 
 
Figure 2 
 
Preparing the Inhaler for Use: 
The inhaler comes in a foil pouch that contains a drying packet (desiccant). 
• Take the inhaler out of the foil pouch. 
• Throw away the pouch and the drying packet.  Do not eat or inhale the contents of the 
drying packet.   
• Remove the Cap from the Mouthpiece as shown in Figure 3.   
 
Figure 3 
 
Prime the inhaler before you use it for the first time. 
 

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Priming the Inhaler: 
• Check inside the Mouthpiece for objects before use. 
• Hold the Actuator with the Mouthpiece pointing away from you and others as shown in 
Figure 4a. 
• Shake the inhaler well before each puff. 
• Push down fully on the center (not ‘off center’) of the Dose indicator on top of the 
Canister (see Figure 1) until the Canister stops moving in the Actuator to release a 
puff from the Mouthpiece as shown in Figure 4b.  Note: It is normal to hear a soft click 
from the dose indicator as it counts down during use. 
• Repeat this priming step 3 more times for a total of 4 times, shaking the inhaler each time 
before you press it. 
• After completing the 4 priming puffs, your inhaler is now primed ready to use for the first 
time. 
You must re-prime your inhaler again if you have not used it in more than 7 days.  Take the 
cap off the mouthpiece and shake and spray the inhaler 2 times into the air away from your 
face. 
Figure 4 
 
 
Using the Inhaler: 
Your dose of medicine comes from 2 puffs from the inhaler. 
Refer to Figure 5 for Step 1 through Step 8. 
• Step 1: Remove the Cap from the Mouthpiece. 
• Step 2: Shake the inhaler well before each puff. 
• Step 3: While holding the inhaler with the Mouthpiece pointing towards you breathe out 
through your mouth to empty as much air from your lungs as possible. 

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• Step 4: Close your lips around the Mouthpiece and tilt your head back slightly to make 
sure your tongue is away from the Mouthpiece. 
• Step 5: Take a deep breath in (inhale) slowly through your mouth while pressing down 
firmly on the center (not ‘off center’) of the Dose indicator until the Canister stops 
moving in the Actuator and a puff has been released.  Then, stop pressing the Dose 
indicator.   
• Step 6: When you have finished breathing in, remove the Mouthpiece from your mouth 
and hold your breath for 10 seconds or as long as comfortable.   
• Step 7: Then, breathe out normally.   
 
Take your second puff of medicine by repeating Step 2 through Step 7.   
• Step 8: Replace the Cap back on the Mouthpiece. 
 

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Figure 5 
 
 
How to clean the Inhaler: 
It is very important to keep your inhaler clean so medicine will not build-up and block the 
spray through the Mouthpiece.  See Figure 6. 

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Figure 6 
 
The Canister should be gently pulled from the top of the Actuator once a week and the 
Actuator cleaned.  Do not clean the Canister or let it get wet. 
• Step 1: Pull the Canister out of the Actuator as shown in Figure 7. 
 

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Figure 7 
 
• Step 2: Set the Canister aside where it will not get wet. 
• Step 3: Take the Cap off the Mouthpiece. 
• Step 4: Rinse the Actuator through the top with warm running water for 30 seconds.  
Then rinse the actuator again through the Mouthpiece (see Figure 8). 
 
Figure 8 
 
• Step 5: Shake all of the water droplets out of the Actuator. 
• Step 6: Look in the Actuator and the Mouthpiece to make sure it is clean and clear. 
 

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Repeat Step 4 through Step 6, until the Actuator and the Mouthpiece are clean and clear. 
• Step 7: Let the Actuator dry completely, such as overnight as shown in Figure 9.  Do 
Not put the Canister back into the Actuator if it is still wet. 
 
Figure 9 
 
Reassembly of the Inhaler and Instructions for Use after Cleaning: 
• After the Actuator is completely dry, gently press the Canister down in the Actuator as 
shown in Figure 10.  It is not necessary to press down on the Canister hard enough to 
cause a puff to be released. 
 

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Figure 10 
 
• Re-prime your inhaler 2 times after each cleaning. 
• Hold the Actuator with the Mouthpiece pointing away from you and others as shown in 
Figure 4. 
• Shake the inhaler well before each puff. 
• Push down fully on the center (not ‘off center’) of the Dose indicator on top of the 
Canister until the Canister stops moving in the Actuator to release a puff from the 
Mouthpiece. 
• Repeat this re-priming step 1 more time for a total of 2 times. 
• After re-priming your inhaler 2 times, your inhaler is now ready to use. 

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Appendix 3 
Instructions for Use of Symbicort® Turbuhaler® 
Inhalation Powder Device 
Preparing your new Symbicort Turbohaler 
Before using your new Symbicort Turbohaler for the first time, you need to prepare it for 
use as follows: 
• Unscrew the cover and lift it off.  You may hear a rattling sound. 
• Hold your Turbohaler upright with the red grip at the bottom. 
• Turn the red grip as far as it will go in one direction.  Then turn it as far as it will go in 
the other direction (it does not matter which way you turn it first).  You should hear a 
click sound. 
 
 
• Do this again, turning the red grip in both directions. 
• Your Turbohaler is now ready for use. 
 
How to take an inhalation 
Every time you need to take an inhalation, follow the instructions below. 
1. Unscrew the cover and lift it off.  You may hear a rattling sound. 
2. Hold your Turbohaler upright with the red grip at the bottom.   
3. Do not hold the mouthpiece when you load your Turbohaler.  To load your Turbohaler 
with a dose, turn the red grip as far as it will go in one direction.  Then turn it as far as it 
will go in the other direction (it does not matter which way you turn it first).  You should 
hear a click sound.  Your Turbohaler is now loaded and ready to use.  Only load your 
Turbohaler when you need to use it.   
4. Hold your Turbohaler away from your mouth.  Breathe out gently (as far as is 
comfortable).  Do not breathe out through your Turbohaler.   
5. Place the mouthpiece gently between your teeth.  Close your lips.  Breathe in as deeply 
and as hard as you can through your mouth.  Do not chew or bite on the mouthpiece. 
 

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6. Remove your Turbohaler from your mouth.  Then breathe out gently. 
The amount of medicine that is inhaled is very small.  This means you may not be able to 
taste it after inhalation.  If you have followed the instructions, you can still be confident 
that you have inhaled the dose and the medicine is now in your lungs. 
 
7. If you are to take a second inhalation, repeat steps 2 to 6.   
8. Replace the cover tightly after use.   
9. Rinse your mouth with water after your daily morning and/or evening doses, and spit it 
out.   
Do not try to remove or twist the mouthpiece.  It is fixed to your Turbohaler and must not be 
taken off.  Do not use your Turbohaler if it has been damaged or if the mouthpiece has come 
apart from your Turbohaler. 
Cleaning your Turbohaler  
Wipe the outside of the mouthpiece once a week with a dry tissue.  Do not use water or 
liquids. 
How to store Symbicort Turbohaler  
• Keep this medicine out of the sight and reach of children.   
• Do not use this medicine after the expiry date that is stated on the carton or on the label 
of your inhaler after EXP.  The expiry date refers to the last day of that month.   
• Do not store above 30°C.   
• Keep the container/cap tightly closed, in order to protect from moisture.   
• Do not throw away any medicines via wastewater or household waste.  Ask your 
pharmacist how to throw away medicines you no longer use.  These measures will help 
protect the environment. 

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Appendix 4 
Instructions for Use of Atrovent® HFA Inhalation 
Aerosol Device 
Instructions for Use: 
1. Insert the metal canister into the clear end of the mouthpiece (See Figure 1).  Make 
sure the canister is fully and firmly inserted into the mouthpiece. 
- 
The ATROVENT HFA canister is to be used only with the ATROVENT HFA 
mouthpiece. 
- 
Do not use the ATROVENT HFA mouthpiece with other inhaled medicines. 
2. Remove the green protective dust cap.  If the cap is not on the mouthpiece, make sure 
there is nothing in the mouthpiece before use.  For best results, the canister should be at 
room temperature before use. 
3. Breathe out (exhale) deeply through your mouth.  Hold the inhaler upright (See 
Figure 2), between your thumb and first 2 fingers.  Put the mouthpiece in your mouth 
and close your lips. 
- 
Keep your eyes closed so that no medicine will be s prayed into your eyes.  If sprayed 
into the eyes, ATROVENT HFA can cause blurry vision and other vision 
abnormalities, eye pain or discomfort, dilated pupils, or narrow-angle glaucoma or 
worsening of this condition.  If any combination of these symptoms develops, you 
should consult your physician immediately. 
 
Figure 1 
 

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Figure 2 
 
 
4. Breathe in (inhale) slowly through your mouth and at the same time spray the 
ATROVENT HFA into your mouth. 
- 
To spray ATROVENT HFA firmly press the canister against the mouthpiece 1 time 
(See Figure 3).  Keep breathing in deeply. 
 
Figure 3 
 
5. Hold your breath for ten seconds and then take the mouthpiece out of your mouth and 
breathe out slowly (See Figure 4). 
 

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Figure 4 
 
6. Wait at least 15 seconds and repeat steps 3 to 5 again. 
7. Replace the green protective dust cap after use. 
8. Keep the mouthpiece clean.  At least once a week, wash the mouthpiece, shake it to 
remove excess water and let it air dry all the way (see Mouthpiece Cleaning 
Instructions). 
 
Mouthpiece Cleaning Instructions: 
Step A.  Remove and set aside the canister and dust cap from the mouthpiece (See Figure 1). 
Step B.  Wash the mouthpiece through the top and bottom with warm running water for at 
least 30 seconds (See Figure 5).  Do not use anything other than water to wash the 
mouthpiece. 
Figure 5 
 
Step C.  Dry the mouthpiece by shaking off the excess water and allow it to air dry all the 
way. 

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Step D.  When the mouthpiece is dry, replace the canister.  Make sure the canister is fully 
and firmly inserted into the mouthpiece. 
Step E.  Replace the green protective dust cap. 
If little or no medicine comes out of the mouthpiece, wash the mouthpiece as described in 
Steps A to E under the "Mouthpiece Cleaning Instructions". 
This product does not contain any chlorofluorocarbon (CFC) propellants. 
The contents of ATROVENT HFA are under pressure.  Do not puncture the canister.  Do not 
use or store near heat or open flame.  Exposure to temperatures above 120°F may cause 
bursting.  Never throw the container into a fire or incinerator.  Keep ATROVENT HFA and 
all medicines out of the reach of children. 
Store ATROVENT HFA at Room Temperature [77°F (25°C)].  Short-term exposure to 
higher or lower temperatures [from 59°F (15°C) to 86°F (30°C)] is acceptable. 

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Appendix 5 
Instructions for Use of Ventolin HFA Inhalation Aerosol 
Device 
Instructions for Use 
For Oral Inhalation Only 
Your VENTOLIN HFA inhaler 
• The metal canister holds the medicine.  See Figure A. 
 
Figure A 
 
 
Figure A 
The canister has a counter to show how many sprays of medicine you have left.  The number 
shows through a window in the back of the actuator.  See Figure B. 

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Figure B 
 
 
Figure B 
• The counter starts at either 204 or 064, depending on which size inhaler you have.  The 
number will count down by 1 each time you spray the inhaler.  The counter will stop 
counting at 000. 
• Do not try to change the numbers or take the counter off the metal canister.  The counter 
cannot be reset, and it is permanently attached to the canister. 
• The blue plastic actuator sprays the medicine from the canister.  The actuator has a 
protective cap that covers the mouthpiece.  See Figure A.  Keep the protective cap on the 
mouthpiece when the canister is not in use.  The strap keeps the cap attached to the 
actuator. 
• Do not use the actuator with a canister of medicine from any other inhaler. 
• Do not use a VENTOLIN HFA canister with an actuator from any other inhaler. 
 
Before using your VENTOLIN HFA inhaler 
Before you use VENTOLIN HFA for the first time, you must prime the inhaler so that 
you will get the right amount of medicine when you use it. 
To prime the inhaler, take the cap off the mouthpiece and shake the inhaler well.  Then spray 
the inhaler 1 time into the air away from your face.  See Figure C.  Avoid spraying in eyes. 

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Figure C 
 
 
Figure C 
• Shake and spray the inhaler like this 3 more times to finish priming it.  The counter 
should now read 200 or 060, depending on which size inhaler you have.  See Figure D. 
 
Figure D 
 
 
Figure D 
You must prime your inhaler again if you have not used it in more than 14 days or if you 
drop it.  Take the cap off the mouthpiece and shake and spray the inhaler 4 times into the air 
away from your face. 

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How to use your VENTOLIN HFA inhaler 
Follow these steps every time you use VENTOLIN HFA. 
Step 1.  Make sure the canister fits firmly in the actuator.  The counter should show through 
the window in the actuator. 
Shake the inhaler well before each spray. 
Take the cap off the mouthpiece of the actuator.  Look inside the mouthpiece for foreign 
objects, and take out any you see. 
Step 2.  Hold the inhaler with the mouthpiece down.  See Figure E. 
Figure E 
 
 
Figure E 
Step 3.  Breathe out through your mouth and push as much air from your lungs as you can.  
Put the mouthpiece in your mouth and close your lips around it.  See Figure F. 

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Figure F 
 
 
Figure F 
Step 4.  Push the top of the canister all the way down while you breathe in deeply and 
slowly through your mouth.  See Figure F. 
Step 5.  After the spray comes out, take your finger off the canister.  After you have breathed 
in all the way, take the inhaler out of your mouth and close your mouth. 
Step 6.  Hold your breath for about 10 seconds, or for as long as is comfortable.  Breathe 
out slowly as long as you can. 
If your healthcare provider has told you to use more sprays, wait 1 minute and shake the 
inhaler again.  Repeat Steps 2 through Step 6. 
Step 7.  Put the cap back on the mouthpiece after every time you use the inhaler.  Make sure 
it snaps firmly into place. 
Cleaning your VENTOLIN HFA inhaler 
Clean your inhaler at least 1 time each week.  You may not see any medicine build-up on the 
inhaler, but it is important to keep it clean so medicine build-up will not block the spray.  See 
Figure G. 

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Figure G 
 
 
Figure G 
Step 8.  Take the canister out of the actuator, and take the cap off the mouthpiece.  The strap 
on the cap will stay attached to the actuator. 
Step 9.  Hold the actuator under the faucet and run warm water through it for about 30 
seconds.  See Figure H. 
Figure H 
 
 
Figure H 
Step 10.  Turn the actuator upside down and run warm water through the mouthpiece for 
about 30 seconds.  See Figure I. 

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Figure I 
 
 
Figure I 
Step 11.  Shake off as much water from the actuator as you can.  Look into the mouthpiece to 
make sure any medicine build-up has been completely washed away.  If there is any build-
up, repeat Steps 9 and 10. 
Step 12.  Let the actuator air-dry overnight.  See Figure J. 
Figure J 
 
 
Figure J 
Step 13.  When the actuator is dry, put the protective cap on the mouthpiece and then put the 
canister in the actuator and make sure it fits firmly.  Shake the inhaler well, remove the cap, 

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and spray the inhaler once into the air away from your face.  (The counter will count down 
by 1 number.) Put the cap back on the mouthpiece. 
If you need to use your inhaler before the actuator is completely dry: 
• Shake as much water off the actuator as you can. 
• Put the cap on the mouthpiece and then put the canister in the actuator and make sure it 
fits firmly. 
• Shake the inhaler well and spray it 1 time into the air away from your face. 
• Take your VENTOLIN HFA dose as prescribed. 
• Follow cleaning Steps 8 through 13 above. 

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Appendix 6 
Spirometry Performance Recommendations 
Spirometry data of the highest quality must be obtained for proper interpretation of the 
results of this protocol.  To these ends, a standard spirometer will be used (provided by 
Pearl), central training provided, qualification will be required, and specific operating 
instruction will also be provided. 
Series “ATS/ERS Task Force: Standardization of Lung Function Testing: Number 2 in 
Series.  European Respiratory Journal 2005;26(2):319-338. 
FEV1 and FVC Maneuvers 
Equipment Requirements 
The spirometer must be capable of accumulating volume for >15 s (longer times are 
recommended) and measuring volumes of >8 L (body temperature (ie, 37°C), ambient 
pressure, saturated with water vapor, BTPS) with an accuracy of at least +3% of reading or 
+0.050 L, whichever is greater, with flows between 0 and 14 L-s-1.  The total resistance to 
airflow at 14.0 L-s-1 must be <1.5 cmH2O L-1s-1 (0.15 kPa L-1s-1).  The total resistance 
must be measured with any tubing, valves, pre-filter, etc.  included that may be inserted 
between the subject and the spirometer.  Some devices may exhibit changes in resistance due 
to water vapor condensation, and accuracy requirements must be met under BTPS conditions 
for up to 8 successive FVC maneuvers performed in a 10-minute period without inspiration 
from the instrument. 
Display 
For optimal quality control, both flow–volume and volume–time displays are useful, and test 
operators should visually inspect the performance of each maneuver for quality assurance 
before proceeding with another maneuver.  This inspection requires tracings to meet the 
minimum size and resolution requirements set forth in this standard.  Displays of flow versus 
volume provide more detail for the initial portion (first 1 s) of the FVC maneuver.  Since this 
portion of the maneuver, particularly the peak expiratory flow (PEF), is correlated with the 
pleural pressure during the maneuver, the flow–volume display is useful to assess the 
magnitude of effort during the initial portions of the maneuver.  The ability to overlay a 
series of flow–volume curves registered at the point of maximal inhalation may be helpful in 
evaluating repeatability and detecting sub-maximal efforts.  However, if the point of maximal 
inhalation varies between blows, then the interpretation of these results is difficult because 
the flows at identical measured volumes are being achieved at different absolute lung 
volumes.  In contrast, display of the FVC maneuver as a volume–time graph provides more 
detail for the latter part of the maneuver.  A volume–time tracing of sufficient size also 
allows independent measurement and calculation of parameters from the FVC maneuvers.  In 
a display of multiple Studys, the sequencing of the blows should be apparent to the user.  For 
the start of test display, the volume–time display should include >0.25 s, and preferably 1 s, 
before exhalation starts (zero volume).  This time period before there is any change in 
volume is needed to calculate the back extrapolated volume (EV) and to evaluate effort 

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during the initial portion of the maneuver.  Time zero, as defined by EV, must be presented 
as the zero point on the graphical output.  The last 2 s of the maneuver should be displayed to 
indicate a satisfactory end of test. 
When a volume–time curve is plotted as hardcopy, the volume scale must be >10 mm L-1 
(BTPS).  For a screen display, 5 mm L-1 is satisfactory (Table A1-1).   
Table A1-1.  Recommended Minimal Scale Factors for Time, Volume and 
Flow on Graphical Output 
Parameter 
Instrument Display 
Hardcopy Graphical 
Output 
 
Resolution Required 
Scale Factor 
Resolution Required 
Volume* 
0.050 L 
5 mm-L-1 
0.050 L 
Flow* 
0.200 L-s-1 
2.5 mm L-1 s-1 
0.200 L-s-1 
Time 
0.2 s 
10 mm-s-1 
0.2 s 
*The correct aspect ratio for flow versus volume display is two units of flow per one unit of volume 
 
The time scale should be >20 mm-s-1, and larger time scales are preferred (>30 mm-s-1) when 
manual measurements are made.  When the volume–time plot is used in conjunction with a 
flow–volume curve (i.e., both display methods are provided for interpretations and no hand 
measurements are performed), the time scale requirement is reduced to 10 mm-s-1 from the 
usually required minimum of 20 mm-s-1 (Table A1-1).  The rationale for this exception is that 
the flow–volume curve can provide the means for quality assessment during the initial 
portion of the FVC maneuver.  The volume–time curve can be used to evaluate the latter part 
of the FVC maneuver, making the time scale less critical. 
Validation 
It is strongly recommended that spirometry systems should be evaluated using a computer-
driven mechanical syringe or its equivalent, in order to test the range of exhalations that are 
likely to be encountered in the test population.  Testing the performance of equipment is not 
part of the usual laboratory procedures. 
Quality Control 
Attention to equipment quality control and calibration is an important part of Good 
Laboratory Practice.  At a minimum, the requirements are as follows: 1) a log of calibration 
results is maintained; 2) the documentation of repairs or other alterations which return the 
equipment to acceptable operation; 3) the dates of computer software and hardware updates 
or changes; and 4) if equipment is changed or relocated (eg., industrial surveys), calibration 
checks and quality-control procedures must be repeated before further testing begins. 
Key aspects of equipment quality control are summarized in Table A1-2. 

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Table A1-2.  Summary of Equipment Quality Control 
Test 
Minimal 
Interval 
Action 
Volume 
Daily 
Calibration check with a 3 L syringe 
Leak 
Daily 
2 cm H2O (0.3 kPa) constant pressure for 1 minute 
Volume 
Linearity 
Quarterly 
1 L increments with a calibrating syringe measured over the 
entire volume range 
Flow 
Linearity 
Weekly 
Test at least 3 different flow ranges 
Time 
Quarterly 
Mechanical recorder check with stop watch 
Software 
New versions 
Log installation date and perform test using “known” 
subject 
 
Calibration is the procedure for establishing the relationship between sensor-determined 
values of flow or volume and the actual flow or volume.  A calibration check is different 
from calibration and is the procedure used to validate that the device is within calibration 
limits, eg., +3% of true.  If a device fails its calibration check, then a new calibration 
procedure or equipment maintenance is required.  Calibration checks must be undertaken 
daily, or more frequently, if specified by the manufacturer.  The syringe used to check the 
volume calibration of spirometers must have an accuracy of +15 mL or +0.5% of the full 
scale (15 mL for a 3-L syringe), and the manufacturer must provide recommendations 
concerning appropriate intervals between syringe calibration checks.  Users should be aware 
that a syringe with an adjustable or variable stop may be out of calibration if the stop is reset 
or accidentally moved.  Calibration syringes should be periodically (eg, monthly) leak tested 
at more than one volume up to their maximum; this can be done by attempting to empty them 
with the outlet corked.  A dropped or damaged syringe should be considered out of 
calibration until it is checked. 
With regard to time, assessing mechanical recorder time scale accuracy with a stopwatch 
must be performed at least quarterly.  An accuracy of within 2% must be achieved. 
Quality Control for Volume-Measuring Devices 
The volume accuracy of the spirometer must be checked at least daily, with a single 
discharge of a 3-L calibrated syringe.  Daily calibration checking is highly recommended so 
that the onset of a problem can be determined within 1 day, and also to help define day-to-
day laboratory variability.  More frequent checks may be required in special circumstances, 
such as: 1) during industrial surveys or other studies in which a large number of subject 
maneuvers are carried out, the equipment’s calibration should be checked more frequently 
than daily; and 2) when the ambient temperature is changing (eg, field studies), volume 
accuracy must be checked more frequently than daily and the BTPS correction factor 
appropriately updated.   

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The accuracy of the syringe volume must be considered in determining whether the measured 
volume is within acceptable limits.  For example, if the syringe has an accuracy of 0.5%, a 
reading of +3.5% is appropriate. 
The calibration syringe should be stored and used in such a way as to maintain the same 
temperature and humidity of the testing site.  This is best accomplished by keeping the 
syringe in close proximity to the spirometer, but out of direct sunlight and away from heat 
sources. 
Volume-type spirometer systems must be evaluated for leaks every day.  The importance of 
undertaking this daily test cannot be overstressed.  Leaks can be detected by applying a 
constant positive pressure of >3.0 cmH2O (0.3 kPa) with the spirometer outlet occluded 
(preferably at or including the mouthpiece).  Any observed volume loss of 30 mL after 
1 minute indicates a leak and needs to be corrected. 
At least quarterly, volume spirometers must have their calibration checked over their entire 
volume range using a calibrated syringe or an equivalent volume standard.  The measured 
volume should be within +3.5% of the reading or 65 mL, whichever is greater.  This limit 
includes the 0.5% accuracy limit for a 3-L syringe.  The linearity check procedure provided 
by the manufacturer can be used if it is equivalent to one of the following procedures: 1) 
consecutive injections of 1-L volume increments while comparing observed volume with the 
corresponding cumulative measured volume, eg., 0–1,1–2, 2–3,…6–7 and 7–8 L, for an 8-L 
spirometer; and 2) injection of a 3-L volume starting at a minimal spirometer volume, then 
repeating this with a 1-L increment in the start position, eg., 0–3, 1–4, 2–5, 3–6, 4–7 and 
5-8 L, for an 8-L spirometer.  The linearity check is considered acceptable if the spirometer 
meets the volume accuracy requirements for all volumes tested. 
Quality Control for Flow-Measuring Devices 
With regards to volume accuracy, calibration checks must be undertaken at least daily, using 
a 3-L syringe discharged at least 3 times to give a range of flows varying between 0.5 and 
12 L-s-1 (with 3-L injection times of 6 s and 0.5 s).  The volume at each flow should meet the 
accuracy requirement of +3.5%.  For devices using disposable flow sensors, a new sensor 
from the supply used for patient tests should be tested each day. 
For linearity, a volume calibration check should be performed weekly with a 3-L syringe to 
deliver 3 relatively constant flows at a low flow, then 3 at a mid-range flow and finally 3 at a 
high flow.  The volumes achieved at each of these flows should each meet the accuracy 
requirement of +3.5%. 
VC Maneuvers 
Equipment 
For measurements of VC, the spirometer or flow meter must comply with the requirements 
for FVC (as described previously) and be capable of accumulating volume for >30 s.  
Expiratory maneuvers or, ideally, both inspiratory and expiratory maneuvers should be 

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included in the display of VC maneuver.  Regardless of whether the inspiratory or expiratory 
maneuver is used for deriving measurements, a display of the entire recorded VC maneuver 
must be provided.  The maximal expiratory volume must be assessed to determine whether 
the subject has obtained a plateau in the expiratory effort.  For display of the slow VC, the 
time scale may be reduced to 5 mm-s-1. 
Technical Considerations 
Minimal recommendations for spirometry systems 
Accurate results require accurate equipment.  Spirometer equipment recommendations apply 
to all spirometers and are minimal requirements.  In some circumstances, it may be 
appropriate to exceed these requirements (ie, in some research/surveillance applications).  
Instrumentation recommendations should be followed to provide accurate spirometric data 
and information that is comparable from laboratory to laboratory and from one time period to 
another.  The accuracy of a spirometry system depends on characteristics of the entire 
system, from the volume or flow transducer and the use of an in-line filter, to the recorder, 
display or processor.  Changes in any aspect of the equipment or errors at any step in the 
process can affect the accuracy of the results.  For example, if the BTPS correction factor is 
wrong, an accurately measured FVC will be incorrectly reported.  Spirometers are not 
required to measure all of the indices in Table A1-3, but must meet the recommendations for 
those that are measured.  Accuracy and repeatability recommendations apply over the entire 
volume range of the instrument. 
Table A1-3.  Range and Accuracy Recommendations Specified for Forced 
Expiratory Maneuvers 
Test 
Range/Accuracy (BTPS) 
Flow 
Range 
(L-s-1) 
Time 
(s) 
Resistance and 
Back Pressure 
Test Signal 
VC 
0.5–8 L, +3% of reading 
or +0.050 L, whichever is 
greater 
0-14 
30 
 
3-L Calibration 
syringe 
FVC 
0.5–8 L, +3% of reading 
or +0.050 L, whichever is 
greater 
0-14 
15 
<1.5 cm H2O L-1 s-1 
(0.15 kPa L-1s-1) 
24 ATS 
waveforms, 3-
L Cal Syringe 
FEV1 
0.5–8 L, +3% of reading 
or +0.050 L, whichever is 
greater 
0-14 
1 
<1.5 cm H2O L-1 s-1 
(0.15 kPa L-1s-1) 
24 ATS 
waveforms 
Time 
Zero 
The time point from which 
all FEVt measurements are 
taken.   
 
 
Back extrapolation 
 
FEVt: forced expiratory volume in t seconds 
 

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BTPS correction 
All spirometry values should be reported at BTPS by any method (measuring temperature 
and barometric pressure) proven effective by the manufacturer.  For volume-type 
spirometers, the temperature inside the spirometer should be measured for each breathing 
maneuver.  Regardless of the BTPS correction technique used, the ambient temperature must 
always be recorded with an accuracy of +1°C.  In situations where the ambient air 
temperature is changing rapidly (>3°C in <30 min), continuous temperature corrections may 
be necessary.  Spirometer users should be aware of potential problems with testing performed 
at lower ambient temperatures: 17°C is the lower limit for ambient temperature, unless a 
manufacturer states that their spirometer will operate accurately at lower ambient 
temperatures.  If barometric pressure is not used in calculating the BTPS correction factor, 
the range of barometric pressures over which the BTPS correction factor is valid must be 
published. 

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Appendix 7 
Spirometry Assessment Criteria 
Acceptable Versus Usable Tests 
Acceptable Tests must meet the following 7 Criteria: 
1. Acceptable start of exhalation with brisk upstroke, no hesitation or false start, and back 
extrapolation volume (EV) <5% of FVC or 0.150 L, whichever is the greater.  (Refer to 
example in Figure A2-1) 
2. No cough during the first second. 
3. No valsalva maneuver. 
4. No leak. 
5. No obstruction of mouthpiece. 
6. No extra breaths. 
7. Plateau achieved, i.e., the volume-time curve shows no change in volume (<0.025 L) for 
≥1 second, and the patient has tried to exhale for at least 6 seconds. 
 
An acceptable test meets all 7 criteria listed.  This is to be considered the “gold standard”. 
Useable spirometry tracings are those that only meet criteria 1 and 2.  When this occurs, 
repeat testing up to 8 attempts in an effort to obtain 3 acceptable spirograms.  If only Usable 
tests are obtained, report results based on the 3 best Usable Studys with observed limitations. 
Figure A2-1.   
Example of a Usable Spirogram 
 
The expanded version of the early part of a subject’s volume-time spirogram, illustrating 
back extrapolation through the steepest part of the curve, where flow is peak expiratory flow 
(PEF), to determine the new “time zero”.  Forced vital capacity (FVC)-4.291 L; back 
extrapolated volume (EV) – 0.123 L (2.9% FVC): back extrapolation line through PEF. 

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Between-Maneuver Reproducibility Criteria 
After 3 acceptable spirograms have been obtained, apply the following tests 
• The 2 largest values of FVC must be within 0.150 L of each other 
• The 2 largest values of FEV1 must be within 0.150 L of each other 
 
If these criteria are met, the spirometry testing for that time-point may conclude.  The highest 
FEV1 and the highest FVC obtained at each testing time-point (even if from different 
reproducible tracings), will be collected.   
If acceptability criteria are not met, continue testing until they are met or the patient cannot/ 
should not continue (Maximum of 8 attempts). 

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Appendix 8 
Chronic Obstructive Pulmonary Disease Assessment 
Test 
(The sample provided here is for illustrative purposes only) 
 

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Appendix 9 
Baseline Dyspnea Index/Transition Dyspnea Index 
Questionnaire 
(The sample provided here is for illustrative purposes only) 
 

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Appendix 11 
European Quality of Life 5 Dimensions-5 Level 
Questionnaire (EQ-5D-5L) 
(The sample provided here is for illustrative purposes only) 
 

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Appendix 12 
EXACT 
(The sample provided here is for illustrative purposes only) 
EXACT version 1.1-English (Universal) 
Please note that on 7 March 2016, the EXACT-Respiratory Symptoms Scale was 
renamed the Evaluating Respiratory Symptoms (E-RS) measure. 
Description 
Required Text 
Translation 
Title  
EXACT Daily Diary 
EXACT Daily Diary 
DD 
Daily Diary 
Daily Diary 
Q 1 of 14 
Question 1 {1} of 14 
Question 1 {1} of 14 
Instructions 
As you answer the following questions, 
please select the option that best describes 
your experience. 
As you answer the following questions, 
please select the option that best 
describes your experience. 
1 
 
 
 
Did your chest feel congested today? 
Did your chest feel congested today? 
 
Not at all 
Not at all 
 
Slightly 
Slightly 
 
Moderately 
Moderately 
 
Severely 
Severely 
 
Extremely 
Extremely 
2 
 
 
 
How often did you cough today? 
How often did you cough today? 
 
Not at all 
Not at all 
 
Rarely 
Rarely 
 
Occasionally 
Occasionally 
 
Frequently 
Frequently 
 
Almost constantly 
Almost constantly 
3 
 
 
 
How much mucus (phlegm) did you bring 
up when coughing today? 
How much mucus (phlegm) did you 
bring up when coughing today? 
 
None at all  
None at all  
 
A little 
A little 
 
Some 
Some 
 
A great deal 
A great deal 
 
A very great deal 
A very great deal 
4 
 
 
 
How difficult was it to bring up mucus 
(phlegm) today? 
How difficult was it to bring up mucus 
(phlegm) today? 

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Description 
Required Text 
Translation 
 
Not at all  
Not at all  
 
Slightly  
Slightly  
 
Moderately  
Moderately  
 
Quite a bit  
Quite a bit  
 
Extremely  
Extremely  
5 
 
 
 
Did you have chest discomfort today? 
Did you have chest discomfort today? 
 
Not at all  
Not at all  
 
Slight  
Slight  
 
Moderate  
Moderate  
 
Severe  
Severe  
 
Extreme  
Extreme  
6 
 
 
 
Did your chest feel tight today? 
Did your chest feel tight today? 
 
Not at all 
Not at all 
 
Slightly 
Slightly 
 
Moderately 
Moderately 
 
Severely 
Severely 
 
Extremely 
Extremely 
7 
 
 
 
Were you breathless today? 
Were you breathless today? 
 
Not at all 
Not at all 
 
Slightly 
Slightly 
 
Moderately 
Moderately 
 
Severely 
Severely 
 
Extremely 
Extremely 
8 
 
 
 
Describe how breathless you were today: 
Describe how breathless you were today: 
 
Unaware of breathlessness 
Unaware of breathlessness 
 
Breathless during strenuous activity 
Breathless during strenuous activity 
 
Breathless during light activity 
Breathless during light activity 
 
Breathless when washing or dressing 
Breathless when washing or dressing 
 
Present when resting  
Present when resting  
9 
 
 
 
Were you short of breath today when 
performing your usual personal care 
activities like washing or dressing? 
Were you short of breath today when 
performing your usual personal care 
activities like washing or dressing? 
 
Not at all 
Not at all 

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Description 
Required Text 
Translation 
 
Slightly 
Slightly 
 
Moderately 
Moderately 
 
Severely 
Severely 
 
Extremely 
Extremely 
 
Too breathless to do these 
Too breathless to do these 
10 
 
 
 
Were you short of breath today when 
performing your usual indoor activities 
like cleaning or household work? 
Were you short of breath today when 
performing your usual indoor activities 
like cleaning or household work? 
 
Not at all 
Not at all 
 
Slightly 
Slightly 
 
Moderately 
Moderately 
 
Severely 
Severely 
 
Extremely 
Extremely 
 
Too breathless to do these 
Too breathless to do these 
11 
 
 
 
Were you short of breath today when 
performing your usual activities outside 
the home such as yard work or errands? 
Were you short of breath today when 
performing your usual activities outside 
the home such as yard work or errands? 
 
Not at all 
Not at all 
 
Slightly 
Slightly 
 
Moderately 
Moderately 
 
Severely 
Severely 
 
Extremely 
Extremely 
 
Too breathless to do these 
Too breathless to do these 
12 
 
 
 
Were you tired or weak today? 
Were you tired or weak today? 
 
Not at all 
Not at all 
 
Slightly 
Slightly 
 
Moderately 
Moderately 
 
Severely 
Severely 
 
Extremely 
Extremely 
13 
 
 
 
Last night, was your sleep disturbed? 
Last night, was your sleep disturbed? 
 
Not at all 
Not at all 
 
Slightly 
Slightly 
 
Moderately 
Moderately 
 
Severely 
Severely 

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Appendix 13 
Rules for Evaluation of Abnormal Liver Laboratory 
Values 
INTRODUCTION  
During the course of the study the Investigator will remain vigilant for increases in liver 
biochemistry.  The Investigator is responsible for determining whether a subject meets 
potential Hy’s Law (PHL) criteria at any point during the study. 
The Investigator participates, together with Pearl clinical representatives, in review and 
assessment of cases meeting PHL criteria to agree whether Hy’s Law (HL) criteria are met.  
Hy’s Law criteria are met if there is no alternative explanation for the elevations in liver 
biochemistry other than Drug-Induced Liver Injury (DILI) caused by study drug.   
The Investigator is responsible for recording data pertaining to PHL/HL cases and for 
reporting AEs and SAEs according to the outcome of the review and assessment in line with 
standard safety reporting processes. 
DEFINITIONS 
• Potential Hy’s Law 
The levels of AST or ALT ≥3x ULN and TBL ≥2x ULN at any point during the study 
irrespective of an increase in ALP.  The elevations do not have to occur at the same time or 
within a specified time frame.  
• Hy’s Law 
The levels of AST or ALT ≥3x ULN and TBL ≥2x ULN, where no other reason, other than 
the study drug, can be found to explain the combination of increases, eg., elevated ALP 
indicating cholestasis, viral hepatitis, or another drug.  The elevations do not have to occur at 
the same time or within a specified time frame. 
IDENTIFICATION OF POTENTIAL HY’S LAW CASES 
In order to identify cases of PHL it is important to perform a comprehensive review of 
laboratory data for any subject who meets any of the following identification criteria in 
isolation or in combination: 
• ALT ≥3x ULN 
• AST ≥3x ULN 
• TBL ≥2x ULN 
 
When a subject meets any of the identification criteria in combination, the central laboratory 
will immediately send an alert to the Investigator and Pearl representative.   
The Investigator will also remain vigilant for any laboratory reports where the identification 
criteria are met, the Investigator will: 

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• Request a repeat of the test (new blood draw) by the central laboratory. 
 
When the identification criteria are met from central laboratory results the Investigator will 
without delay: 
• Determine whether the subject meets PHL criteria by reviewing all laboratory reports 
including previous visits.  
• Notify the Pearl representative. 
• Promptly enter the laboratory data into the laboratory CRF.  
 
FOLLOW-UP 
Potential Hy’s Law Criteria not met 
If the subject does not meet PHL criteria the Investigator will: 
• Inform the Pearl representative that the subject has not met PHL criteria. 
• Perform follow up on subsequent laboratory results according to the guidance provided in 
the Clinical Study Protocol.  
 
Potential Hy’s Law Criteria met 
If the subject does meet PHL criteria the Investigator will: 
• Notify the Pearl representative who will then inform the central Study Team. 
 
The Medical Monitor contacts the Investigator, to provide guidance, discuss, and agree on 
method of follow up and the continuous review of data.  Subsequent to this contact, the 
Investigator will: 
• Monitor the subject until liver biochemistry parameters and appropriate clinical 
symptoms and signs return to normal or baseline levels, or as long as medically indicated. 
• Investigate the etiology of the event and perform diagnostic investigations as discussed 
with the Pearl Medical Monitor. 
• If at any time (in consultation with the Pearl Medical Monitor) the PHL case meets 
serious criteria, report the event as an SAE using standard reporting procedures. 
 
REVIEW AND ASSESSMENT OF POTENTIAL HY’S LAW CASES 
The instructions in this section should be followed for all cases where PHL criteria are met. 
No later than 2 weeks after the biochemistry abnormality was initially detected, the Pearl 
Medical Monitor contacts the Investigator in order to review available data and agree on 
whether there is an alternative explanation for meeting PHL criteria other than DILI caused 

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by the study drug.  The Pearl Medical Monitor and other subject matter experts (as 
appropriate) will collaborate in the review and assessment of these cases. 
According to the outcome of the review and assessment, the Investigator will follow the 
instructions below. 
If there is an agreed alternative explanation for the ALT or AST and TBL elevations, a 
determination of whether the alternative explanation is an AE will be made and subsequently 
whether the AE meets the criteria for an SAE: 
• If the alternative explanation is not an AE, record the alternative explanation on the 
appropriate CRF. 
• If the alternative explanation is an AE/SAE, record the AE /SAE in the CRF accordingly 
and follow the standard reporting procedures. 
 
If it is agreed that there is no explanation that would explain the ALT or AST and TBL 
elevations other than the study drug: 
• Report as an SAE (report term “Hy’s Law case”) according to Pearl standard processes.   
• The “Medically Important” serious criterion should be used if no other serious criteria 
apply. 
• As there is no alternative explanation for the HL case, a causality assessment of “related” 
should be assigned. 
 
If, there is an unavoidable delay of over 2 weeks in obtaining the information necessary to 
assess whether or not the case meets the criteria for HL, then it is assumed that there is no 
alternative explanation.  Until an informed decision can be made, the following procedure 
should be followed: 
• Report as an SAE (report term “Potential Hy’s Law”) applying serious criteria and 
causality assessment as per above. 
 
Continue follow up and review according to the agreed plan.  Once the necessary 
supplementary information is obtained, repeat the review and assessment to determine 
whether HL criteria are met.  Update the SAE Report Form according to the outcome of the 
review. 

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Appendix 15 
Investigator’s Signature 
Study Title: 
A Randomized, Double-Blind, Parallel-Group, 24-Week, Chronic-
Dosing, Multi-Center Study to Assess the Efficacy and Safety of 
PT010, PT003, PT009 Compared With Symbicort® Turbuhaler® as 
an Active Control in Subjects with Moderate to Very Severe 
Chronic Obstructive Pulmonary Disease 
Study Number: 
PT010006-02 
Final Date: 
25 Aug 2017 
I agree: 
• 
To assume responsibility for the proper conduct of the study at this site. 
• 
To conduct the study in compliance with the protocol and with any other study conduct 
procedures provided by Pearl Therapeutics, Inc. (hereafter referred to as Pearl). 
• 
Not to implement any changes to the protocol without agreement from Pearl and prior review 
and written approval from the Institutional Review Board/Independent Ethics Committee, 
except where necessary to eliminate an immediate hazard to the subjects, or for administrative 
aspects of the study (where permitted by all applicable regulatory requirements). 
• 
That I am aware of, and will comply with Good Clinical Practices and all applicable 
regulatory requirements. 
• 
That I am thoroughly familiar with the appropriate use of the investigational product(s), and 
other information provided by Pearl including, but not limited to, the following: the protocol 
and the current Investigators Brochure (IB). 
• 
To ensure that all persons assisting me with the study are qualified, adequately informed 
about the investigational product(s) and of their study-related duties and functions. 
• 
To supply Pearl with any necessary information regarding ownership interest and financial 
ties; to promptly update this information if any relevant changes occur during the course of 
the study and for 1 year following completion of the study; and agree that Pearl may disclose 
any information it has about such ownership interests and financial ties to regulatory 
authorities. 
• 
I agree to report all information or data in accordance with the protocol and any other study 
conduct procedures provided by Pearl. 
• 
That since the information in this protocol and IB is confidential, I understand that its 
disclosure to any third parties, other than those involved in approval, supervision, or conduct 
of the study is prohibited. 
• 
To accurately transfer all required data from each subject’s source document to the electronic 
case report forms (eCRFs).  The eCRFs will be provided to Pearl in a timely manner at the 
completion of the study, or as otherwise specified by Pearl. 
• 
To allow authorized representatives of Pearl or regulatory authority representatives to conduct 
on-site visits to review, audit, and copy study documents.  I will personally meet with these 
representatives to answer any study-related questions. 
 
Signature: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Date: 
 
 
 
 
 
Name:   
 
 
 
 
 
 
 
 
 
 
 
 
Site Name: