Randomised, Double Blind, Placebo Controlled, Multicentre Study to Evaluate the Efficacy and Safety of Givinostat in Ambulant Patients With Duchenne Muscular Dystrophy
Phase: PHASE3
Conditions: Duchenne Muscular Dystrophy
Sponsor: Italfarmaco

 
 
 
 
 
ITALFARMACO 
 
CLINICAL STUDY PROTOCOL 
Protocol Number: DSC/14/2357/48 
Protocol Title: Randomised, double blind, placebo controlled, multicentre 
study to evaluate the efficacy and safety of givinostat in ambulant patients 
with Duchenne Muscular Dystrophy. 
 
 
IND Number: 
 
126598 
EudraCT Number: 
2016-000401-36 
Name of Product: 
Givinostat 
Phase of Development: 
3 
Indication: 
Duchenne Muscular Dystrophy (DMD) 
Sponsor: 
Paolo Bettica, MD, PhD 
Director of Clinical Research and 
Development  
ITALFARMACO  S.p.A. 
54, Via dei Lavoratori 
20092 Cinisello Balsamo, Italy 
Tel: 
+ 39 02 64431 
Fax:  + 39 02 644346 
Protocol Version: 
8.0  
Protocol Date: 
  08 APR 2020 
-CONFIDENTIAL- 
This document and its contents are the property of and confidential to 
Italfarmaco S.p.A.  Any unauthorized copying or use of this document is 
prohibited. 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 2 of 120 
 
SPONSOR APPROVAL PAGE 
 
 
Date: 
10 April 2020 
Paolo Bettica, MD, PhD 
Director of Clinical Research and 
Development 
 
 
 
 
 
 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 3 of 120 
INVESTIGATOR PROTOCOL AGREEMENT PAGE 
 
I agree: 
 
To assume responsibility for the proper conduct of the study at this site. 
 
To conduct the study in compliance with this protocol, any future amendments, and 
with any other study conduct procedures provided by Italfarmaco S.p.A. 
 
Not to implement any changes to the protocol without written agreement from 
Italfarmaco S.p.A and prior review and written approval from the Institutional Review 
Board/Independent Ethics Committee, except where necessary to eliminate an 
immediate hazard to subjects.  
 
That I am thoroughly familiar with the appropriate use of the study drug, as described 
in this protocol and any other information provided by Italfarmaco S.p.A including, 
but not limited to, the Investigator’s Brochure (IB).  
 
That I am aware of, and will comply with, GCP and all applicable regulatory 
requirements. 
 
To ensure that all persons assisting me with the study are adequately informed about 
the Italfarmaco S.p.A study drug and of their study-related duties and functions as 
described in the protocol. 
 
Signature: 
 
 
Date: 
 
 
Name 
(print): 
 
 
 
 
Site 
Number: 
Principal Investigator 
 
___________ 
 
 
 
 
 
 
 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 4 of 120 
  
1 
SYNOPSIS 
Title of Study: 
Randomised, double blind, placebo controlled, multicentre study to 
evaluate the efficacy and safety of givinostat in ambulant patients 
with Duchenne Muscular Dystrophy  
Acronym 
EPIDYS – Epigenetic Rescue of Dystrophin Dysfunction 
Protocol Number: 
DSC/14/2357/48 
Study Design: 
Randomised, double blind, parallel group, placebo controlled study.  
Subjects will be randomised 2:1 to givinostat or placebo. 
Investigators/Study 
Sites: 
Approximately 50 sites worldwide  
Phase of 
Development: 
3 
Objectives: 
Primary objective: 
 To establish the effects of givinostat versus placebo 
administered chronically over 18 months to slow disease 
progression in ambulant DMD subjects. 
Secondary objectives: 
 To assess the safety and tolerability of givinostat versus 
placebo administered chronically in DMD subjects.  
 To evaluate the pharmacokinetic (PK) profile of givinostat 
administered chronically in DMD subjects;  
 To evaluate the impact on quality of life and activities of daily 
living of givinostat versus placebo administered chronically. 
Secondary exploratory objectives: 
 To evaluate the correlation between PK profile of givinostat 
and pharmacodynamics (PD) data;  
 To explore whether the effects of givinostat versus placebo 
administered chronically may be related to the type of DMD 
mutation or to the biomarkers. 
Study Population 
and Subset 
Definition: 
Ambulant male paediatric subjects aged ≥6 years at baseline affected 
by DMD will be included in this study. 
Target population (Group A): subjects with a baseline vastus lateralis 
muscle fat fraction (VL MFF) assessed by MRS  in the range >5% 
and ≤30%. 
Off-target population (Group B): subjects with a baseline vastus 
lateralis muscle fat fraction (VL MFF) assessed by MRS  in the 
range ≤5% or >30%. 
MR Cohort: all subjects in the target population  who will perform 
the magnetic resonance assessment at baseline, 12 and 18 months. 
 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 5 of 120 
Selection of 
Subjects: 
 
 
 
 
 
 
 
 
 
Main Inclusion Criteria: 
Subjects must meet all the following inclusion criteria: 
1. 
Are ambulant males aged ≥6 years at randomisation with 
DMD characteristic clinical symptoms or signs (e.g., 
proximal muscle weakness, Gowers’ maneuver, elevated 
serum creatinine kinase level) already present at 
screening; 
2. 
Have DMD diagnosis confirmed by genetic testing;  
3. 
Are able to give informed assent and/or consent in writing 
signed by the subject and/or parent/legal guardian 
(according to local regulations); 
4. 
Are able to complete 2 Four Stairs Climb test (4SC) 
screening assessments; the results of these tests must be 
within ±1 second of each other; 
5. 
Have the mean of 2 screening 4SC assessments ≤8 
seconds; 
6. 
Have time to rise from floor between ≥3 and <10 seconds 
at screening; 
7. 
Have manual muscle testing (MMT) of quadriceps at 
screening ≥ Grade - 3; 
8. 
Have used systemic corticosteroids for a minimum of 
6 months immediately prior to the start of study 
treatment, with no significant change in corticosteroids 
type or dosage or dosing regimen (excluding changes 
related to body weight change) for a minimum of 6 
months immediately prior to start of study treatment and a 
reasonable expectation that dosage and dosing regimen 
will not change significantly for the duration of the study. 
9. 
Subjects must be willing to use adequate contraception.  
Contraceptive methods must be used from Randomization 
Visit 3 through 3 months after the last dose of study drug, 
and include the following: 
• True abstinence (absence of any sexual intercourse), 
when in line with the preferred and usual lifestyle of the 
subject. Periodic abstinence (e.g. calendar, ovulation, 
symptothermal, postovulation methods) and withdrawal 
are not acceptable methods of contraception. 
• Condom with spermicide and the female partner must 
use an acceptable method of contraception, such as an 
oral, transdermal, injectable or implanted steroid-based 
contraceptive, or a diaphragm or a barrier method of 
contraception in conjunction with spermicidal jelly such 
as for example cervical cap with spermicide jelly. 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 6 of 120 
Main Exclusion Criteria: 
Subjects presenting with any of the following criteria will not be 
included in the study: 
1. 
Have exposure to another investigational drug within 
3 months prior to the start of study treatment (only 
exception allowed is use of Deflazacort in US as part of 
the Expanded Access Program and in Canada as part of 
the Special Access Program); 
2. 
Have exposure to idebenone within 3 months prior to the 
start of  study treatment;  
3. 
Have exposure to any dystrophin restoration product (e.g., 
Ataluren, Exon-skipping) within 6 months prior to the 
start of study treatment; 
4. 
Use of any pharmacologic treatment, other than 
corticosteroids, that might have had an effect on muscle 
strength or function within 3 months prior to the start of 
study treatment (e.g., growth hormone); Vitamin D, 
calcium, and any other supplements will be allowed as 
long as their intake has been stable for 3 months prior to 
the start of study treatment; Testosterone will also be 
allowed if it is used as a replacement therapy for the 
treatment of delayed puberty, and testosterone dose and 
regimen have been stable for at least 6 months and 
circulating testosterone levels are within the normal 
ranges for the subject’s age; 
5. 
Have surgery that might have an effect on muscle 
strength or function within 3 months before study entry or 
planned surgery at any time during the study; 
6. 
Loss of ≥30 degrees of plantar flexion from the normal 
range of movement at the ankle joint due to contracture 
(i.e. fixed loss of more than 10 degrees of plantar flexion 
from plantigrade, assuming normal range of dorsiflexion 
of 20 degrees); 
7. 
Change in contracture treatment such as serial casting, 
contracture control devices, night splints, stretching 
exercises (passive, active, self) within 3 months prior to 
enrollment, or expected need for such intervention during 
the study; 
8. 
Have presence of other clinically significant disease, 
which, in the Investigator’s opinion, could adversely 
affect the safety of the subject, making it unlikely that the 
course of treatment or follow-up would be completed, or 
could impair the assessment of study results; 
9. 
Have a diagnosis of other uncontrolled neurological 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 7 of 120 
diseases or presence of relevant uncontrolled somatic 
disorders that are not related to DMD; 
10. 
Have platelets count, White Blood Cell and Hemoglobin 
at screening <Lower Limit of Normal (LLN) (for 
abnormal screening laboratory test results (<LLN), the 
platelets count, White Blood Cell and Hemoglobin will be 
repeated once; if the repeat test result is still <LLN, then 
exclusionary);  
11. 
Have symptomatic cardiomyopathy or heart failure (New 
York Heart Association Class III or IV) or left ventricular 
ejection fraction <50% at screening; 
12. 
Have a current or history of liver disease or impairment, 
including but not limited to an elevated total bilirubin (i.e. 
> 1.5 x ULN), unless secondary to Gilbert disease or 
pattern consistent with Gilbert's; 
13. 
Have inadequate renal function, as defined by serum 
Cystatin C >2 x the upper limit of normal (ULN). If the 
value is >2 x ULN, the serum Cystatin C will be repeated 
once; if the repeated test result is still >2 x ULN, the 
subject should be excluded);  
14. 
Have Triglycerides > 300 mg/dL (3.42 mmol/L) in fasting 
condition at screening visit; 
15. 
Have a positive test for hepatitis B surface antigen, 
hepatitis C antibody, or human immunodeficiency virus at 
screening; 
16. 
Have a baseline corrected QT interval, Fridericia’s 
correction (QTcF) >450 msec, (as the mean of 3 
consecutive readings 5 minutes apart) or history of 
additional risk factors for torsades de pointes (e.g., heart 
failure, hypokalemia, or family history of long QT 
syndrome); 
17. 
Have a psychiatric illness/social situations rendering the 
potential subject unable to understand and comply with 
the muscle function tests and/or with the study protocol 
procedures; 
18. 
Have any hypersensitivity to the components of study 
medication; 
19. 
Have a sorbitol intolerance or sorbitol malabsorption, or 
have the hereditary form of fructose intolerance. 
20. 
Have 
contraindications 
to 
MRI 
or 
MRS 
(e.g., 
claustrophobia, metal implants, or seizure disorder).  
At the discretion of the Investigator, subjects not meeting 
inclusion/exclusion criteria may be re-screened twice with an interval 
of at least 3 months between assessments. 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 8 of 120 
Planned Sample 
Size: 
The primary, target population for formal statistical analysis and 
inference is those children with a baseline vastus lateralis muscle fat 
fraction (VL MFF) assessed by MRS  in the range >5% and ≤30% 
(Group A). A total of 110 male ambulant subjects in this target 
population will be randomised. Up to 50 subjects (about 35% of the 
overall population) outside of the target may also be recruited into 
the study (Group B).  The overall subject population (Group A + 
Group B)  will provide supportive data.   
Stratification: 
Subjects will be stratified for their concomitant use of steroids in 
4 strata: 
1. Deflazacort Daily regimen 
2. Deflazacort Intermittent regimen 
3. Other steroids Daily regimen 
4. Other steroids Intermittent regimen 
Randomisation 
ratio:  
2:1  
Study duration for 
participants: 
The study duration is planned for 19 months. 
The study comprises 2 phases: 
1. Screening period: starting 4 weeks before randomisation 
2. Treatment period: 18 months of treatment 
Reference 
Therapy: 
Givinostat or placebo oral suspension (10 mg/mL) twice daily (bid) 
(in a fed state) as described below: 
Placebo or Givinostat starting dose 
Weight 
(kg) 
≥10 
and 
<12.
5 
≥12.5 
and 
<20 
≥20 
and 
<25 
≥25 
and 
<30 
≥30 
and 
<40 
≥40 
and 
<50 
≥50 
and 
<60 
≥60 
and 
< 70 
≥70 
Dose 
(mg) 
bid 
13.3 
16.7 
20 
23.3 
26.7 
33.3 
36.7 
40 
46.7 
Oral 
suspen
sion 
(mL) 
bid 
1.3 
1.7 
2.0 
2.3 
2.7 
3.3 
3.7 
4 
4.7 
 
The subjects who were randomized under protocol version 4.0 will 
continue the current dose. 
If subjects (i.e. those already in treatment or those who will be 
randomized under protocol version 6.0, or 7.0 or 8.0) gain weight 
during the study the drug dose must be kept unchanged. If  subjects 
(i.e. those already in treatment or those who will be randomized 
under protocol version 6.0, or 7.0 or 8.0) lose weight during the 
study, the drug dose should be adjusted accordingly. 
Criteria for 
Evaluation: 
Efficacy: 
The primary efficacy assessment in the target population is the time 
to climb 4 standard stairs. 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 9 of 120 
The secondary key efficacy assessments in the target population are: 
1. Time to rise from floor; 
2. Distance walked in 6 minutes using six-minute walking test 
(6MWT); 
3. Physical function assessed by North Star Ambulatory 
Assessment (NSAA); 
4. Muscle strength evaluated by knee extension, elbow flexion 
as measured by hand-held myometry (HHM). 
5. Fat fraction of vastus lateralis muscles evaluated by MRS 
technique (MR Cohort) 
The exploratory efficacy assessments are: 
 Time to walk/run 10 meters; 
 Quality of life assessed by Paediatric Outcomes Data 
Collection Instrument (PODCI);  
 %-predicted 6MWT; 
 MRI parameters (e.g., fat fraction of thigh muscles, cross 
sectional area (CSA) of vastus lateralis and other thigh 
muscles, etc.) only in the MR cohort; 
 Time to 10% persistent worsening in 6MWT (Baseline 
through end of study); 
 Proportion of subjects with ≥10% worsening in 6MWT at end 
of study; 
 Time to loss of standing (Baseline through end of study); 
 Proportion of subjects who loose ambulation during the study. 
 Evaluation of any correlation between the effect of Givinostat 
on disease progression and the type of DMD mutation, 
LTBP4 and Osteopontin genotype;  
 Evaluation of any possible DMD serum biomarker. 
Pharmacokinetic: 
The concentration of givinostat and its metabolites will be 
determined from the plasma samples using a validated analytical 
method. 
Safety: 
Safety and tolerability will be evaluated by monitoring hematology 
and blood chemistry, coagulation, urinalysis; by measurement of 
vital signs, physical examinations, weight, height, echocardiogram 
(ECHO) and electrocardiogram (ECG) recording; and by respiratory 
function evaluation, cognitive function evaluation, and by adverse 
events (AEs) recording to be performed at protocol-specified visits. 
In addition, the evaluation of acceptability/palatability of the oral 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 10 of 120 
suspension will be assessed. 
Study Endpoints: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary efficacy endpoints: 
 
Mean change in 4SC before and after 18 months of 
treatment of givinostat versus placebo. 
Key secondary efficacy endpoints: 
Function: 
 
Mean change in time to rise from floor; 
 
Mean change in 6MWT; 
 
Mean change in NSAA;  
 
Cumulative loss of function on the NSAA  
 
Mean change in muscle strength evaluated by knee 
extension, elbow flexion  as measured by HHM;  
Imaging: 
 
Mean change in vastus lateralis muscles fat fraction; 
The above endpoints will be formally assessed after 18 months of 
treatment 
 
Safety endpoints: 
 
Number of subjects experiencing treatment-emergent 
adverse events (TEAEs) and serious adverse events 
(SAEs) (Baseline through end of study [EOS]); 
 
Type, incidence, and severity of TEAEs and SAEs 
(Baseline through EOS); 
 
Changes from baseline to end of study of:  
 
Vital signs and clinical laboratory tests (blood chemistry 
and hematology); 
 
Respiratory function evaluated by forced vital capacity 
(FVC), forced expiratory volume at 1 second (FEV1), 
FVC/FEV1, Peak Expiratory Flow (PEF); 
 
Cardiac function evaluated by ECG and ECHO; 
 
Cognitive function evaluated by the Raven coloured 
progressive matrices; 
 
Weight, height, and body mass index (BMI). 
 
Evaluation of acceptability/palatability of the oral 
suspension. 
Pharmacokinetic Endpoints:   
 
Description of the PK of givinostat and its major 
metabolites: ITF2374 and ITF2375 in the subject 
population; 
 
Identification 
of 
the 
relevant 
demographic 
and 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 11 of 120 
pathophysiological covariates influencing the PK of 
givinostat. 
Exploratory endpoints: 
 
Mean changes in:  
 
time to walk/run 10 meters; 
 
PODCI scores; 
 
%-predicted 6MWT;  
 
Only in the MR cohort: MRI parameters (e.g., fat fraction 
of thigh muscles, CSA of vastus lateralis and other thigh 
muscles).  
 
Time to 10% persistent worsening in 6MWT (Baseline 
through end of study); 
 
Proportion of subjects with ≥10% worsening in 6MWT at 
end of study; 
 
Time to loss of standing (Baseline through end of study); 
 
Proportion of subjects who loose ambulation during the 
study; 
 
Evaluation of any correlation between the effect of 
Givinostat on disease progression and the type of DMD 
mutation, LTBP4 and Osteopontin genotype;  
 
Evaluation of any possible DMD serum biomarker; 
 
PK-PD analyses: relationships between metrics of 
exposure and efficacy/safety endpoints of givinostat. 
Rules for cessation 
of randomised 
treatment in an 
individual 
participant: 
Individual subjects may cease taking randomised treatment at the 
discretion of the Investigator. 
Study drug should be permanently stopped if any of the following 
occur: 
 severe drug-related diarrhoea (i.e., increase of ≥7 stools per 
day);  
 any drug-related SAE; 
 QTcF >500 msec; 
 platelets count ≤50 x 109/L (to avoid laboratory errors and 
anomalous values, platelets count ≤50 x 109/L must be 
confirmed with a repeated test performed on the next working 
day.  The treatment should be stopped until the retest result 
becomes available.  If the repeated platelets count is still ≤50 
x 109/L, study drug must be permanently discontinued.  If the 
repeated test is acceptable, the subject can resume 
treatment.); 
 white blood cells  ≤2.0 x 109/L (to avoid laboratory errors and 
anomalous values, white blood cells  ≤2.0 x 109/L must be 
confirmed with a repeated test performed on the next working 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 12 of 120 
day.  The treatment should be stopped until the retest result 
becomes available.  If the repeated white blood cells is still 
≤2.0 x 109/L, study drug must be permanently discontinued.  
If the repeated test is acceptable, the subject can resume 
treatment.);   
 hemoglobin  ≤8.0 g/dL (to avoid laboratory errors and 
anomalous values, hemoglobin  ≤8.0 g/dL must be confirmed 
with a repeated test performed on the next working day.  The 
treatment should be stopped until the retest result becomes 
available.  If the repeated hemoglobin is still ≤8.0 g/dL, study 
drug must be permanently discontinued.  If the repeated test 
is acceptable, the subject can resume treatment.).  
Study drug should be temporarily stopped if any of the following 
occur: 
 moderate or severe diarrhoea (i.e., increase more than 4 stools 
per day); 
 platelets count <75 x 109/L but >50 x 109/L (the treatment 
should be temporarily stopped and a platelets count has to be 
performed by 1 week and re-tested until platelets will be 
normalized); 
 white blood cell  <3.0 x 109/L but >2.0 x 109/L (the treatment 
should be temporarily stopped and white blood cells have to 
be measured by 1 week and re-tested until white blood cells  
will be normalized); 
 hemoglobin  <10.0 g/dL but > 8.0 g/dL (the treatment should 
be temporarily stopped and hemoglobin has to be measured 
by 1 week and re-tested until hemoglobin will be 
normalized); 
 
Triglycerides >300 mg/dL (3.42 mmol/L) in fasting condition 
(the 
treatment 
should 
be 
temporarily 
stopped 
and  
triglycerides has to be measured every 2 weeks until 
triglycerides return to levels below 300mg/dL (3.42 mmol/L); 
Dose adjustment: 
In case the study drug is temporarily stopped, the study drug can be 
resumed at a level 20% smaller (see table below) than the one at 
which the AE leading to temporary stop occurred, once platelets 
and/or white blood cell and/or hemoglobin are normalized  and/or 
triglycerides return to levels below 300 mg/dL (3.42 mmol/L ) or 
diarrhoea is mild. 
Rules for Dose Reduction of 20%  
Starting Dose 
(mg) bid 
13.3 
16.7 
20 
23.3 
26.7 
33.3 
36.7 
40 
46.7 
Oral 
suspension 
(mL) bid 
1.3 
1.7 
2.0 
2.3 
2.7 
3.3 
3.7 
4 
4.7 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 13 of 120 
Reduced Dose 
(mg) bid 
10.6 
13.4 
16 
18.6 
21.4 
26.6 
29.4 
32 
37.4 
Oral 
suspension 
(mL) bid 
1.1 
1.3 
1.6 
1.9 
2.1 
2.7 
2.9 
3.2 
3.7 
In addition, in case a subject will have a consistent (e.g., at least 2 
consecutive evaluations) platelets count ≤150 x 109/L and not 
meeting the stopping criteria for platelets, the Investigator will have 
to reduce the dose by 20% of the current dose. 
Only one dose reduction is allowed during the treatment period. 
Subjects who were randomized under protocol version 4.0, will 
continue to follow the instructions of protocol version 4.0, related to 
starting dose and dose modifications:   
In case the study drug was temporarily stopped, the study drug can 
be resumed at a level 1/3 smaller (see table below) than the one at 
which the AE leading to temporary stop occurred, once platelets 
and/or white blood cell and/or hemoglobin are normalized  and/or 
triglycerides return to levels below 300 mg/dL (3.42 mmol/L) or 
diarrhoea is mild. 
Rules for Dose Reduction of 1/3  
Starting Dose 
(mg) bid 
20 
25 
30 
35 
40 
50 
55 
60 
70 
Oral 
suspension 
(mL) bid 
2.0 
2.5 
3.0 
3.5 
4.0 
5.0 
5.5 
6.0 
7.0 
Reduced 
Dose (mg) bid 
13.3 
16.7 
20 
23.3 
26.7 
33.3 
36.7 
40 
46.7 
Oral 
suspension 
(mL) bid 
1.3 
1.7 
2.0 
2.3 
2.7 
3.3 
3.7 
4 
4.7 
In addition, in case a subject will have a consistent (e.g., at least 2 
consecutive evaluations) platelets count ≤150 x 109/L and not 
meeting the stopping criteria for platelets, the Investigator will have 
to reduce the dose of 1/3 of the current dose. 
Moreover, for subjects who have already reduced the dose of 1/3 an 
additional reduction by 20%  is allowed for safety reasons.  
For all subjects, during the first month of treatment, platelets count 
assessment will be performed weekly, while during the second 
month it will be performed every 2 weeks, in order to strictly 
monitor this parameter for safety reasons. 
If the dose is reduced due to platelet count ≤150 x 109/L, and/or 
white blood cell  <3.0 x 109/L and/or hemoglobin <10.0 mg/dL, a 
complete blood count (i.e.CBC) test must be performed weekly for 8 
consecutive weeks. 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 14 of 120 
Any decision relevant to the dose adjustment and/or modification of 
schedule of assessments can be discussed with the Medical Monitor, 
but the final decision remains with the Investigator only or its 
authorized designee 
Other: 
As the subjects to be randomised are on stable steroids, the 
recommended national immunisation schedule, including varicella 
immunity, should be completed (i.e., as recommended in the 
“Diagnosis and Management of Duchenne muscular dystrophy” 
DMD guideline4), before the Screening Visit. However, in case of 
live or live attenuated vaccines to be administered during the study, 
the Investigator can discuss, but it is not mandatory, the case with the 
Medical Monitor of the study and must carefully monitor the subject. 
Independent Data 
Monitoring 
Committee: 
An independent Data Monitoring Committee (IDMC) will review, 
evaluate and categorise safety findings every 3 months during the 
study and will be responsible for oversight of the formal interim 
analysis (see below).  The IDMC will have access to unblinded data, 
if necessary, and will operate according to the rules defined in the 
IDMC charter. 
Sample size 
calculation: 
The sample size (utilizing a 2:1 randomisation scheme) is calculated 
to provide 90% power and a 1-sided alpha of 2.5% to detect a true 
difference between givinostat and placebo in the target population, in 
4SC 18 month change from baseline, of 3 seconds, assuming a 
common standard deviation (SD) of 6 seconds. The estimated SD is 
based on publicly available Phase 3 study data on ataluren and 
drisapersen in subjects with DMD in addition to internal Italfarmaco 
S.p.A data. 
 
Vastus lateralis muscles fat fraction (VL MFF) assessed via MRS is 
the first key endpoint in the MR cohort and will be formally assessed 
in the target population at 12 months.  Based on internal Italfarmaco 
S.p.A. data, a total of N=99 subjects will be sufficient to provide 
80% power to detect a 55% reduction in the annual mean increase in 
MFF (of 6.6%) with givinostat as compared to placebo with a 1-
sided alpha of 2.5% and assuming an SD for the change from 
baseline in MFF of 6%. 
 
The pre-planned interim analysis was performed in January 2020, 
concluding that futility was not met and the trial should continue, and 
thus a pre-planned blinded sample size re-calculation was performed.  
The within treatment SD for the change in 4SC from baseline to 18 
month was estimated to be 3.094 seconds, approximately half of the 
SD that as assumed in the original power calculation.  With this 
revised SD estimate, N= 102 (on 2:1 basis) subjects is sufficient to 
provide 90% power to detect a true difference in 4SC of 2 seconds 
between givinostat and placebo in the target population at a 1-sided 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 15 of 120 
alpha of 2.5%.  With an estimated drop-out rate of 8%, a total of 110 
subjects in the target population (Group A) will be randomized. 
 
For the MR cohort, the blinded SD estimate was 5.941%, being in 
line with SD assumed in the original power calculation for VLFF, 
hence all the subjects in the target population will be included in the 
analysis of the MR cohort. 
 
Interim analysis: 
One formal interim analysis is planned and will be overseen by the 
IDMC in order to ensure study integrity ; this is to assess futility on 
VLFF and, if not futile, esecute a blinded sample size reestimation.  
Statistical Methods 
and Planned 
Analyses: 
An IDMC charter will be prepared to describe the role, function and 
operations of the IDMC and the rules to be used when reviewing 
interim data.  
 
The planned interim analysis will be performed when the first N=50 
subjects randomised in the target population have reached the 12 
month time point.  In this interim analysis, the IDMC will evaluate 
the effects of givinostat versus placebo on the VL MFF in terms of 
futility. Futility will be considered if VLMFF in the givinostat group 
is equal to or worse than that seen in the placebo group since the 
biologic plausibility of a subsequent treatment effect on 4SC time 
would be greatly diminished. The IDMC will only communicate to 
the Sponsor whether the study should proceed or it should be stopped 
having met the futility criteria.  
If the IDMC indicates that the study should proceed, a blinded 
sample size re-estimation will be conducted for MFF and 4SC in the 
target population as follows:  
 
To maintain the blind on the primary endpoint, the within treatment 
SD for the change from baseline will be estimated as  𝝈̂𝒘𝒊𝒕𝒉𝒊𝒏=
√𝝈̂𝒐𝒗𝒆𝒓𝒂𝒍𝒍
𝟐
−(
𝜟
𝟐)
𝟐
 where 𝝈̂𝒐𝒗𝒆𝒓𝒂𝒍𝒍  is the overall SD for the change 
from baseline in 4SC based on the n=50 subjects in the interim and 
𝛥 is the hypothesized treatment effect, i.e. 𝛥= 3 seconds.  
Dependent upon the blinded SD estimate, the sample size may be 
decreased or increased to maintain 90% power. Any increase in 
sample size for 4SC will be limited to 1.5 times maximum of the 
initial target population sample size, i.e., to a maximum of 
1.5 × 192 = 288 subjects.  For a 20% increase in the SD, this 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 16 of 120 
degree of increase in sample size will maintain 90% power, and for 
a 40% increase in SD power will be maintained at 80%.    
 With respect to VL MFF, a similar approach will be applied; 
the within treatment SD for the change from baseline will be 
estimated as 𝝈̂𝒘𝒊𝒕𝒉𝒊𝒏= √  𝝈̂𝒐𝒗𝒆𝒓𝒂𝒍𝒍
𝟐
−(
𝜟
𝟐)
𝟐
 where 𝝈̂𝒐𝒗𝒆𝒓𝒂𝒍𝒍  is the 
overall SD for the change from baseline in MFF and 𝛥 is the 
hypothesized treatment effect, i.e. 𝛥= 3.63% (i.e. 55% of 
6.6%).  Dependent upon the blinded SD estimate, the sample 
size may be decreased or increased to maintain 90% power. 
Any increase in sample size require to assess VL MFF will 
also be limited to 1.5 times the required target population 
sample size stated in the preceding power calculation, to a 
maximum of 1.5 × 99 = 150 subjects.  
At the interim futility analysis, there will be no efficacy assessment, 
no unblinded analysis of the primary endpoint and, hence, no alpha 
spend nor early stopping of the study for efficacy.  
The interim took place as planned on 14th January 2020 and included 
50 patients with 12 month data and 37 with 18 month data. The 
independent data monitoring committee (IDMC) meeting to review 
the VL MFF data for futility took place on 23rd January 2020 and 
concluded that futility was not met and the trial should continue. 
The sample size reassessment therefore took place, with estimated 
overall SDs of 3.094 seconds and 5.941% for the change from 
baseline in 4SC at 18 months and the change from baseline in VL 
MFF at 12 months respectively.   
 
The revised sample size (utilizing a 2:1 randomisation scheme) N= 
102 was calculated to provide 90% power and a 1-sided alpha of 
2.5% to detect a true difference between givinostat and placebo in 
the target population, in 4SC 18 month change from baseline, of 2 
seconds, with the blinded SD estimates during the interim analysis of 
3.094 seconds.  With an estimated drop-out rate of 8%, a total of 110 
subjects in the target population (Group A) will be randomized. 
For the MR cohort, since the blinded SD estimate was 5.941%, all 
the subjects in the target population will be part of the MR cohort. 
Since the interim only assessed futility on VLFF and executed  a 
blinded sample size reestimation, no alpha was spent and, hence the 
analysis of the primary endpoint conducted at the end of the trial will 
continue to be assessed at the 0.025 1-sided level.   
 
 
Statistical analysis: 
General 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 17 of 120 
All efficacy analyses will be performed on Intent-To-Treat (ITT) 
population. Formal efficacy analyses will be performed in the target 
population; overall population analyses will be supportive and 
informal.  Randomised subjects who have taken at least 1 dose of 
randomised therapy will be included in the relevant analyses.  
Descriptive statistics for qualitative data will include frequency 
tabulation and presentation of percentages.  Descriptive statistics for 
quantitative data will include mean and SD or geometric mean, 
coefficient of variation, median and interquartile range.  
A comprehensive SAP will be prepared prior to the planned interim 
analysis to provide full details of all planned analyses and 
methodology. 
Primary Efficacy Endpoint 
The change in 4-stairs climb (4SC) from baseline to 18 months will 
be evaluated in the target population. The data will be analyzed using 
an Analysis of Covariance (ANCOVA) model with the change in 
4SC from baseline to 18 months as the dependent variable and with 
terms for baseline 4SC value as a covariate and randomised 
treatment, concomitant steroid use and age at baseline as independent 
class variables.  Least squares means (Lsmeans) will be estimated for 
givinostat and placebo.  The treatment effect, being difference in 
Lsmeans, will be presented along with the associated 95% 
confidence interval and the p-value.   Significance will be achieved if 
the 1-sided p-value is ≤0.025.   
Analysis of   Key Secondary Endpoints 
Formal analyses of functional secondary endpoints  (i.e.,cumulative 
loss of function in the NSAA, change  in 6MWT, NSAA, time to rise 
from floor and muscle strength by knee extension and elbow flexion) 
and Vastus lateralis MFF will be performed in the target population 
at 18 months using the same approach as described for the primary 
endpoint.  Possible need for log transformation of these variables 
will be assessed prior to unblinding by assessment of ANCOVA 
model residuals without a treatment effect term.   
Safety Data 
Safety data will be evaluated descriptively.  All subjects (target and 
off-target population combined) who took at least 1 dose of study 
drug will be included in the summary of safety.  The following 
parameters will be summarized: rates of discontinuation, AEs, and 
laboratory abnormalities.  Adverse event data will be coded using the 
Medical Dictionary for Competent Activities (MedDRA).  Summary 
statistics will be presented for changes in vital signs.  Laboratory test 
values will be summarised similarly, but will also include tabulation 
of the number of subjects shifting from within the reference range at 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 18 of 120 
baseline to outside of the reference range on randomised treatment. 
 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 19 of 120 
2 
TABLE OF CONTENTS 
 
1 
SYNOPSIS ............................................................................................................. 4 
2 
TABLE OF CONTENTS ................................................................................... 19 
3 
LIST OF ABBREVIATIONS ............................................................................ 24 
4 
INTRODUCTION .............................................................................................. 27 
4.1 
Background on Duchenne Muscular Dystrophy ................................................... 27 
4.2 
Background on Givinostat .................................................................................... 28 
4.2.1 Nonclinical Studies ..................................................................................... 31 
4.2.2 Clinical Experience with Givinostat Including Risks and Benefits ............ 35 
4.2.3 Rationale of the study ................................................................................. 37 
5 
STUDY OBJECTIVES AND ENDPOINTS..................................................... 40 
5.1 
Study Objectives ................................................................................................... 40 
5.1.1 Primary Objective ....................................................................................... 40 
5.1.2 Secondary Objectives.................................................................................. 40 
5.1.3 Secondary Exploratory Objectives ............................................................. 40 
5.2 
Study Endpoints .................................................................................................... 40 
5.2.1 Primary Endpoint ........................................................................................ 40 
5.2.2 Key Secondary Endpoints ........................................................................... 41 
5.2.3 Safety Endpoints ......................................................................................... 41 
5.2.4 Pharmacokinetic Endpoints ........................................................................ 41 
5.2.5 Exploratory Endpoints ................................................................................ 41 
6 
INVESTIGATIONAL PLAN ............................................................................ 42 
6.1 
Description of Overall Study Design and Plan ..................................................... 42 
6.2 
Discussion of Study Design .................................................................................. 44 
7 
SELECTION AND WITHDRAWAL OF SUBJECTS ................................... 46 
7.1 
Inclusion Criteria .................................................................................................. 46 
7.2 
Exclusion Criteria ................................................................................................. 47 
7.3 
Withdrawal, Removal, and Replacement of Subjects ........................................... 49 
7.3.1 Safety Stopping Rules ................................................................................. 50 
8 
TREATMENTS .................................................................................................. 53 
8.1 
Details of Study Treatments ................................................................................. 53 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 20 of 120 
8.2 
Dosage .................................................................................................................. 53 
8.2.1 Rational for Dose Selection ........................................................................ 53 
8.2.2 Dosage Schedule ......................................................................................... 55 
8.3 
Study Treatment Assignment ................................................................................ 58 
8.4 
Blinding ................................................................................................................ 59 
8.5 
Drug Supply .......................................................................................................... 60 
8.5.1 Packaging .................................................................................................... 60 
8.5.2 Labelling ..................................................................................................... 60 
8.5.3 Storage ........................................................................................................ 61 
8.6 
Treatment Accountability and Compliance .......................................................... 62 
8.7 
Prior and Concomitant Illnesses and Medications ................................................ 62 
8.7.1 Prior and Concomitant Illnesses ................................................................. 62 
8.7.2 Prior and Concomitant Medications ........................................................... 63 
9 
STUDY PROCEDURES .................................................................................... 64 
9.1 
Procedures by Study Visit ..................................................................................... 68 
9.1.1 Visit 1 and Visit 2 - Screening (Week -4 ± 2 weeks) ................................. 68 
9.1.2 Visit 3 - Randomisation (Week 0) .............................................................. 69 
9.1.3 Visits 4 (Week 1, ±3 days) .......................................................................... 70 
9.1.4 Visits 5, 6 and 8 (Weeks 2, 3 and 6, ±3 days) ............................................. 70 
9.1.5 Visit 7 (Week 4, ±3 days) ........................................................................... 71 
9.1.6 Visits 9 (Week 8, ± 3 days) ......................................................................... 71 
9.1.7 Visits 10 – 14 (Weeks 12-60, ± 7 days) ...................................................... 72 
9.1.8 Visit 15: End of Study Visit (also named “EOS Visit”, Week 72 ± 7 days), 
and early withdrawal visit ................................................................. 73 
9.1.9 Follow up Visit (Week 76)( ± 7 days) ........................................................ 74 
9.1.10 Unscheduled Visits ..................................................................................... 75 
9.2 
Study Conclusion .................................................................................................. 75 
10 
EFFICACY ASSESSMENTS ............................................................................ 75 
10.1 
Primary Efficacy Assessment ............................................................................... 75 
10.2 
Secondary Efficacy Assessments (All Subjects) .................................................. 76 
11 
PHARMACOKINETICS ................................................................................... 78 
11.1 
Pharmacokinetic Sampling ................................................................................... 78 
11.1.1 Blood Samples ............................................................................................ 78 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 21 of 120 
11.2 
Pharmacokinetic Analytical Methodology ........................................................... 79 
12 
SAFETY ASSESSMENTS ................................................................................. 79 
12.1 
Vital Signs ............................................................................................................. 80 
12.2 
Physical Examination ........................................................................................... 80 
12.3 
Electrocardiogram ................................................................................................. 80 
12.4 
Echocardiogram .................................................................................................... 81 
12.5 
Respiratory Function Test ..................................................................................... 81 
12.6 
Cognitive Function Test ........................................................................................ 81 
12.7 
Acceptability/Palatability Evaluation ................................................................... 82 
12.8 
Laboratory Assessments ....................................................................................... 83 
12.9 
Adverse Events ..................................................................................................... 85 
12.9.1 Definitions................................................................................................... 85 
12.9.2 Adverse Event Reporting ............................................................................ 86 
12.9.3 Serious Adverse Event Reporting ............................................................... 89 
12.9.4 Overdose ..................................................................................................... 90 
12.9.5 Pregnancy reporting .................................................................................... 91 
13 
STATISTICAL ANALYSIS .............................................................................. 92 
13.1 
Overall Statistical Strategy ................................................................................... 92 
13.2 
Determination of Sample Size .............................................................................. 92 
13.3 
Analysis Population .............................................................................................. 93 
13.3.1 Intent-To-Treat Population ......................................................................... 93 
13.3.2 Safety Population ........................................................................................ 94 
13.4 
Demographic and Baseline Characteristics .......................................................... 94 
13.5 
Investigational Medicinal Products ..................................................................... 94 
13.6 
Prior and Concomitant Therapy ............................................................................ 94 
13.7 
Efficacy Analysis .................................................................................................. 95 
13.7.1 Analysis of the Primary Efficacy Endpoint ................................................ 95 
13.7.2 Analysis of Key Secondary Efficacy Endpoints ......................................... 95 
13.7.3 Analysis of Exploratory Efficacy Endpoints .............................................. 96 
13.8 
Pharmacokinetic Analysis ..................................................................................... 97 
13.9 
Safety Analysis ..................................................................................................... 97 
13.10 Interim Analysis ................................................................................................... 98 
13.10.1 Interim Analysis ......................................................................................... 98 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 22 of 120 
13.10.2 Final  Analysis ......................................................................................... 100 
13.11 Independent Data Monitoring Committee ......................................................... 100 
14 
STUDY MANAGEMENT ................................................................................ 100 
14.1 
Approval and Consent ........................................................................................ 100 
14.1.1 Regulatory Guidelines .............................................................................. 100 
14.1.2 Institutional Review Board/Independent Ethics Committees ................... 101 
14.1.3 Independent Data Monitoring Committee ................................................ 101 
14.1.4 Subject Informed Consent......................................................................... 102 
14.1.5 Discontinuation of the study by the Sponsor ............................................ 103 
14.1.6 Data Handling ........................................................................................... 103 
14.2 
Source Documents .............................................................................................. 104 
14.3 
Record Retention ................................................................................................ 105 
14.4 
Monitoring .......................................................................................................... 105 
14.5 
Quality Control and Quality Assurance .............................................................. 106 
14.6 
Protocol Amendment and Protocol Deviation .................................................... 106 
14.6.1 Protocol Amendment ................................................................................ 106 
14.6.2 Protocol Deviations ................................................................................... 107 
14.7 
Ethical Considerations ........................................................................................ 107 
14.8 
Financing and Insurance ..................................................................................... 107 
14.9 
Publication Policy/Disclosure of Data and Confidentiality ................................ 108 
15 
REFERENCES .................................................................................................. 109 
16 
APPENDICES ................................................................................................... 113 
16.1 
Combined list of drugs that prolong QT and/or cause torsades de Pointes (TDP)
 ............................................................................................................................ 114 
16.2 
Drugs knows to be a substrate of OCT2 transporter ........................................... 118 
16.3 
Drugs known to be P-glycoprotein inhibitors ..................................................... 119 
 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 23 of 120 
IN-TEXT TABLES 
Table 1: Exposure margins for Cmax and AUC:  rat vs. DMD subjects and monkey vs. DMD 
subjects ................................................................................................................... 33 
Table 2: Placebo or Givinostat Starting Dose ....................................................................... 55 
Table 3: Placebo or Givinostat Starting Dose for subjects enrolled under Protocol version 
4.0  ......................................................................................................................... 55 
Table 4: Placebo or Givinostat Dose Modification for subjects randomized under study 
protocol version 6.0 or 7.0 or 8.0. .......................................................................... 56 
Table 5: Placebo or Givinostat Dose Modification for subject randomized under study 
prococol version 4.0 ............................................................................................... 57 
Table 6:    Schedule of Assessments ....................................................................................... 65 
Table 7: Laboratory Assessment Samples ............................................................................ 84 
 
IN-TEXT FIGURES 
Figure 6-1: 
Study Design .................................................................................................... 43 
Figure 12-2:  Five Point Hedonic Scale - Face Descriptions ................................................ 82 
 
 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 24 of 120 
3 
LIST OF ABBREVIATIONS 
Abbreviation 
Definition 
4SC 
4-stairs climb 
6MWT 
Six-minute walking test 
ADR 
Adverse drug reaction 
AE 
Adverse event 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase 
ANCOVA 
Analysis of covariance  
aPTT 
Activated partial thromboplastin time 
AST 
ATS 
Aspartate Aminotransferase 
American Thoracic Society 
AUC 
Area under the curve  
bid 
twice daily 
BMI 
Body mass index  
BUN 
Blood urea nitrogen 
CBC 
Complete Blood Count 
CFR 
Code of Federal Regulations 
Cmax 
Maximum observed concentration 
CRA 
Clinical research associate  
CRF 
Case Report Form 
CSA 
Cross sectional area  
CSOM 
Clinical Study Operations Manual 
CSR 
Clinical study report 
DAPC 
Dystrophin-associated protein complex 
DMD 
Duchenne muscular dystrophy  
DNA 
Deoxyribonucleic acid 
ECG 
Electrocardiogram 
ECHO 
Echocardiogram 
eCRF 
electronic Case Report Form 
EDC 
Electronic Data Capture 
EOS 
End of study 
EU 
European Union 
FAPs 
Fibro-adipogenic progenitors 
FDA 
Food and Drug Administration 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 25 of 120 
FEV1 
Forced Expiratory Volume at 1 second  
FVC 
Forced Vital Capacity  
GCP 
Good Clinical Practice 
GGT 
Gamma-glutamyl transpeptidase 
GI 
Gastrointestinal  
GSPV 
Global Safety and Pharmacovigilance 
Hct 
Hematocrit 
HDAC 
Histone deacetylase  
HDACi 
Histone deacetylase inhibitors  
HDL 
High-Density Lipoprotein  
HHM 
Hand-held myometry 
HIPPA 
Health C Portability Accountability Act 
IB 
Investigator’s Brochure 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonization 
IDMC 
Independent Data Monitoring Committee  
IEC 
Independent Ethics Committee 
IL-1β 
Interleukin-1 beta 
IND 
Investigational New Drug  
IRB 
Institutional Review Board 
IRT 
Interactive response technology  
ITT 
Intention-to-Treat 
LDH 
Lactate dehydrogenase 
LDL 
Low-Density Lipoprotein  
IFN-γ 
Interferon gamma 
IL-6 
Interleukin-12  
IL-12 
Interleukin-6 
LLN 
Lower Limit Normal 
Lsmeans 
Least squares means  
MCH 
Mean corpuscular hemoglobin 
MCHC 
Mean corpuscular hemoglobin concentration 
MCV 
Mean corpuscular volume 
MedDRA 
Medical Dictionary for Competent Activities 
MFAF 
Muscle Fibers Area Fraction  
MFF 
Muscle fat fraction 
MMT 
Manual muscle testing  

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 26 of 120 
MoA 
Mechanism of action 
MRI 
Magnetic resonance imaging  
MRS 
Magnetic resonance spectroscopy 
mRNA 
Messenger ribonucleic acid 
nNOS 
Neuronal nitric oxide synthase 
NO 
Nitric oxide 
NOAEL 
No-Adverse Effect Level 
NSAA 
North Star Ambulatory Assessment  
OCT 
Organic Cation Transporter 2 
PEF 
Peak Expiratory Flow  
PI 
Principal Investigator 
PK 
Pharmacokinetic  
PODCI 
Paediatric Outcomes Data Collection Instrument  
PT 
Prothrombin time 
QT 
QT interval 
QTc 
Corrected QT interval 
QTcF 
QT interval, Fridericia’s correction  
RBC 
Red blood cell 
ROM 
Range of motion 
SAE 
Serious adverse event 
SAP 
Statistical Analysis Plan 
SD 
Standard deviation  
TEAE 
Treatment-emergent adverse event  
TFT 
Timed function test 
TNF-α 
Tumor necrosis factor-alpha 
TSA 
Trichostatin A 
ULN 
Upper Limit Normal 
US 
United States 
VL MFF 
Vastus lateralis muscle fat fraction 
WBC 
White blood cell 
 
 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 27 of 120 
4 
INTRODUCTION 
4.1 
Background on Duchenne Muscular Dystrophy  
Duchenne muscular dystrophy (DMD) is a rare degenerative, X-linked recessive genetic 
disorder with estimated incidence of 1 in 5000 live births (Mendell, J. R., et al.1), caused by 
mutations in the dystrophin gene.  In DMD, mutations in the dystrophin gene disrupt the 
open-reading frame, resulting in an absence of functional dystrophin, a critically important 
part of the protein complex that connects the cytoskeletal actin of a muscle fiber to the 
extracellular matrix.   
Lack of dystrophin causes repetitive muscle damage.  In a normal muscle, the physiological 
repair process removes the damaged muscle fibers and reconstitutes normal muscle fibers.  In 
DMD, on the other hand, the repair process leads to a combination of new muscle fibers, fatty 
replacement and fibrosis, with the two latter components progressively prevailing as a process 
called fibroadipose degeneration.  This detrimental outcome typically compromises muscle 
function, alters the tissue environment, and probably limits the potential effectiveness of 
regenerative approaches.  As described by Peverelli et al.2, fibrosis is already significant at 
one year of age in DMD patients constituting approximately 16% of a muscle biopsy (3% in 
age matched controls) and remains relatively constant until 7 years of age.  At this age, there 
is an important increase in the proportion of fibrosis that reaches approximately 30% of 
muscle biopsy between 7 and 10 years of age.  Similarly MRI studies have shown that fat 
infiltration is already present at 5 years of age and constantly increases (Forbes, et al.3). 
Duchenne muscular dystrophy is characterized by progressive symmetrical muscular 
weakness that affects proximal muscles more than distal muscles, often accompanied by calf 
muscle pseudo hypertrophy.   
Significant motor deficits may be present during the first year of life, but diagnosis is usually 
made between the ages of 3 to 5 years when the affected patients begin to show waddling gait, 
toe walking, and difficulty climbing stairs.  Over time, ambulation becomes increasingly 
abnormal, and by 8 years of age, most patients lose the ability to rise from the floor and climb 
stairs, and often fall while walking.  By 12 to 14 years of age, most lose the ability to walk 
and the heart and respiratory muscles also are affected.  Upper limb, cardiac, and 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 28 of 120 
diaphragmatic muscles progressively weaken during adolescence.  After 18 years all patients 
are affected by cardiomyopathy.  Only few survive beyond the third decade; most patients die 
because of respiratory complications and heart failure due to cardiomyopathy.  There are still 
no curative treatments for such a debilitating disease and the current management of the 
disease is based on prevention and management of complications (Bushby, et al.4). 
Corticosteroids (e.g., prednisone or deflazacort) have been demonstrated to slow the rate of 
muscle weakness when initiated in ambulatory boys,  however, the use of corticosteroids is 
limited by all the potential side effects, including weight gain, cataracts, osteopenia, and 
avascular necrosis (Manzur, A, et al.5).  Recently, the European Medicines Agency has 
granted a conditional approval to Ataluren, which targets nonsense mutations as the cause of 
DMD, which is relevant for only 13% of DMD population, or approximately 2,000 patients in 
the United States (US) and 2,500 patients in the European Union (EU).   
In addition, FDA has granted an accelerated approval to Eteplirsen and Golodirsen, which 
targets DMD gene mutations skippable with exon 51 skipping and exon 53 skipping, 
respectively, which are relevant for only 21% of DMD population, or approximately 3,200 
patients in the United States (US).   
Ataluren, Eteplirsen and Golodirsen are  the first of a number of treatments that are aimed at 
correcting the original genetic defect in the dystrophin gene.   
Genetic Duchenne therapy via AAV Micro-dystrophin  may be promising.  
In light of the above considerations, it becomes evident that an unmet therapeutic need exists 
for the treatment of this disabling and fatal condition. 
4.2 
Background on Givinostat 
Zinc dependent histone deacetylases (HDACs) are a class of 11 isoenzymes associated with 
numerous nuclear repressor complexes that, once recruited to specific sites of euchromatin, 
maintain nucleosome histones in a state of deacetylation so that deoxyribonucleic acid (DNA) 
remains tightly bound and inaccessible to transcription factors for gene expression.  In 
contrast, inhibition of HDAC results in hyperacetylation of these histones and allows the 
unraveling of DNA sufficient for the binding of transcription factors and the synthesis of 
messenger ribonucleic acid (mRNA). 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 29 of 120 
Some HDACs may shuttle between nucleus and cytosol in a stimulus-dependent way or may 
have a predominantly cytosolic localization, where they affect the post-translational 
modification of cytosolic proteins (Choudhary C et al. 20096). 
Givinostat is an orally active hydroxamic acid derivative possessing a potent HDAC (Class I 
and II) inhibitory activity.  As potent and specific inhibitor of the HDAC enzymes, givinostat 
shares the anti-tumor properties of the histone deacetylase inhibitor (HDACi)- class, i.e., 
cell-cycle inhibition, induction of apoptosis and stimulation of cell-differentiation. 
In the clinic, the HDACi doses required to achieve efficacy in cancer patients are generally 
poorly tolerated and dose-limiting toxicities include thrombocytopenia, gastrointestinal (GI) 
tract adverse events (AEs), and fatigue (Guha 20157).  While reactivation of epigenetically 
silenced tumor suppressors apparently requires high concentrations of HDACi, some gene 
promoters may be affected at much lower and better tolerated doses.  It has been suggested 
that regulators of cell fate decisions in stem or progenitor cells are under the control of 
promoters that are in a poised, “bivalent” state, characterized by the simultaneous presence of 
both chromatin activation and silencing marks, within the same regulatory region (Azuara, 
Perry et al. 20068; Bernstein, Mikkelsen et al. 20069).  Exposure to low doses of HDACi may, 
in these cases, tip the balance and redirect differentiation programs.  Dystrophin interacts with 
a group of peripheral membrane and transmembrane proteins through the C-terminal domain 
to form the dystrophin-associated protein complex (DAPC), which provides the molecular 
link between the cytoskeleton and the extracellular matrix of skeletal myofibers that is 
disrupted in dystrophic muscle (Ervasti 200710).  As such, DAPC supports sarcolemmal 
integrity during muscle contraction.  Neuronal nitric oxide synthase (nNOS) is an important 
component of the DAPC.  Nitric oxide (NO) produced by nNOS was shown to specifically 
inactivate HDAC2 via S-nitrosylation of a cysteine residue (Colussi, Mozzetta et al. 200811).  
This mechanism is dysfunctional in dystrophic muscle, leading to aberrantly upregulated 
HDAC activity.  There are at least two distinct mechanisms by which this upregulation 
impinges pathologically on cell fate decisions during muscle regeneration (Consalvi, Saccone 
et al. 201112):  
1. Resident muscle interstitial cells fibro-adipogenic progenitors (FAPs) retain the ability 
to turn into fibroadipocytes in response to signals released by degenerating muscles.  

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 30 of 120 
These cells affect differentiation of muscle satellite cells into muscle fibers through 
secretion of follistatin, the endogenous antagonist of the most potent inhibitor of 
skeletal myogenesis, myostatin.  Direct inhibition of myostatin or delivery of 
follistatin exerted similar beneficial effects in mdx mice, the mouse model of DMD.  
The follistatin gene promoter is controlled by HDAC2 in muscle cells (Minetti, 
Colussi et al. 200613) and direct inhibition of HDAC2 by HDACi, or inactivation by 
either NO donors or by reconstitution of the dystrophin-NO signaling leads to 
derepression of follistatin, which mediates the ability of HDACi and NO signaling to 
stimulate myogenesis in vitro and counters muscle degeneration in mdx mice. 
2. Histone deacetylase inhibitors may directly stimulate the myogenic differentiation of 
FAPs.  The HDAC inhibition induces two core components of the myogenic 
transcriptional machinery, MyoD and BAF60C, and up-regulates the myogenic miRs 
(myomiRs) (miR-1.2, miR-133, and miR-206), which target the alternative BAF60 
variants BAF60A and BAF60B, ultimately promoting promyogenic differentiation 
while suppressing the fibro-adipogenic phenotype (Saccone, Consalvi et al. 201414).  
Histone deacetylase inhibitors, therefore, seem to derepress a ‘‘latent’’ myogenic 
program in FAPs from dystrophic muscles, at least at early stages of disease. 
By inhibiting several pro-inflammatory cytokines (e.g., tumor necrosis factor-alpha [TNF-α], 
interleukin-1 beta [IL-1β], interferon gamma [IFN-γ], Interleukin-6 [IL-6], and Interleukin 12 
[IL-12]), givinostat also reduces the production and activity of pro-inflammatory cytokines 
(Leoni, F et al. 200515 and Joosten, L. A., F. Leoni, et al 201116).  Pro-inflammatory cytokines 
have been shown to inhibit muscle satellite cells differentiation into muscle fibers in DMD, 
thus contributing to the impaired muscle regeneration in this disease (Boldrin et al, 201517, 
Tierney et al. 201418, Doles, Olwin, 201419)  
Experimentally, the preclinical effectiveness of givinostat was demonstrated in mouse models 
with muscular dystrophy, such as the mdx mice.  Givinostat produced beneficial functional 
and morphological effects, such as increased cross-sectional area of myofibers, decreased 
inflammatory infiltrate, and prevention of fibrotic scars, which contribute to counter the 
muscle loss and the functional decline that are typically observed in mdx mice (see Section 
4.2.1). 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 31 of 120 
4.2.1 Nonclinical Studies  
A standard nonclinical program composed of safety pharmacology, pharmacokinetics, single 
and repeat dose toxicity, mutagenicity/genotoxicity, reprotoxicity and juvenile toxicity studies 
has already been carried out to support the oral administration of givinostat to adult and 
paediatric subjects.  Details of each study are available in the current Investigator’s 
Brochure (IB). 
In summary, in rats the predominant toxicities at the highest doses were hematologic, with 
larger decreases in white blood cells (WBC) (-84% males, -78% females) and smaller effects 
on red blood cells (RBC) (-10% males, -5% females) and platelets (-16% males, -11% 
females).  It has to be pointed out, that this toxicity pattern is different from what is observed 
clinically in humans, where thrombocytopenia and not leukopenia is dose-limiting, suggesting 
a different sensitivity of the hematopoietic lineage in rats versus humans. 
Non-hematologic toxicity in rats included changes in blood chemistry: decrease in total 
proteins, alkaline phosphatase (ALP), alanine aminotransferase (ALT) and increase in 
aspartate aminotransferase (AST), bilirubin, urea, creatinine and triglycerides.  All of these 
changes were modest (equal to or less than 50%), their extent overlapped with control animals 
and they were not considered of toxicological significance.  Lower weight of liver, spleen and 
adrenals was also observed.  In all cases the underlying histopathological changes were 
minimal.  All pathologic effects trended toward reversibility or completely reversed following 
the recovery period.   
In contrast to rats, in the 39-week study in monkeys, hematologic toxicities were of minor 
significance, with a minimal decrease in RBC counts seen during and at the end of the 
treatment period at the high dose only.  A dose-related decrease in weight of the thymus was 
observed in both sexes at all doses.  Histologically, an increased incidence of minimal 
involution/atrophy was observed in high-dose animals.  In animals at recovery, the decrease 
of thymus weight was minimal, whilst no histological changes were noted.  The dose of 
12 mg/kg/day was therefore defined as the No-Adverse Effect Level (NOAEL) under the 
conditions used in the present study, even if the compound was well tolerated also at the 
highest dose of 30 mg/kg/day.  Similar effects on thymus weight were reported also for other 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 32 of 120 
HDACi and are likely reflective of the known and well-characterized cytostatic mechanism of 
action of high doses of these compounds (Kerr, Galloway et al. 201020).   
Additional findings of possible toxicological relevance included minimal effects on hepatic 
enzymes (ALT, AST), triglycerides, and bilirubin.  Some of these effects were observed at 
intermediate examination (Week 20) and partially recovered at the end of the treatment 
period.  Treatment-related effects were observed at the high dose also in the bone marrow and 
liver.  The bone marrow showed slightly reduced cellularity in two animals given 
30 mg/kg/day.  Also this effect can be ascribed to the well-characterized cytostatic 
mechanism of action of high doses of the HDACi (Kerr, Galloway et al. 201020). The liver 
showed minimal bile duct hyperplasia in two male animals out of four, receiving 
30mg/kg/day, whilst males from the others dose-groups and females at all doses were 
unaffected.  After recovery, a similar finding was still noted in a single animal. 
Givinostat is eliminated for approximately 50% in faeces after IV administration of 
14C-ITF2357 to rats, highlighting the quantitative importance of the biliary excretion route.  
In addition, a more intensive biotransformation occurs in animal species with respect to 
humans as shown in in vitro metabolic stability tests with hepatocytes of different species 
(Intrinsic Clearance (µL/min*106 cells: humans=4.0; monkey=25.4; dog=32.4; rat=33.8; 
mouse=42.0). 
Thus, the bile duct hyperplasia is likely to be the result of a pronounced metabolism and 
excretion of givinostat in the preclinical species, which is also associated with increased 
plasma bilirubin levels.  Therefore, this finding can be easily monitored in humans.  Of note, 
no increase of hepatic enzyme or bilirubin was recorded in approximately 450 subjects treated 
so far; bilirubin levels are also monitored clinically in DMD subjects with, so far, no evidence 
for significant alterations, providing no confirmation for the occurrence of analogous 
toxicities in humans. 
The maximum observed concentration (Cmax) and area under the curve (AUC) safety margins 
were calculated using the NOAEL of 10 mg/kg/day obtained in rats after 6 months of 
administration, the NOAEL of 12 mg/kg/day obtained after exposing monkeys for 39 
consecutive weeks, and the actual human data obtained in the clinical study in DMD subjects 
(Study DSC/11/2357/43) after 12 month the administration of 37.5 mg twice daily (bid) (i.e., 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 33 of 120 
Cmax approximately 104 ng/mL and AUC approximately 1144 ng*h/mL).  The human 
exposure achieved at this dose level is the exposure to be used in this study 
(DSC/14/2357/48).  Only data from male animals were considered since DMD occurs in male 
subjects. 
Safety ratios calculated using data from both the animal species used in toxicology studies 
differed quite markedly one from the other.  The rat to human exposure margins (Table 1) 
were 0.16 (Cmax) and 0.04 (AUC) at the human exposure considered (i.e., Cmax approximately 
100 ng/mL and AUC approximately 1150 ng*h/mL), while the exposure margins Cmax and 
AUC were larger for monkeys than those seen in rats.  The Cmax ratio was about 2.4 fold and 
the mean AUC ratio was 0.34.  A more intensive biotransformation is observed in rats and 
monkeys as evidenced by the larger intrinsic clearance and the shorter half-life of givinostat 
in rats and monkeys compared to humans.  
Table 1: 
Exposure margins for Cmax and AUC:  rat vs. DMD subjects and monkey vs. DMD 
subjects 
Ratios NOAEL rats/paediatric DMD exposure 
Ratios NOAEL monkey/paediatric DMD exposure 
 
Cmax 
AUC0-t 
 
Cmax 
AUC0-t 
Week 26 
0.16 
0.04 
Week 39 
2.40 
0.34 
NOAEL= no-observed-adverse-effect-level; DMD = Duchenne muscular dystrophy; Cmax= maximum observed 
concentration; AUC0-4 = area under the curve (over the first 4 hours) 
Even though the safety margin between NOAEL in non-clinical studies/paediatric DMD 
exposure, are <1 (except for Cmax monkey), the main findings observed in non-clinical 
toxicology studies (e.g., reduction in white blood cells, cellularity reduction in bone marrow, 
reduced thymus weight, and bile duct hyperplasia) were observed at high doses of givinostat 
(e.g., rats, 90-160-250 mg/kg/day depending on the treatment duration; dogs, 50 mg/kg/day; 
and monkeys, 30-90 mg/kg/day); all of them, as described above, can and will be carefully 
monitored during this clinical study. 
A post-weaning study in young rats treated with givinostat 20 to 180 mg/kg/day for 4 weeks 
was also performed and showed a toxicological profile similar to that seen in adult animals.  
Givinostat did not affect the behavioral and physical development and reproductive 
performance of pups.  The NOAEL in this study was 60 mg/kg/day. 
Concerning the safety pharmacology, givinostat has a favorable profile.  The IC50 of 
givinostat in the in vitro hERG assay was 1.4 µM.  At 3 and 10 µM, givinostat increased the 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 34 of 120 
action potential duration at 50% and 90% repolarization during bradycardia, although not in a 
statistically significant manner.  Givinostat did not induce any marked changes in heart rate, 
electrocardiogram (ECG) intervals, or waveform at any dose in in vivo, in a cardiovascular 
study in dogs.  The combined evidence from these in vitro and in vivo studies plus the lack of 
accumulation of drug in the heart as seen in tissue distribution studies, suggest that the drug is 
unlikely to exert any cardiovascular side effect at therapeutic doses.  The maximal circulating 
concentrations seen in subjects both adults and paediatric subjects receiving the highest doses 
of givinostat were generally below 100-150 ng/mL (200-300 nM) of total givinostat, 
corresponding to 5-7.5 ng/mL (10-15 nM) of free givinostat, approximately 90-140 fold less 
than the IC50 on hERG. 
Finally, givinostat was positive for frameshift mutations in the bacterial mutagenesis assay (2 
out of 5 strains), but givinostat did not display any genotoxicity/mutagenic potential in 
mammalians in both in vitro and in vivo studies.  
Nonclinical evidence supports a potential therapeutic role of givinostat in DMD.   
A dose-finding study using doses of givinostat ranging from 1 to 10 mg/kg/day orally 
delivered daily for 3 months to mdx (i.e., murine model of DMD) mice (2 month old at the 
beginning of the treatment) was performed (Consalvi, et. Al 201212).  The effect of these 
doses was compared to that of vehicle alone (oral delivered) or the HDACi TSA (0.6 mg/kg, 
i.p.) and assessed by monitoring total body weight during the time of exposure, the weight of 
single muscles at the end of the treatment, and by measuring muscle function (with treadmill 
test at specific time points during the treatment) CSA at the end of the treatment.  The results 
showed an increase of the weight of a single muscle analysed, a dose-dependent reduction of 
intramuscular fibrosis and inflammatory infiltrate (by myeloperoxidase activity) and a dose-
related increase of muscle mass and fibers CSA.  All these histological effects translated into 
an improvement in function as assessed by monitoring the performance of mdx mice on a 
treadmill test at defined time points during the treatment.  To further elucidate the relationship 
between givinostat exposure and effects on muscle tissue and on performance, a 
pharmacokinetic/pharmacodynamic (PK/PD) analysis was conducted.  The PK/PD analysis 
showed that at least a blood AUC0-24 of 600 nmol*h/L (i.e., corresponding to 300 ng*h/mL) 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 35 of 120 
was estimated to be needed to exert the beneficial histological and functional effects 
in mouse. 
4.2.2 Clinical Experience with Givinostat Including Risks and Benefits 
Completed and updated data that describe the clinical experience with givinostat are reported 
in Section 6 “Effects in Humans” of the current Investigator Brochure Dossier related 
to ITF2357. 
Givinostat has been tested in a number of clinical studies in adults and paediatric populations.  
Three major indications have been explored with Givinostat, chronic inflammatory diseases, 
neuromuscular disorder and oncology.  The maximum administered dose was a single dose of 
600 mg in healthy volunteers and up to 400 mg once per week in subjects with multiple 
myeloma.  Doses up to approximately 100 mg bid were generally well tolerated in adults.  In 
paediatric subjects, doses up to 0.75 mg/kg bid have been administered for up to 6 months 
(with 1 additional subject having been treated for 2 years and 7 months) in patients with 
Juvenile Idiopathic Arthritis.  In subjects with DMD enrolled in study DSC/11/2357/43 (i.e., 
subjects between 7 and 10 years of age at study start), the maximum dose administered in the 
dose escalation phase was 50 mg bid for up to 2 weeks i.e., while the maximum dose 
administered for up to 1 year in the second part of the study was 37.5 mg bid.  Since, 
clearance increases with increased weight (see Section 8.2.1) doses have been increased in the 
extension phase of study DSC/11/2357/43 due to the increase in weight of the enrolled 
children; as a result the maximum dose administered in this extension phase is  60 mg bid.  
The most common AEs observed were thrombocytopenia, as well as gastrointestinal 
toxicities.  Adverse events were generally mild to moderate and reversible upon 
discontinuation of study drug.  Moreover, dose-dependent asymptomatic and reversible 
platelets count reductions were observed both in healthy volunteers and subjects treated with 
givinostat.  These decreases typically occurred within the first week after treatment initiation, 
reached a nadir after 2 to 3 weeks of treatment, and then remained at a plateau (see the IB, 
Section 7).  The majority of thrombocytopenic events were mild in severity with fewer than 
10% of subjects developing platelets count below 75 x 109/L.  All occurrences resolved 
completely within 2 to 3 weeks of discontinuation of treatment, suggesting a rapidly 
reversible effect. Overall, sixteen haemorrhagic drug-related AEs were reported by 14 patients 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 36 of 120 
in the completed clinical trials with Givinostat. However, only in seven of these cases the 
haemorrhagic drug-related AE occurred in patients with concomitant thrombocytopenia; these 
were all oncology patients and in some of these patients thrombocytopenia up to grade 4 was 
already present before givinostat treatment start. In all the remaining cases (nine 
haemorrhagic drug-related AEs occurred in seven subjects) platelet counts at the time of the 
haemorrhagic AE were either within the normal range or above the upper limit of normal 
range. None of the above summarized drug-related hemorrhagic episodes were observed in 
DMD subjects.  
Therefore, given these known effects of HDAC inhibitors including Givinostat a thorough 
monitoring of haematologic parameters will be implemented in order to avoid the occurrence 
of severe thrombocytopenia (see Section 12.8). 
In addition, during the study particular attention will be paid in monitoring possible effects on 
QTc (see Table 6:    Schedule of Assessments for details), since some episodes (21 episodes in 
15 subjects) of Corrected QT interval (QTc) prolongation have been recorded during the 
clinical studies performed so far.  It is worth noting that 90% of the recorded events were 
reported in oncological studies in subjects treated at highest doses (e.g., ≥100 mg/daily) and 
no events were recorded during the previous study in DMD subjects. 
Concerning the clinical experience in DMD, the aforementioned histological results observed 
in the mdx mouse model were replicated in a Phase 2 study of givinostat (Study 
DSC/11/2357/43, EudraCT n. 2012-002566-12) in 20 ambulant DMD subjects (from 7 to 
10 years of age at study start, on stable steroid treatment) where, after one year of treatment, 
the muscle biopsy analysis showed a significant increase in muscle fibers area fraction 
(MFAF) and a significant reduction of muscle necrosis, fatty replacement and fibrosis.  
Analysis of the effect on CSA of the muscle fibers showed that givinostat significantly 
increases CSA of all type of fibers (small, medium, large) in a similar manner and that such 
effect on CSA predicts the increase in MFAF and the reduction of fibrosis.  In addition, an 
increase in the number of regenerating fibers and satellite cells was observed.  Moreover, 
descriptive analysis conducted on the secondary efficacy endpoints on muscle function (i.e., 
six-minute walking test [6MWT], North Star Ambulatory Assessment [NSAA], time function 
tests and pulmonary function tests) showed an overall stability after 1 year of treatment in this 
population. 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 37 of 120 
The risk/benefit ratio of the proposed study is postulated to be favorable for both the results of 
the clinical safety and pre-clinical toxicology studies and for the efficacy results in the 
previous Phase 2 DMD study. 
4.2.3 Rationale of the study 
Nonclinical studies have shown that givinostat has a potent anti-inflammatory effect (see 
(current IB) and that HDACi regulate the transcription of a number of factors that are key in 
muscle regeneration, e.g., follistatin.  The combination of these effects is expected to re-
balance the repair process in DMD muscle towards increased muscle regeneration and 
reduced fatty infiltration and fibrosis.  Indeed, in a study in mdx mice and in a phase 2 study 
in DMD children, givinostat was shown to reduce muscle inflammation, necrosis and fibrosis 
and to increase muscle regeneration. 
These results indicate that the induction of an active regeneration program, the reduction of 
adipose replacement and the enlargement of pre-existing muscle fibers are all key elements of 
givinostat’s putative mechanism of action (MoA), supporting the potential therapeutic role of 
givinostat in counteracting muscle tissue degeneration, which occurs downstream of the 
genetic defect in DMD. 
On the basis of its putative MoA as described above, givinostat is expected to act at all stages 
of the disease and to counter the disease pathogenetic events in all muscular districts.  
However, as the fibers CSA enlarging effect appears key in givinostat’s pharmacological 
effect, the functional benefit obtained will likely depend on the amount of muscle that is still 
present when therapy is started.   
In Study DSC/11/2357/43, in ambulant DMD subjects ≥7 years of age on steroid for more 
than 6 months, only 50% of the muscle biopsy was occupied by muscle fibers at baseline with 
the remainder being represented mainly by fibrotic tissue.  Although after one year of 
treatment with givinostat, the histological results showed a significant increase in muscle 
fibers CSA and a significant improvement in all the histological parameters analyzed, the fact 
that already 50% of muscle was lost in these children suggests that givinostat should be 
started at an earlier age if the objective is to achieve a clinical benefit in terms of ambulation 
within a reasonable timeframe.  Several studies, however, have shown that ambulatory 
function naturally improves in children with DMD up to the age of 7 years (Goemans, 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 38 of 120 
Klingels et al. 201322; McDonald, Henricson et al. 201323) suggesting that studies in DMD 
children <7 years of age may require larger numbers and a longer treatment duration to show 
a significant difference from placebo.  As a result all the pivotal studies in DMD ambulant 
children reported so far (e.g., Ataluren, Drisapersen, Tadalafil phase III trial ) have selected 
children who were expected to have a sufficient decline in ambulatory function after 1 year on 
placebo based on age and 6 Minute Walk Test at baseline.  However, all these studies were 
not able to show a functional benefit of the tested drug versus placebo.   
Although a lack of efficacy cannot be ruled out, the poor therapeutic response observed in 
these studies could be the result of selecting a patient population characterized by a degree of 
functional impairment that may be less likely to benefit from treatment. This is also suggested 
by the fact that while ambulatory function improves up to the age of 7 years and then 
declines, the underlying muscle morphology constantly declines from the age of 5 years 
(Forbes, et al.3). A post-hoc analysis on study DSC/11/2357/43 suggests that children with a 
more preserved Vastus Lateralis (VL) muscle at baseline MRI (score 0 to 2 on a 0 to 5 semi-
quantitative MRI score, modified Mercuri’s score24) have a lesser degree of functional decline 
2 years after start of givinostat treatment.  This is in line with data from the Imaging DMD 
group suggesting that changes from baselite at 1 year in VL Fat Fraction (FF) assessed by 
magnetic resonance spectroscopy (MRS) are correlated with Timed Function Tests  (TFTs) 
and 6MWT (Data on file).   These analyses, however, have also shown that children with a 
baseline MVL MFF <10% show very little change in any parameter (MRI/MRS or function) 
within 1 year. A more recent (i.e. July 2018) and detailed analysis of Imaging DMD data 
showed that patients with a baseline MRS VL FF up to 5% have little change in clinically 
relevant functional parameters such as 4 stairs climb after 1 and 2 years. Based on these data, 
the current protocol will select a population of subjects with a VL MFF >5% but ≤30% 
(corresponding approximately to a score >2 in the aforementioned 0 to 5 semi-quantitative 
MRI score Mercuri, et al. 200224) as this population is expected to still have enough muscle to 
build on and to have enough function decline in 18 months if on placebo.  Since the analyses 
of the Imaging DMD data (Data on file) also suggested that TFTs predict VL MFF, an 
algorhythm has been developed to identify at screening those children with a VL MFF within 
the required range.  However, the screening data colleted up to 18th June 2018 showed that the 
accuracy of the algorithm was less predictive since it did not allow the selection of a 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 39 of 120 
population with the predefined range of VL FF that identified a population most likely to 
benefit from treatment. As a result, the algorhythm is removed and the selection of eligible 
subjects will be based on age and the functional tests at screening (see below). The 
assessment of VL FF at screening (range >5% to ≤30%), on the other end, will be used to 
identify the target population on which to perform the primary and key secondary analyses. 
The inclusion of an additional off-target population (up to 50 subjects) outside of the VL FF 
range of  >5% to ≤30% will provide supportive data. Considering the recent recommendations 
outlined in the EMA “Guideline on the clinical investigation of medicinal products for the 
treatment of Duchenne and Becker muscular dystrophy” (December 2015) and in the Federal 
Drug Administration (FDA) draft guidance for industry “Duchenne Muscular Dystrophy and 
related dystrophinopathies: developing drugs for treatment” (June 2015), the time to climb 4 
standard-sized stairs has been chosen to evaluate the efficacy of givinostat in slow down 
disease progression.  Timed function tests, such as time to climb 4-stairs (4SC), to walk 10 m, 
and to stand up, are reliable and feasible in the majority of the DMD population from age 4 
and older (McDonald, C. M., et al. 201325) and have a documented response to therapeutic 
intervention with steroids (Manzur AY, K. T., 200926).  In particular, time to climb 4 
standard-sized stairs is a TFT that represents stair climbing ability, a clinically meaningful 
function in and of itself.  It has been used as an endpoint in DMD studies for decades and the 
test is reproducible and simple to administer.  It is predictive of loss of stair climbing ability, 
loss of ambulation and time to 10% decline in ambulatory capacity (Bushby, K. 201127).  
Furthermore, climbing stairs requires a greater range of motion (ROM) from the joints of the 
lower limb and greater muscle strength than 6MWT, which is a functional test more related to 
endurance.  Therefore, in light of givinostat MoA (e.g., increase fibers CSA) the time to 4SC 
test is expected to be more appropriate to evaluate the efficacy of givinostat in DMD subjects. 
The key secondary endpoints (cumulative loss of function in the NSAA, change inTime to 
Rise from Floor, in NSAA, in 6MWT and in strength) include those parameters which are 
considered relevant in this population to corroborate the results obtained on the primary 
endpoint.  
Changes in MRS parameters will be also key endpoints.  Previous studies have shown that 
MRI can visualize structural alterations of muscle in muscular dystrophies (Willcocks, 201428, 
201629, Wren 200830, Bonati 201531) and have shown that fat fraction measured by MRI or 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 40 of 120 
magnetic resonance spectroscopy (MRS) highly correlates with lower limb function.  
Although longitudinal data on MRI/MRS particularly from randomised clinical trials are still 
limited, a number of randomized clinical trials currently ongoing include magnetic resonance 
evaluations and both the FDA and EMA guidelines identify MRI/MRS as a potential 
biomarker. 
Finally safety and tolerability and pharmacokinetics will be also assessed in the study for a 
proper risk-benefit evaluation of givinostat. 
5 
STUDY OBJECTIVES AND ENDPOINTS 
5.1 
Study Objectives 
5.1.1 Primary Objective 
To establish the effects of givinostat versus placebo administered chronically over 18 months 
to slow disease progression in ambulant DMD subjects. 
5.1.2 Secondary Objectives 
The secondary objectives of this study are: 
 To assess the safety and tolerability of givinostat versus placebo administered 
chronically in DMD subjects.  
 To evaluate the PK profile of givinostat administered chronically in DMD subjects  
 To evaluate the impact on quality of life and activities of daily living of givinostat 
versus placebo administered chronically. 
5.1.3 Secondary Exploratory Objectives 
 To evaluate the correlation between PK profile of givinostat  and pharmacodynamics 
(PD) data; 
 To explore whether the effects of givinostat versus placebo administered chronically 
may be related to the type of DMD mutation (Pane M et al. 201432) or to the 
biomarkers. 
5.2 
Study Endpoints 
5.2.1 Primary Endpoint  
The primary endpoint of this study is the mean change in 4SC before and after 18 months of 
treatment of givinostat versus placebo. 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 41 of 120 
5.2.2 Key Secondary Endpoints 
The key secondary efficacy endpoints for this study are as follows: 
Function : 
 Mean change in time to rise from floor  
 Mean change in 6MWT  
 
Mean change in NSAA  
 Cumulative loss of function on the NSAA 
 Mean change of muscle strength evaluated by knee extension, elbow flexion  as 
measured by hand-held myometry (HHM)  
Imaging: 
 Mean change in vastus lateralis muscles fat fraction   
The above endpoints will be formally assessed after 18 months of treatment. 
 
5.2.3 Safety Endpoints 
The safety endpoints of this study are as follows: 
 Number of subjects experiencing treatment-emergent adverse events (TEAEs) and 
serious adverse events (SAEs) (Baseline through end of study [EOS]); 
 Type, incidence, and severity of TEAEs and SAEs (Baseline through EOS); 
 Changes from baseline to end of study of: 
o Vital signs and clinical laboratory tests (blood chemistry and hematology); 
o Respiratory function evaluated by forced vital capacity (FVC), forced expiratory 
volume at 1 second (FEV1), FVC/FEV1, peak expiratory flow (PEF); 
o Cardiac function evaluated by ECG and echocardiogram (ECHO); 
o Cognitive function evaluated by the Raven coloured progressive matrices; 
o Weight, height, and body mass index (BMI); 
 Evaluation of acceptability/palatability of the oral suspension. 
5.2.4 Pharmacokinetic Endpoints 
The PK endpoints of this study are as follows: 
 Description of the PK of givinostat and its major metabolites: ITF2374 and ITF2375 
in the subject population; 
 Identification of the relevant demographic and pathophysiological covariates 
influencing the PK of givinostat; 
5.2.5 Exploratory Endpoints 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 42 of 120 
The exploratory endpoints of this study are as follows: 
 Mean changes  in:  
o time to walk/run 10 meters; 
o PODCI scores. 
o %-predicted 6MWT (the predicted value is against healthy subjects and is 
calculated using the equation of Geiger [Henricson, et.al.33]); 
o Only in the MR cohort:  MRI parameters (e.g., fat fraction of  thigh muscles, 
CSA of vastus lateralis and other thigh muscles);  
 Time to 10% persistent worsening in 6MWT (Baseline through end of study); 
 Proportion of subjects with ≥10% worsening in 6MWT at end of study; 
 Time to loss of standing (Baseline through end of study); 
 Proportion of subjects who loose ambulation during the study; 
 Evaluation of any correlation between the effect of Givinostat on disease progression 
and the type of DMD mutation, LTBP4 and Osteopontin genotype; 
 Evaluation of any possible DMD serum biomarker; 
 PK-PD analyses: relationships between metrics of exposure and efficacy/safety 
endpoints of givinostat.  
6 
INVESTIGATIONAL PLAN 
6.1 
Description of Overall Study Design and Plan 
This is a Phase 3, randomised, double blind, placebo controlled, multicentre study to evaluate 
the efficacy and safety of givinostat in ambulant subjects with DMD.  This study will include 
ambulant male paediatric subjects aged ≥6 years at baseline affected by DMD.  
A total of  110 subjects in the target population (Group A: subjects with a baseline vastus 
lateralis muscle fat fraction (VL MFF) assessed by MRS  in the range >5% and ≤30%) will be 
randomised.  Up to 50 subjects (about 35% of the overall population) outside of the target 
may also be recruited into the study (Group B: subjects with a baseline vastus lateralis muscle 
fat fraction (VL MFF) assessed by MRS  in the range ≤5% or >30%). Subjects who assent to 
participate in this study (if capable of doing so) and whose parent/legal guardian sign the 
Informed Consent Form (ICF) to participate will undergo pre-study screening assessments up 
to 4 weeks before the first scheduled dose of study drug.  

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 43 of 120 
At the randomisation visit, in addition to the continued standard of care corticosteroids 
regimen, DMD subjects will be randomised (2:1 ratio) to receive givinostat oral suspension 
10 mg/mL or placebo oral suspension bid (in a fed state) as described in Section 8.3. 
At randomisation, subjects will be stratified for their concomitant use of steroids in 4 strata: 
1. Deflazacort Daily regimen 
2. Deflazacort Intermittent regimen 
3. Other steroids Daily regimen 
4. Other steroids Intermittent regimen 
 The study duration is planned for 19 months and comprises 2 phases: 
1. 
Screening period: starting 4 weeks (± 2 weeks) before randomisation 
2. 
Treatment period: 18 months of treatment 
An overview of the study is provided in  
Figure 6-1. 
 
 
Figure 6-1: 
Study Design 
There will be a total of 15 visits, including the Screening and the Randomisation Visits and 
excluding the Follow up Visit.  Subjects may be evaluated more often if necessary for safety 
reasons.  Subjects who discontinue the study drug early will be asked to come in for an  Early 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
Double-blind Treatment 
Period  
Randomisation 
Screening
-
 
Period
 
Screening
 
Period
  
1 month  
  
Placebo 
18 months
  
Givinostat
 
 
  
 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 44 of 120 
Withdrawal Visit within 2 weeks after the last dose of study drug.  Subjects who have 
ongoing AEs at discontinuation will be followed until resolution or stabilization.  
In order to guarantee the continuation of treatment with givinostat, the Sponsor has planned a 
long-term study which will start when the first subject enrolled in this study has attended his 
last visit.  As a consequence, at the end of the treatment, parent/ legal guardian will be asked 
to consent and subject will be asked to assent/consent to his participation to the long-term 
study.  In case the subject will not assent/consent and/or the parent/ legal guardian will not 
consent it, a final follow up visit will be performed 4 weeks after last dose administration. 
6.2 
Discussion of Study Design 
This study is designed as a conventional parallel group design.  Since the study will be 
conducted in a paediatric population with a serious and life-threatening disease, the unequal 
randomisation ratio (i.e., 2:1 to givinostat and placebo) will be applied to reduce the exposure 
to placebo to only one third of subjects.    A 2:1 randomisation also provides for an increased 
number of subjects who are exposed to givinostat. 
The sample size was originally calculated to provide 90% power and a 1-sided alpha of 2.5% 
to detect a true difference between givinostat and placebo in the target population in the 4SC 
18 month change from baseline of 3 seconds, assuming a common standard deviation (SD) of 
6 seconds (being based on publicly available phase 3 study data on ataluren and drisapersen in 
DMD subjects in addition to internal Italfarmaco S.p.A data.), giving rise to an estimated 
sample size of N=192 subjects.  However, the planned  interim analysis took place in January 
2020 based upon the first 50 randomised patients reaching 12 months of treatment.  This 
interim provided a revised, blinded within treatment SD estimate of 3.094 seconds, 
approximately half of that assumed in the original power calculation. Based on this revised 
SD estimate, the revised sample size is N=102 which provides 90% power for a 2 second 
difference between givinostat and placebo for the change in 4SC at 18 months.    
In a recent analyses performed by C-Tap (Wong B, et al. Action Duchenne International 
Conference, November 9–11, 2018, Birmingham, UK), the minimally clinically important 
difference (MCID) for timed function tests (TFTs) in DMD was estimated at ~1.0 to 
1.6 seconds. These results were confirmed by additional analyses performed on the CINRG 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 45 of 120 
natural history database (Data on File), which showed that a change of 1 to 1.5 seconds in 
TFTs has clinical meaningfulness based on health-related QoL and participation measures in 
DMD and that a 1.6 to 1.7 second change over 12-months in TFTs translates to a 3-year 
prolongation of ambulation in DMD. Together, these new data suggest that 2 seconds is an 
appropriate conservative estimate of a clinically meaningful effect size for TFTs in DMD, 
which is less than the 3 seconds originally hypothesized in the study protocol(MCID; 
McDonald CM et al. 201322); however, with the blinded SD estimate made at the planned 
interim, the revised total number of subjects, N=102 has 90% power to detect this smaller, yet 
clinically relevant treatment effect.   The treatment duration of 18 months has been chosen 
because DMD children with more preserved muscle mass will be enrolled in this study,  and 
despite the underlying progression of muscle tissue deterioration, a decline of function is 
expected to be slower in the selected patient population compared to DMD subjects in 
“decline phase” (e.g., DMD subjects >7 years with 6MWT < 350 meter, McDonald, 
Henricson et al. 201323);  thus, a longer observation period is needed to demonstrate 
functional benefits compared givinostat to placebo controls. 
At randomisation, the population will be stratified according to steroid type and regimens 
(i.e., daily regimen or intermittent regimen) because some evidence suggests Deflazacort use 
was associated with later loss of ambulation and increased frequency of side effects (Bello et 
al. 201536) and daily administration of steroids to be more eﬀective than treatment on alternate 
days (Bushby, Finkel et al. 201034; Ricotti, Baranello et al. 201335).   Thus, to help to ensure 
balance between the randomised treatment arms stratification by steroid type and regimens 
will be implemented.  
Daily regimen means every daily intake of steroids, while intermittent regimens comprise 
steroids used every other day, high dose weekend and 10 days on alternate to 10 or 20 days 
off.  Different schedule can be discussed with the Medical Monitor before the subject 
randomisation, however the decision remains with the Investigator only or its authorized 
designee. 
An Independent Data Monitoring Committee (IDMC) will review, evaluate, and categorise 
safety findings every three months during the study and will be responsible for oversight of 
the interim analysis (see below) at which futility will be assessed and a blinded sample size 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 46 of 120 
reestimation will be made.  The IDMC will have access to unblinded data, if necessary, and 
will operate according to the rules defined in the IDMC charter. 
A single interim analysis has been planned in this study which will be overseen by the IDMC 
in order to ensure the study integrity: 
 The first interim analysis will be performed when the first N=50 subjects randomised 
in the target population have reached the 12 month time point and the effects of 
givinostat versus placebo on the mean vastus lateralis muscles fat fraction (VL MFF) 
assessed by MRS will be evaluated.  The purpose of this interim is to assess futility. 
There will be no formal assessment of efficacy and no unblinded evaluation of the 
primary endpoint, even by the IDMC.    
Based on prior data, a 5% annual mean increase in VL MFF in the placebo group is 
expected and a corresponding 3.5% annual mean increase in the givinostat group is 
desired.  Futility will be considered if the mean change in VL MFF in the givinostat 
group is equal to or worse than that seen in the placebo group since the biologic 
plausibility of a subsequent treatment effect on 4SC time would be greatly diminished.  
The IDMC will only communicate to the Sponsor, whether the study should proceed 
or be stopped, based on whether the study has met the futility criteria.  If the IDMC 
indicates that the study should proceed, a blinded sample size re-estimation will also 
be conducted for VL MFF and 4SC in the target population.   
More details about the interim analysis are described in Section 13.10. 
7 
SELECTION AND WITHDRAWAL OF SUBJECTS 
The study will enroll male subjects with an established molecular diagnosis of DMD who are 
at least 6 years of age at randomisation. 
Specific entry criteria are detailed in Section 7.1 and in Section 7.2. 
Subjects dropping out before the end of treatment will not be replaced.  
7.1 
Inclusion Criteria 
Subjects must meet all of the following criteria in order to be included in the study: 
1. Are an ambulant male aged ≥6 years at randomisation with DMD characteristic 
clinical symptoms or signs (e.g., proximal muscle weakness, Gowers’ maneuver, 
elevated serum creatinine kinase level) already present at screening; 
2. Have DMD diagnosis confirmed by genetic testing;  
3. Are able to give informed assent and/or consent in writing signed by the subject and/or 
parent/legal guardian (according to local regulations); 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 47 of 120 
4. Are able to complete 2 Four Stairs Climb test (4SC) screening assessments; the results 
of these tests must be within ±1 second  of each other;  
5. Have the mean of 2 screening 4SC assessments ≤8 seconds;  
6. Have time to rise from floor between ≥3 and  <10 seconds at screening; 
7. Have manual muscle testing (MMT) of quadriceps at screening ≥ Grade - 3; 
8. Have used systemic corticosteroids for a minimum of 6 months immediately prior to 
the start of study treatment, with no significant change in corticosteroids type or 
dosage or dosing regimen (excluding changes related to body weight change) for a 
minimum of 6 months immediately prior to start of study treatment and a reasonable 
expectation that dosage and dosing regimen will not change significantly for the 
duration of the study. 
9. Subjects must be willing to use adequate contraception.  
Contraceptive methods must be used from Randomization Visit 3 through 3 months 
after the last dose of study drug, and include the following: 
o True abstinence (absence of any sexual intercourse), when in line with the 
preferred and usual lifestyle of the subject. Periodic abstinence (e.g. calendar, 
ovulation, symptothermal, postovulation methods) and withdrawal are not 
acceptable methods of contraception. 
o Condom with spermicide and the female partner must use an acceptable 
method of contraception, such as an oral, transdermal, injectable or implanted 
steroid-based contraceptive, or a diaphragm or a barrier method of 
contraception in conjunction with spermicidal jelly such as for example 
cervical cap with spermicide jelly. 
7.2 
Exclusion Criteria 
Subjects meeting any of the following criteria are ineligible to participate in this study: 
1. Have exposure to another investigational drug within 3 months prior to the start of 
study treatment  (only exception allowed is use of Deflazacort in US as part of the 
Expanded Access Program and in Canada as part of the Special Access Program;  
2. Have exposure to idebenone within 3 months prior to the start of study treatment;  
3. Have exposure to any dystrophin restoration product (e.g., Ataluren, Exon-skipping) 
within 6 months prior to the start of study treatment; 
4. Use of any pharmacologic treatment, other than corticosteroids, that might have had an 
effect on muscle strength or function within 3 months prior to the start of study 
treatment (e.g., growth hormone); Vitamin D, calcium, and any other supplements will 
be allowed as long as their intake has been stable for 3 months prior to the start of 
study treatment; Testosterone will also be allowed if it is used as a replacement 
therapy for the treatment of delayed puberty, and testosterone dose and regimen have 
been stable for at least 6 months and circulating testosterone levels are within the 
normal ranges for the subject’s age; 
5. Have surgery that might have an effect on muscle strength or function within 3 months 
before study entry or planned surgery at any time during the study; 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 48 of 120 
6. Loss of ≥30 degrees of plantar flexion from the normal range of movement at the 
ankle joint due to contracture (i.e. fixed loss of more than 10 degrees of plantar flexion 
from plantigrade, assuming normal range of dorsiflexion of 20 degrees); 
7. Change in contracture treatment such as serial casting, contracture control devices, 
night splints, stretching exercises (passive, active, self) within 3 months prior to 
enrollment, or expected need for such intervention during the study; 
8. Have presence of other clinically significant disease, which, in the Investigator’s 
opinion, could adversely affect the safety of the subject, making it unlikely that the 
course of treatment or follow-up would be completed, or could impair the assessment 
of study results; 
9. Have a diagnosis of other uncontrolled neurological diseases or presence of relevant 
uncontrolled somatic disorders that are not related to DMD; 
10. Have platelets count, White Blood Cell and Hemoglobin at screening < Lower Limit 
of Normal (LLN) (for abnormal screening laboratory test results (<LLN), the platelets 
count, White Blood Cell and Hemoglobin will be repeated once; if the repeat test 
result is still <LLN, then exclusionary); 
11. Have symptomatic cardiomyopathy or heart failure (New York Heart Association 
Class III or IV) or left ventricular ejection fraction <50% at screening; 
12. Have a current or history of liver disease or impairment, including but not limited to 
an elevated total bilirubin (i.e. > 1.5 x ULN), unless secondary to Gilbert disease or 
pattern consistent with Gilbert's; 
13. Have inadequate renal function, as defined by serum Cystatin C >2 x the upper limit 
of normal (ULN).  If the value is >2 x ULN, the serum Cystatin C will be repeated 
once; if the repeated test result is still >2 x ULN, the subject should be excluded);  
14. Have Triglycerides > 300 mg/dL (3.42 mmol/L) in fasting condition at screening visit; 
15. Have a positive test for hepatitis B surface antigen, hepatitis C antibody, or human 
immunodeficiency virus at screening; 
16. Have a baseline corrected QT interval, Fridericia’s correction (QTcF) >450 msec, (as 
the mean of 3 consecutive readings 5 minutes apart) or history of additional risk 
factors for torsades de pointes (e.g., heart failure, hypokalemia, or family history of 
long QT syndrome); 
17. Have a psychiatric illness/social situations rendering the potential subject unable to 
understand and comply with the muscle function tests and/or with the study protocol 
procedures; 
18. Have any hypersensitivity to the components of study medication; 
19. Have a sorbitol intolerance or sorbitol malabsorption, or have the hereditary form of 
fructose intolerance; 
20. Have contraindications to MRI or MRS (e.g., claustrophobia, metal implants, or 
seizure disorder). 
At the discretion of the Investigator, subjects not meeting inclusion/exclusion criteria may be 
re-screened twice with an interval of at least 3 months between assessments. 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 49 of 120 
7.3 
Withdrawal, Removal, and Replacement of Subjects  
Withdrawal from study participation and study medication may occur under the following 
circumstances: 
 Withdrawal of consent.  The subject or his parent/guardian desire to withdraw from 
further participation in the study in the absence of the Investigator determining a 
medical need to withdraw.  If the subject or parent/guardian give a reason for 
withdrawing, it should be recorded in the electronic Case Report Form (eCRF). 
 Protocol Violation.  The subject’s findings or conduct failed to meet the protocol entry 
criteria or failed to adhere to the protocol requirements (e.g.,  failure to return for 
defined number of visits). Before withdrawing a subject each case will be discussed 
with the study medical monitor and if the safety of the subject can be reasonably 
assured, the subject will not be discontinued.  
 Lost to Follow-Up.  The subject stopped coming for visits, and study personnel were 
unable to contact the subject. 
 Other reason.  The subject was terminated for a reason other than those listed above, 
such as at the discretion of the Investigator (i.e., any other condition that, in the 
opinion of the Investigator, may jeopardize the study conduct according to the 
protocol, or when the Investigator feels that it is in the best interest of the subject to 
discontinue) or termination of study by the Sponsor. 
Withdrawal from study medication may occur under the following circumstance: 
 Adverse event.  Clinical or laboratory events occur that, in the medical judgment of 
the Investigator for the best interest of the subject, are grounds for discontinuation.  
Moreover, if the subject meets one of the safety stopping criteria described in Section 
7.3.1, he will be withdrawn from the study medication.  In case of withdrawal due to 
AEs/SAEs, the Investigator will follow up with the subject until resolution or 
acceptable stabilization of the event and document all the relevant information, as 
applicable. 
In case of withdrawal from study participation and /or study medication, the following general 
rules apply: 
 If a subject is discontinued from study medication and is withdrawn from the study 
for any reason, the study site must immediately notify the medical monitor. 
 When a subject withdraws from the study, the date and reasons for withdrawal shall 
be recorded by the Investigator on the Subject’s Medical File and on the relevant 
page of the eCRF.  

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 50 of 120 
In case of multiple reasons, AEs should be indicated as the primary reason whenever 
applicable.  All relevant information related to the reason for treatment 
discontinuation including contributory factors must be included on the eCRF. 
 All subjects prematurely discontinuing the study must be seen for a final evaluation 
performed within 2 weeks after the last drug intake.  Final evaluation is defined as 
completion of the assessments scheduled for the Early Termination Visit (as detailed 
in Section 9.1.8).  Data collected during the final evaluation are crucial to the 
integrity of the final study analysis because early withdrawal could be related to the 
safety profile of the study drug.  The Investigator will make every effort to see 
subjects who fail to return for a final visit.   
 In the event that a subject is discontinued prematurely from the study due to a 
treatment-related TEAE or serious TEAE, the TEAE or serious TEAE will be 
followed until it resolves (returns to normal or baseline values) or stabilizes, or until 
it is judged by the Investigator to be no longer clinically significant. 
 Once a subject is withdrawn from the study, he may not re-enter the study. 
7.3.1 Safety Stopping Rules   
Study drug should be permanently interrupted if any of the following occurs: 
 severe drug-related diarrhoea (i.e., increase of  ≥7 stools per day);  
 any drug-related SAE; 
 QTcF >500 msec*; 
 platelets count ≤50 x 109/L (to avoid laboratory errors and anomalous values, platelets 
count ≤50 x 109/L must be confirmed with a repeated test performed on the next 
working day.  The treatment should be stopped until the retest result becomes 
available.  If the repeated platelets count is still ≤50 x 109/L, study drug must be 
permanently discontinued.  If the repeated test is acceptable, the subject can resume 
treatment.);   
 white blood cells  ≤2.0 x 109/L (to avoid laboratory errors and anomalous values, 
white blood cells  ≤2.0 x 109/L must be confirmed with a repeated test performed on 
the next working day.  The treatment should be stopped until the retest result becomes 
available.  If the repeated white blood cells is still ≤2.0 x 109/L, study drug must be 
permanently discontinued.  If the repeated test is acceptable, the subject can resume 
treatment.);   
 hemoglobin  ≤8.0 g/dL (to avoid laboratory errors and anomalous values, hemoglobin  
≤8.0 g/dL must be confirmed with a repeated test performed on the next working day.  
The treatment should be stopped until the retest result becomes available.  If the 
repeated hemoglobin is still ≤8.0 g/dL, study drug must be permanently discontinued.  
If the repeated test is acceptable, the subject can resume treatment.).   

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 51 of 120 
The Investigator will follow up on him until resolution or acceptable stabilization of the event 
occurs and document all the relevant information, as applicable.  After the 
resolution/stabilization of the event, the subject will be withdrawn from the study and the 
EOS Visit (see Section 9.1.8) will be performed. 
* based on average QTc value of triplicate ECGs.  For example, if an ECG demonstrates a prolonged QTcF 
interval >450msec, 2 more ECGs should be obtained over a brief period, and then the averaged QTcF values of 
the 3 ECGs should be used to determine whether the subjects should be discontinued from the study.  If the mean 
QTcF value of the 3 replicates still meets the stopping criteria the subject has to interrupt the study drug, the 
medical monitor has to be informed and the value must be confirmed by the central reading before withdraw the 
subject from the study.  The QTc has to be calculated with the Fridericia formula QTc = QT/RR1/3. 
Study drug should be temporarily stopped if any of the following occur: 
 moderate or severe diarrhoea (i.e., increase more than 4 stools per day).  
 platelets count <75 x 109/L but >50 x 109/L (the treatment should be temporarily 
stopped and platelets count has to be performed by 1 week and re-tested until platelets 
will be normalized); 
 white blood cell  <3.0 x 109/L but >2.0 x 109/L (the treatment should be temporarily 
stopped and white blood cells have to be measured by 1 week and re-tested until white 
blood cells  will be normalized); 
 hemoglobin  <10.0 g/dL but > 8.0 g/dL (the treatment should be temporarily stopped 
and hemoglobin has to be measured by 1 week and re-tested until hemoglobin will be 
normalized); 
 Triglycerides >300 mg/dL (3.42 mmol/L) in fasting condition (the treatment should be 
temporarily stopped and  triglycerides has to be measured every 2 weeks until  
triglycerides return to levels below 300 mg/dL (3.42 mmol/L); 
For subjects randomized under protocol version 6.0, or 7.0 or 8.0: 
Study drug can be reduced by 20% of the current dose at which the AE leading to temporary 
stop occurred, once platelets and/or white blood cell and/or hemoglobin are normalized, 
and/or triglycerides return to levels below 300 mg/dL (3.42 mmol/L), or diarrhoea is mild.  
The subject may have more than the usual number of scheduled visits if needed, until the AE 
resolves, and then will continue the study as per scheduled visits. 
In addition, in case a subject will have a consistent (e.g., at least two consecutive evaluation) 
platelets count ≤150 x 109/L and not meeting the stopping criteria for platelets, the 
Investigator will have to reduce the dose by 20% of the current dose (see Section 8.2.2 for 
more details). 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 52 of 120 
For subjects randomized under protocol version  6.0 or 7.0 or 8.0, only one dose reduction is 
allowed during the treatment period. 
Any decision relevant to the dose interruption and/or modification of the schedule of 
assessments can  be discussed with  the Medical Monitor, but the final decision remains with 
the Investigator only or its authorized designee. 
For subjects randomized under protocol version 4.0: 
Study drug can be reduced by 1/3 of the starting dose at which the AE leading to temporary 
stop occurred, once platelets and/or white blood cell and/or hemoglobin are normalized and/or 
triglycerides return to levels below 300 mg/dL (3.42 mmol/L), or diarrhoea is mild.  The 
subject may have more than the usual number of scheduled visits if needed, until the AE 
resolves, and then will continue the study as per scheduled visits.  
If a subject was randomized with baseline triglycerides above 300 mg/dL (3.42 mmol/L) the 
Investigator can discuss how to manage the case with the medical monitor, however the final 
decision remains with the Investigator only or its authorized designee. 
In addition, in case a subject will have a consistent (e.g., at least two consecutive evaluations) 
platelets count ≤150 x 109/L and not meeting the stopping criteria for platelets, the 
Investigator will have to reduce the dose  by 1/3 vs the starting dose (see Section 8.2.2 for 
more details).  
If a subject has a medical event not necessarily drug related that requires interruption of study 
drug dosing for >4 weeks, the Investigator can discuss the case with the medical monitor if 
the subject may resume study drug treatment, however the final decision remains with the 
Investigator only or its authorized designee.  
Moreover, for subjects who have already reduced the dose of 1/3 an additional reduction of 
20%  is allowed for safety reasons following the inscruction in section “For subjects 
randomized under protocol version 6.0, or 7.0 or 8.0”. 
Any decision relevant to the dose interruption and/or modification of the schedule of 
assessments can  be discussed with  the Medical Monitor, but the final decision remains with 
the Investigator only or its authorized designee. 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 53 of 120 
8 
TREATMENTS 
8.1 
Details of Study Treatments 
The investigational study drug to be used in this study is givinostat (ITF2357) and a placebo.  
For the duration of the study, givinostat and placebo will be supplied by Italfarmaco S.p.A. 
 
Investigational Medicinal Drug 
 
Test treatment 
Comparator 
Product name: 
ITF2357/givinostat* 
Placebo 
Dosage form: 
Oral suspension 
Oral suspension 
Unit dose 
strength: 
Bottle containing 140 mL of givinostat 
10 mg/mL  
Bottle containing 140 mL of 
placebo 
Route of 
Administration 
Oral administration under fed 
conditions 
Oral administration under fed 
conditions 
Dosing 
instructions: 
See Table 2 
See Table 2 
Physical 
description: 
White to off-white or faintly pink, 
homogenous suspension when mixed  
White to off-white or faintly 
pink, homogenous suspension 
when mixed 
Device included 
in the packaging: 
Two graduated dosing syringes for 
oral use: 
One 5 mL syringe and 
One 1 mL syringe 
Two graduated dosing syringes 
for oral use: 
One 5 mL syringe and 
One 1 mL syringe 
*Givinostat is used to indicate the whole study drug name givinostat hydrochloride monohydrate.  The 
dosages/concentrations of the study drug are expressed as givinostat hydrochloride monohydrate. 
 
The investigational sites will be supplied initially with a congruous number of suspension 
bottles, in order to have sufficient supply of study drug to treat subjects who are enrolled in 
the study. 
8.2 
Dosage  
8.2.1 Rational for Dose Selection 
The dose for this study has been selected based on: the dose ranging evaluation done in the 
mdx model; the results of the Phase 2 study in DMD paediatric subjects (DSC/11/2357/43), 
and the evaluation of PK and efficacy results obtained in other inflammatory diseases.   
The PK/PD analysis done with the data collected during the non-clinical studies in mdx 
model, showed that a blood AUC0-24 of at least 300 ng*h/mL was estimated to be needed to 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 54 of 120 
exert the beneficial histological and functional effects in mouse and thus was considered the 
target exposure for the exploratory Phase 2 study in the DMD population (DSC/11/2357/43 
study).  
The study DSC/11/2357/43 was designed to first verify that doses of givinostat leading to an 
AUC0-24 of at least 300 ng*h/mL in the majority of DMD subjects were tolerated and then to 
verify that such exposures would translate into a significant histological benefit.  Results have 
confirmed that doses of 25/37.5 mg bid are tolerated, do result in an AUC0-24 of at least 300 
ng*h/mL in the majority of treated DMD subjects, and result in a significant histological 
benefit. 
On the other hand, previous clinical experience in chronic inflammatory diseases in adult and 
paediatric populations (i.e., Crohn’s Disease, Psoriasis, Systemic Onset Juvenile Idiopathic 
Arthritis and Polyarticular Course Juvenile Idiopathic Arthritis) have shown that givinostat 
was overall not efficacious in controlling symptoms and biological features of these diseases 
at exposures (AUC0-24) lower or comparable to those obtained in study DSC/11/2357/43.  
Lack of efficacy of doses lower than those tested in study DSC/11/2357/43 were also 
suggested by the post-hoc analysis of study DSC/11/2357/43 results which showed that a 37.5 
mg bid dose was associated with a larger increase in CSA of fibers compared to 25 mg bid. 
Based on these considerations, the Sponsor believes that doses leading to daily exposures 
lower than those obtained in study DSC/11/2357/43 are very unlikely to be efficacious and 
therefore chose an initial study dose to ensure a mean AUC0-24 similar to that achieved with 
37.5 mg/bid (i.e., approximately 1150 ng*h/mL). As of 18th of June 2018, based on blinded 
safety haematologic data, the Sponsor has evaluated that, a vast majority of randomized 
subjects who had completed at least 8 weeks of treatment (approximately 50 to 60%) had to 
reduce the starting dose due to a decrease in platelet levels. It is, therefore, expected that a 
relevant amount of subjects that will be enrolled into the study will need to require the same 
dose adjustment. Therefore, a new starting dose corresponding to the reduced dose (i.e. 1/3 
lower than the starting dose) of protocol version 4.0 (i.e. 13.3-46.7 mg/bid according to body 
weight) is proposed by the Sponsor in protocol version 6.0. This new starting dose ensures a 
mean AUC0-24 similar to that achieved with 25 mg/bid during the DSC/11/2357/43 study in 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 55 of 120 
DMD patients (i.e., approximately 674 ng*h/mL), which was safe and showed significant 
histological benefit. 
As weight was shown to significantly affect givinostat clearance, and the study will enroll 
paediatric DMD subjects with a broad range of weight, the initial dose will be adjusted to the 
current body weight of the subject (see Table 2). A strict monitoring of platelets count has 
been planned, and it will be followed with dose adjustment instruction as described in the 
safety rules as described in Section 7.3.1 in order to avoid the risk of platelet reduction <75 x 
109/L. 
8.2.2 Dosage Schedule 
The following is a description of the dosage, treatment regimen, and route of administration.  
Givinostat oral suspension (10 mg/mL) and placebo oral suspension have to be administered 
orally as 2 oral doses daily while the subject is in a fed state.  Before its use, the suspension 
must be shaken for at least 30 seconds by rotating the bottle by 180° and the homogeneity of 
the obtained suspension verified.  The suspension will be administered by means of a 
graduated dosing syringe.  The dosage to be administered is based on subject weight and the 
starting doses are described below: 
Table 2: 
Placebo or Givinostat Starting Dose 
Weight (kg) 
≥10 
and 
< 12.5 
≥12.5 
and 
< 20 
≥20 
and 
< 25 
≥25 
and 
< 30 
≥30 
and 
< 40 
≥40 
and 
< 50 
≥50 
and 
< 60 
≥60 
and 
< 70 
≥70 
Dose (mg) bid 
13.3 
16.7 
20 
23.3 
26.7 
33.3 
36.7 
40 
46.7 
Oral suspension 
(mL) bid 
1.3 
1.7 
2.0 
2.3 
2.7 
3.3 
3.7 
4 
4.7 
 
The subjects who were randomized under protocol version 4.0 will continue the current dose 
(see  Table 4). 
Table 3: 
Placebo or Givinostat Starting Dose for subjects enrolled under Protocol version 4.0 
Weight (kg) 
≥10 
and 
<12.5 
≥12.5 
and 
<20 
≥20 
and 
<25 
≥25 
and 
<30 
≥30 
and 
<40 
≥40 
and 
<50 
≥50 
and 
<60 
≥60 
and 
< 70 
≥70 
Dose (mg) bid 
20 
25 
30 
35 
40 
50 
55 
60 
70 
Oral suspension (mL) bid 
2.0 
2.5 
3.0 
3.5 
4.0 
5.0 
5.5 
6.0 
7.0 
Dose Modifications for subjects randomized under protocol version 6.0 or 7.0 or 8.0: 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 56 of 120 
Study drug dose adjustment including safety rules for permanently or temporarily stopping 
study drug are described in Section 7.3.1. 
As mentioned in Section 7.3.1, in case a subject has a consistent (e.g., at least 2 consecutive 
evaluations) platelets count ≤150 x 109/L and but does not meet the stopping criteria due to 
platelet reduction, the Investigator will have to reduce the dose by 20%  of the current dose 
(first example: e.g., starting dose = 20 mg bid  20%  dose reduction  new dose = 16 mg 
bid; second example: starting dose = 26.7 mg bid  20% dose reduction  new dose = 
21.4 mg bid) (see  Table 4). 
 Table 4: Placebo or Givinostat Dose Modification for subjects randomized under study 
protocol version 6.0 or 7.0 or 8.0. 
Weight (kg) 
≥10 
and 
<12.5 
≥12.5 
and 
<20 
≥20 
and 
<25 
≥25 
and 
<30 
≥30 
and 
<40 
≥40 
and 
<50 
≥50 
and 
<60 
≥60 
and 
< 70 
≥70 
Starting Dose 
(mg) bid 
13.3 
16.7 
20 
23.3 
26.7 
33.3 
36.7 
40 
46.7 
Oral suspension 
(mL) bid 
1.3 
1.7 
2.0 
2.3 
2.7 
3.3 
3.7 
4 
4.7 
Reduced Dose 
(mg) bid 
10.6 
13.4 
16 
18.6 
21.4 
26.6 
29.4 
32 
37.4 
Oral suspension 
(mL) bid 
1.1 
1.3 
1.6 
1.9 
2.1 
2.7 
2.9 
3.2 
3.7 
Study drug can be resumed at a level 20% smaller than the dose at which the AE leading to 
temporary stop occurred, once platelets and/or white blood cell and/or hemoglobin are 
normalized  and/or triglycerides return to levels below 300 mg/dL (3.42 mmol/L) or when 
diarrhoea is mild. 
For subjects randomized under protocol version 6.0 or 7.0 or 8.0, only one dose reduction is 
allowed during the treatment period. 
Dose Modifications for subjects randomized under protocol version 4.0: 
The subjects who were randomized under protocol version 4.0, will follow the dose 
modification instruction as per  protocol version 4.0,  as described below in Table 5.  

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 57 of 120 
Table 5: 
Placebo or Givinostat Dose Modification for subject randomized under study 
prococol version 4.0 
Weight (kg) 
≥10 
and 
<12.5 
≥12.5 
and 
<20 
≥20 
and 
<25 
≥25 
and 
<30 
≥30 
and 
<40 
≥40 
and 
<50 
≥50 
and 
<60 
≥60 
and 
< 70 
≥70 
Starting Dose 
(mg) bid 
20 
25 
30 
35 
40 
50 
55 
60 
70 
Oral suspension 
(mL) bid 
2.0 
2.5 
3.0 
3.5 
4.0 
5.0 
5.5 
6.0 
7.0 
Reduced Dose 
(mg) bid 
13.3 
16.7 
20 
23.3 
26.7 
33.3 
36.7 
40 
46.7 
Oral suspension 
(mL) bid 
1.3 
1.7 
2.0 
2.3 
2.7 
3.3 
3.7 
4 
4.7 
Study drug dose adjustment including safety rules for permanently or temporarily stopping 
study drug are described in Section 7.3.1. 
As mentioned in Section 7.3.1, in case a subject has a consistent (e.g., at least 2 consecutive 
evaluations) platelets count ≤150 x 109/L and does not meet the stopping criteria due to 
platelet reduction, the Investigator will have to reduce the dose by 1/3 of the starting dose (see 
Table 5). 
Study drug can be resumed at a level 1/3 smaller than the dose at which the AE leading to 
temporary stop occurred, once platelets and/or white blood cell and/or hemoglobin are 
normalized  and/or triglycerides return to levels below 300 mg/dL (3.42 mmol/L) or when 
diarrhoea is mild. 
If a subject was randomized with baseline triglycerides above 300 mg/dL (3.42 mmol/L), the 
Investigator can discuss how to manage the case with the medical monitor, however the final 
decision remain with the Investigator or its authorized designee only.  
Moreover, for subjects who have already reduced the dose of 1/3 an additional reduction by 
20%  is allowed for safety reasons following the instruction reported in  Table 4.  
Dose Modification (all subjects): 
If subjects (i.e. those already in treatment or those who will be randomized under protocol 
version 6.0 or 7.0 or 8.0) gain weight during the study the drug dose must be kept unchanged.  
If subjects (i.e. those already in treatment or those who will be randomized under protocol 
version 6.0 or 7.0 or 8.0) lose weight during the study, the drug dose should be adjusted 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 58 of 120 
according to Table 2 or Table 3 if the subject is still on treatment at starting dose, or according 
to Table 4 or Table 5 if the subject has already reduced the starting dose. 
All subjects will be asked to have platelets count assessments weekly during the first month of 
treatment and performed every two weeks during the second month of treatment, in order to 
strictly monitor this parameter for safety reasons. 
If the dose is reduced due to platelet count ≤150 x 109/L, and/or white blood cell  <3.0 x 109/L 
and/or hemoglobin <10.0 mg/dL a complete blood count (i.e.CBC) test must be performed 
weekly for 8 consecutive weeks. 
If a dose adjustment and/or modification of schedule of assessments is decided by the 
Investigator or authorized designee, it is advised to discuss this decision with the Medical 
Monitor, however this is not mandatory as the Investigator is the only responsible for the 
medical care of the subject and the Investigator’s decision should not be influenced, deleted 
nor approved by the Medical Monitor. 
8.3 
Study Treatment Assignment 
The Investigator will be responsible for the delivery of study drug to the subject’s parent/legal 
guardian according to the protocol.  Subjects will be administered the study drug on an 
outpatient basis.  All study drug supplies are to be used only for this protocol and for no other 
purpose. 
At Visit 3, subjects fulfilling all inclusion criteria and none of the exclusion criteria will be 
randomised via interactive response technology (IRT). During the randomization procedure, 
the Investigator will be asked to record the type of steroid used by the subject (i.e. Deflazacort 
or other type of steroids) and to record the regimen of intake (i.e. daily regimen or intermittent 
regimen) following the instruction provided in the IRT manual. The IRT will assign the 
subject to one stratum according to the collected information (i.e. Deflazacort Daily regimen, 
Deflazacort Intermittent regimen, Other steroids Daily regimen, Other steroids  Intermittent 
regimen) and them to a treatment arm in a 2:1 ratio to receive givinostat or placebo. 
During the first 3 months, the Investigator will supply the child’s parent/legal guardian with 
the appropriate number of suspension bottles sufficient to cover one month of treatment at 
scheduled visits (i.e., at Visit 3, 7 and 9).  Then, for the remaining part of the study (i.e., at 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 59 of 120 
Visit 10, 11, 12, 13, and 14, the Investigator will supply the child’s parent/legal guardian with 
the appropriate number of suspension bottles sufficient to cover the period between two visits 
(i.e., 3 months of treatment).   
The Investigator is to call using IRT at each dispensing visit in order to obtain the packaging 
number of the study treatment to be dispensed to the subject by the subject’s parent/legal 
guardian.   
Study treatment should be dispensed to each subject’s parent/legal guardian by authorized 
personnel only. 
The Investigator will provide to the subject parent/legal guardian written instruction on the 
dosage and corresponding volume in milliliters of suspension to be taken at each 
administration.  Refer to the relevant Clinical Study Operations Manual (CSOM) for more 
detailed information. 
8.4 
Blinding 
This is a double-blind, placebo controlled study, so subjects receiving givinostat or placebo 
will receive medication indistinguishable in appearance. Personnel involved in the study 
(Investigators, nurses, all other site personnel, clinical research associate (CRA), Medical 
Monitors, Project Managers, and personnel involved in data management) will remain blind at 
all times, unless under exceptional circumstances when knowledge of the study drug is 
essential for treating the subject, such as in case of an AE. If the Investigator or authorized 
designee decides to break the code of a subject, it is suggested that the Monitoring Team 
(Medical Monitor or CRA) would be consulted if possible before breaking the code, however 
this is not mandatory because the decision of the Investigator cannot be influenced, deleted 
nor approved by the Monitoring Team.  
Code breaking can be performed by the Investigator or authorized designee at any time by 
using the proper module of the IRT system. 
If the code is broken, treatment with the study drug must be stopped.  
In any case, after breaking the code, the Investigator must record the date, time, and reason 
for breaking the code in the CRF, and must notify the Monitoring Team as soon as possible. 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 60 of 120 
As platelets count reductions are observed after treatment with givinostat, study site personnel 
who will perform functional tests and MRI/MRS must be different from the personnel who 
will review subjects’ safety results and safety results must not be shared with the personnel 
responsible for the functional tests and MRI/MRS.  
Regarding the PK results, all the personnel involved in the study will remain blind at all times 
and Sponsor may review the PK results only in scrambled format. 
8.5 
Drug Supply 
The investigational site will be supplied initially with a congruous number of suspension 
bottles, in order to have sufficient supply of study drug to treat the children who are enrolled 
in the study. 
8.5.1 Packaging 
The primary packaging will consist of an amber plastic bottle containing the suspension.  
Givinostat/Placebo oral paediatric suspension is supplied in a 150 mL capacity amber PET 
bottle closed by means of a red-white HDPE child-proof screw cap with a LDPE 
shutter/syringe-adapter.  Each bottle contains 140 mL of givinostat 10 mg/mL or placebo.  
The secondary packaging will be a carton box containing one amber bottle and a two syringe 
for oral use as dosing systems for dispensing the suspension. 
8.5.2 Labelling 
The primary and secondary labels will show all the information requested according to the 
Annex 13 of the Good Manufacturing Practice and comply with the legal Investigation use 
requirements of each country.  
Medication labels will be in the local language. 
The labels for European countries will include at least: 
 Name of the medicinal product  
 Pharmaceutical dosage form  
 Route of administration  
 Quantity of dosage units 
 Strength/potency 
 Batch number/Packaging number 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 61 of 120 
 Sponsor’s study code (*) 
 EudraCT number (*) 
 Investigator name (*) 
 Site and subject number (*) 
 Treatment/Randomization number (*) 
 Name, address, and telephone number of the main contact (the sponsor or the 
contract research organization or the investigator)  (*) (**)  
 Period of use (*) 
 Storage conditions (*) 
 Directions for use (*) (**) 
 For clinical trial use only (*) 
 Keep out of reach of children (*)  
Notes:  
(*) According to Annex 13 and EU law in force, when using a centralized electronic 
randomization system, some of the listed information may be omitted from the label.  
(**) According to Annex 13, such information might not need to appear on the label if 
separately provided in a leaflet or card.  
The labels for United State and Canadian sites will include at least: 
 Sponsor’s study code  
 IND number  
 Packaging number  
 Name of the medicinal product  
 Pharmaceutical dosage form  
 Route of administration  
 Quantity of dosage units  
 Strength/potency 
 Batch number  
 Expiry date 
 Administer as per Protocol 
 Caution: Investigational Drug – Limited by Federal (United States) Law to 
Investigational Use  
 Storage conditions  
 Keep out of the reach of children 
 Sponsor. 
8.5.3 Storage 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 62 of 120 
The investigational site will store the study drug under the conditions specified here below, 
ensuring that it is not accessible to unauthorized persons until it is dispensed to the subject’s 
parent/legal guardian. 
Givinostat/Placebo suspension has to be stored in a refrigerated condition at 5°C±3°C.  Once 
the container is firstly opened, the suspension can be administered for a maximum of 30 days. 
8.6 
Treatment Accountability and Compliance 
The study drug packaging will be provided with tear off labels; before treatment dispensation 
the tear-off label should be removed from the subject’s pack by the Investigator and stuck on 
the appropriate drug accountability form. 
At each dispensing visit, the subject’s parent/legal guardian will bring back to the study site 
all bottles previously received (used, partially used and unused) and receive a new supply of 
the study drug.  
Subject compliance will be evaluated through a subject diary indicating how many doses were 
effectively administered by the subject. .  
Compliance will be checked by Italfarmaco S.p.A. or its designee based on the drug 
accountability documented by the site staff and monitored by Italfarmaco S.p.A. or its 
designee.  
The used, partially used, and unused bottles will be collected and sent back to Italfarmaco 
S.p.A. or their designee periodically or at the end of the study.  
Accountability and compliance is detailed in the relevant CSOM. 
8.7 
Prior and Concomitant Illnesses and Medications 
8.7.1 Prior and Concomitant Illnesses 
Investigators should document all prior significant illnesses that the subject has experienced 
within 6 months of screening.  The starting date of corticosteroids use will be also collected. 
Additional illnesses present at the time when informed consent is given and up to the time of 
first dosing (Visit 3) are to be regarded as concomitant illnesses.  

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 63 of 120 
Illnesses first occurring or detected during the study and/or worsening of a concomitant illness 
during the study are to be documented as AEs on the eCRF. 
8.7.2 Prior and Concomitant Medications 
All medications and other treatments taken by the subject during the study, including those 
treatments initiated within 6 months prior to the start of the study, must be recorded on 
the eCRF. 
Subjects should be on systemic corticosteroid therapy for at least 6 months prior to initiation 
of study drug.  That is, there have been no changes in systemic corticosteroid therapy (e.g., 
change in type of drug, dose modification not related to body weight change, schedule 
modification, interruption, discontinuation, or re-initiation) during the previous 6 months. 
As the subjects to be randomised are on stable steroids, the recommended national 
immunisation schedule, including varicella immunity, should be completed (i.e., as 
recommended in the “Diagnosis and Management of Duchenne Muscular Dystrophy” 
guideline4), before the Screening Visit.   
Concomitant treatments are defined as treatments taken after study drug administration.  
Any medication or therapy that is taken by or administered to the subject during the course of 
the study must be recorded in the eCRF.  The entry must include the dose, regimen, route, 
indication, and dates of use. 
After the Screening visit, medication to treat minor treatment-emergent illnesses are generally 
permitted; supportive treatments, such as anti-emetics, anti- diarrhoeals, anti-pyretics, anti-
allergics, analgesics, and antibiotics are allowed. 
Use of Vitamin D, calcium and any other supplements if clinically indicated before 
enrollment and for duration of the study are allowed. 
The following therapies are expressly prohibited throughout the study:  
 Any other investigational drug while on this study,  
 any dystrophin restoration product  
 use of any pharmacologic treatment, other than corticosteroids, that might have an 
effect on muscle strength or function (e.g., growth hormone) 
The following are concomitant therapy requiring caution throughout the study: 

Italfarmaco S.p.A.   
   DSC/14/2357/48 
Givinostat  
               Protocol Version 8.0  
  08 April 2020 
 
Page 64 of 120 
 Drugs known to increase the QT interval (see Appendix 16.1 for a list of such 
compounds).  
 Drugs known to be P-glycoprotein inhibitors (see Appendix 16.3 for a list of such 
compounds). 
 Live or live attenuated vaccines: the subject must be carefully monitored. While the 
decision of the Investigator cannot be influenced, deleted nor approved by the Medical 
Monitor, it is advised but not mandatory that the Investigator discuss the case with the 
Medical Monitor before using these vaccines.  
 Drugs knows to be a substrate of Organic Cation Transporter 2 transporter (see 
Appendix 16.2 for a list of such compounds). 
 Antiplatelets, thrombolytic and anticoaugulants drugs: subject must be carefully 
monitored (i.e. increase the frequency of hematology testing,  evaluate any possible 
sign of bleeding). 
9 
STUDY PROCEDURES 
Table 6 outlines the timing of procedures and assessments to be performed throughout the 
study.  See Section 9.1 for additional details of study procedures. 

Italfarmaco S.p.A.   
DSC/14/2357/48 
Givinostat  
Protocol Version  8.0 
 08 April 2020 
Page 65 of 120 
Table 6:    Schedule of Assessments 
Month 
-1 
0 
1 
2 
3 
6 
9 
12 
15 
18 
19 
Week 
-41 
From 
1 day 
after 
V1 to 
 -2 
0 
1 
2 
3 
4 
6 
8 
12 
24 
36 
48 
60 
72 
76 
Visit window 
± 2 weeks 
+ 3 days 
0 
± 3 
days 
± 3 
days 
± 3 
days 
± 3 
days 
± 3 
days 
± 3 
days 
± 7 
days 
± 7 
days 
± 7 days 
± 7 
days 
± 7 
days 
± 7 days 
± 7 days from 
last dose 
Visit 
V1 
V21 
V3  
V4 
 
 
 
V52 
 
 
 
V62 
 
 
 
V7 
 
 
 
V82 
 
 
 
V9 
 
 
 
V10 
 
 
 
V11 
 
 
 
V12 
 
 
 
V13 
 
 
 
V14 
 
 
 
V15 
V16 
Screening 
Rand 
EOS/Early 
Withdrawal3 
FUV4 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eligibility criteria 
X 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history and 
demographic data 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Prior and concomitant 
medications 
X 
 
X 
X 
 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
Physical examination 
X5 
 
X 
X 
 
 
X 
 
X 
X 
X 
X 
X 
X 
X5 
X 
Vital Signs 
X 
 
X 
X 
 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
Weight 
X 
 
X 
X 
 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
 
Height 
X 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
X 
 
ECG Test6 
X 
 
X 
X 
 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
ECHO 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Pulmonary function tests7 
X7 
 
 
 
 
 
 
 
 
 
 
 
X7 
 
X7 
 
Serology8 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hematology9 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood chemistry10 
X 
 
 
 
 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
Coagulation tests (PT and 
aPTT) 
X 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
Urine analysis11 
X 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
LTBP4 and osteopontin 
genotype 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Exploratory serum 
Biomarkers 
 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
Quality of life test 
(assessed by PODCI) 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
4 -stairs Climb12 
X 
X 
X 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
 
NSAA + 6MWT 
X 
 
X 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
 

Italfarmaco S.p.A.   
DSC/14/2357/48 
Givinostat  
Protocol Version  8.0 
 08 April 2020 
Page 66 of 120 
Month 
-1 
0 
1 
2 
3 
6 
9 
12 
15 
18 
19 
Week 
-41 
From 
1 day 
after 
V1 to 
 -2 
0 
1 
2 
3 
4 
6 
8 
12 
24 
36 
48 
60 
72 
76 
Visit window 
± 2 weeks 
+ 3 days 
0 
± 3 
days 
± 3 
days 
± 3 
days 
± 3 
days 
± 3 
days 
± 3 
days 
± 7 
days 
± 7 
days 
± 7 days 
± 7 
days 
± 7 
days 
± 7 days 
± 7 days from 
last dose 
Visit 
V1 
V21 
V3  
V4 
 
 
 
V52 
 
 
 
V62 
 
 
 
V7 
 
 
 
V82 
 
 
 
V9 
 
 
 
V10 
 
 
 
V11 
 
 
 
V12 
 
 
 
V13 
 
 
 
V14 
 
 
 
V15 
V16 
Screening 
Rand 
EOS/Early 
Withdrawal3 
FUV4 
Muscle strength13 
X 
 
X 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
 
Cognitive function 
evaluation 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
PK blood sample 
collection14 
 
 
 
 
 
 
X 
 
 
X 
X 
 
X 
 
X 
 
Study drug dispensation 
and accountability 
 
 
X 
 
 
 
X 
 
X 
X 
X 
X 
X 
X 
 
 
Subject diary dispensation 
and evaluation of drug 
compliance through diary 
 
 
X 
 
 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
 
Acceptability/ Palatability 
evaluation 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
AE assessment 
X 
 
X 
X 
 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
MRI/MRS15 
 
X 
 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
Genetic Test16 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
6MWT=6-minute walking test; AE=adverse event; NSAA= North Star Ambulatory Assessment;  PODCI= Paediatric Outcomes Data Collection Instrument; 
PFTs= pulmonary function tests; PT=Prothrombin time; aPPT= activated partial thromboplastin time; ECG= electrocardiogram; ECHO= echocardiogram; PK= 
pharmacokinetics;  MRI= magnetic resonance imaging; MRS= magnetic resonance spectroscopy; FEV1= forced expiratory volume at 1 second; FVC=forced 
vital capacity; PEF= peak expiratory flow; RBC-red blood cell; WBC=white blood cell; ALT=alanine aminotransferase; AST=aspartate aminotransferase; LDH= 
lactate dehydrogenase; CRP=C-reactive protein; GGT=gamma-glutamyl transpeptidase; BUN=blood urea nitrogen; fT3= free T3 (the active part of 
triiodothyronine); fT4=Free T4 (the active part of thyroxine); TSH=thyroid-stimulating hormone; eGFR=estimate Glomerular Filtration Rate; HHM=hand-held 
myometry; MMT=manual muscle testing 
1. 
During screening visit V2, the second Time to 4-stair climb test (4SC) will be performed. The second 4SC can be performed one day after V1 up to a 
maximum of 2 weeks (+3 days). 
The cognitive function evaluation by Raven coloured progressive matrices could be performed during this visit if not done during the previous one (i.e. 
V1). Test should be performed at the same time at the beginning and at the end of the study 
MRI/MRS could be performed in a different day (i.e. not necessarily during the same day of Time to 4-stair climb test, due to the fact that the MRI site 
can be performed in a different site).  

Italfarmaco S.p.A.   
DSC/14/2357/48 
Givinostat  
Protocol Version  8.0 
 08 April 2020 
Page 67 of 120 
2. 
These visits may be performed by Investigator’s authorized personnel outside the site location (e.g., at the subject’s home or at the subject’s General 
Practitioner’s practice.  See conditions in Section 9.1.4) 
3. 
If the subject is discontinued from the study treatment, the subject will be asked to return for the early withdrawal visit to be performed within 2 weeks 
of the last dose of study drug.  In this case, the cognitive function evaluation and MRI/MRS may not be performed. 
4. 
The subjects who complete the study (i.e. 18 months of treatment) will be asked to return to the centre for the Follow up visit to be performed after 4 
weeks from the last dose of study drug (i.e. 4 weeks ± 7 days). 
5. 
During the screening visit V1 and at the end of study (i.e. V15) assessment for ankle range of motion (ROM) should be performed.  
6. 
12-lead ECG has to be done in triplicate at the screening visit and during the other visits if an ECG demonstrates a prolonged QTcF interval ˃ 450 msec, 
obtain 2 more ECGs over a brief period, and then use the averaged QTcF values of the 3 ECGs to determine whether the subjects should be discontinued 
from the study (see Section 7.3.1). 12-lead ECG should be performed  at 2,5 hours (i.e 150 minutes) ±30 minutes after drug intake.  
7. 
Pulmonary function tests FEV1, FVC, FEV1/FVC and PEF. In case the test does not achieve ATS criteria and the evaluator does not feel a valid attempt 
has been made, the subject should repeat the test at randomization if the test is failed at screening visit. If the test is failed at 12 months and/or  at 18 
months the subject has to be asked to come back to perform the test. 
8. 
Serology: immunoassay methodology for CMV IgM; in-house methodology of chemiluminescence for HBsAg/HCV/HIV; and ECLIA for EBV IgG. 
9. 
Hematology test: CBC:RBC, WBC (including differential count), hemoglobin, MCH, MCHC, MCV, hematocrit, and platelets.  Test will be done 
according to the schedule (i.e., weekly for the first month of treatment, every 2 weeks for the second month of treatment) and are to be performed more 
frequently if clinically indicated.  Note: Repeat visits for the platelets count will be assumed at the request of the Investigator. If the dose is reduced due 
to platelet count ≤150 x 109/L, and/or white blood cell  <3.0 x 109/L and/or hemoglobin <10.0 mg/dL, a complete blood count (i.e.CBC) test must be 
performed weekly for 8 consecutive weeks. 
10. 
The following blood tests will be assessed: total bilirubin, direct bilirubin, alkaline phosphatase, amylase, ALT, AST, LDH, cystatin C, CRP, GGT, 
creatine kinase, total protein, albumin, uric acid, triglycerides, phosphorus, total cholesterol, LDL, HDL, sodium, potassium, chloride, calcium, glucose, 
creatinine, BUN, TSH, fT3, fT4, bicarbonate). Note that TSH, fT3, and fT4 will be taken  at Visits 7, 9, 10, 11, 12, 13, 14, 15 and 16. 
11. 
Urinalysis: appearance, pH, specific gravity, protein, glucose, ketone bodies, blood and WBCs, and urobilinogen. 
12. 
During the screening period (i.e., 4 weeks ±2), time to 4-stair climb test (4SC) should be  performed at V1 and V2. The 4SC at V2 can be performed one 
day after V1 up to a maximum of 2 weeks (+3 days). For this reason the subjects should go to the centre 2 times (i.e., Visit 1 and Visit 2).  The test 
should be video recorded during Visit 1, Visit 3, Visit 13 and Visit 15. 
13. 
Muscle strength tests: at screening: knee extension, elbow flexion by HHM and knee extension by MMT. During the study and at the end:  knee 
extension, elbow flexion by HHM. 
14. 
Pharmacokinetic sample collection: sampling (2 pre-dose during the treatment and 4 post-dose) will be collected as described in the protocol during the 
following visits: 7 (4 weeks), 10 (12 weeks), 11 (24 weeks), 13 (Week 48) and 15 (Week 72).  At these visits, the subject will be asked to take the 
morning dose at site. 
15. 
The baseline MRI/MRS test has to be performed when all inclusion/exclusion criteria have been already evaluated and the subject is eligible.  At 
screening all subjects will perform the MRI of thigh and MRS of vastus lateralis; then the MRI of thigh and MRS of vastus lateralis will be performed 
also at 12 and 18 months in a subgroup of subjects: the first 99 - 150 randomised subjects in the target population (i.e. with MRS VL MFF between> 5% 
and ≤30%).  The MRI evaluation using Dixon technique and the MRS will be performed at specialized sites.   
16. 
Genetic test should be performed only in case it is not already available. 
 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 68 of 120 
9.1 
Procedures by Study Visit 
There will be at least 15 study visits, including the Screening and Randomisation Visits. 
Assessments will be performed as outlined in the following by-visit subsections.  As platelets 
count reductions are observed after treatment with givinostat, study site personnel who will 
perform functional tests and MRI/MRS must be different from the personnel who will review 
subjects’ safety results and safety results must not be shared with the personnel responsible 
for the functional tests and MRI/MRS. 
At the discretion of the Investigator, subjects not meeting inclusion/exclusion criteria may be 
re-screened twice with an interval of at least 3 months between assessments. 
If needed, safety assessments (e.g. blood test, unscheduled visits) may be performed at the 
subject’s home by a local qualified nurse trained in the study protocol. 
9.1.1 Visit 1 and Visit 2 - Screening (Week -4 ± 2 weeks) 
The Screening visits (Visit 1 and Visit 2) will occur within 4 weeks (± 2 weeks) prior to the 
Randomisation Visit.  The following assessments will be performed at Visit 1 unless noted 
otherwise:  
 Obtain written Informed Consent from the subject’s parent/legal guardian and assent 
or consent from the subject, if applicable; 
 Eligibility criteria: review inclusion and exclusion criteria; 
 Genetic test (only if it is not already available); 
 Collect medical history and demographic data; 
 Collect and record prior medications (taken in the past 6 months); 
 Perform a physical examination (at Visit 1 assessment for ankle ROM should be 
done); 
 Measure vital signs (blood pressure, pulse rate, and body temperature); 
 Measure weight; 
 Measure height; 
 Perform a 12-lead ECG (in triplicate);  
 Perform an ECHO; 
 Perform pulmonary function tests: FEV1, FVC, FEV1/FVC, and PEF; 
 Collect blood samples for:  
o serology tests; 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 69 of 120 
o hematology; 
o blood chemistry; 
o coagulation tests (prothrombin time [PT] and activated partial thromboplastin 
time [aPTT]);  
 Obtain a urine sample for urine analysis; 
 Perform Quality of Life tests (using Paediatric Outcomes Data Collection Instrument 
[PODCI] scores); 
 Perform time to 4SC (the test should be performed at Visit 1 and at Visit 2; the 4SC at 
Visit 2 can be performed one day after V1 up to a maximum of 2 weeks +3 days);  
 Perform NSAA and 6MWT; 
 Perform muscle strength test (both by HHM and MMT); 
 Perform cognitive function evaluation: Raven coloured progressive matrices (at Visit 
1 or at Visit 2. Test should be performed at the beginning and at the end of the study 
at the same time of the day); 
 Assess AEs; 
 If all inclusion and exclusion criteria have been met and the subject is eligible, the 
following assessments must be performed at Visit 2 to conclude the screening period 
before the randomisation: 
o MRI/MRS 
At Visit 1, functional tests will be video recorded. 
Subjects will be instructed to avoid physical activity that would exceed their normal activity 
for 3 days before each visit. 
NB:  As the subjects to be randomised are on stable steroids, the recommended national 
immunisation schedule, including varicella immunity, should be completed (i.e., as 
recommended in the “Diagnosis and Management of Duchenne Muscular Dystrophy” 
guideline4), before the Screening Visit.  However, in the case of live or live attenuated 
vaccines to be administered during the study, the Investigator must carefully monitor the 
subject, and while the decision of the Investigator cannot be influenced, deleted nor approved 
by the Medical Monitor, it is advised but not mandatory that the Investigator discuss the case 
with the Medical Monitor before using these vaccines. 
9.1.2 Visit 3 - Randomisation (Week 0) 
At Visit 3, the following assessments will be performed: 
 Review eligibility criteria; 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 70 of 120 
 Record prior medications; 
 Perform a physical examination; 
 Measure vital signs (blood pressure, pulse rate, and body temperature); 
 Measure weight; 
 Perform a 12-lead ECG;  
 Collect blood samples for hematology;  
 Perform LTBP4 and Osteopontin genotype tests and collect DMD serum biomarkers; 
 Perform time to 4SC; 
 Perform NSAA and 6MWT;  
 Perform muscle strength test; 
 Randomise the child and dispense and account for study drug; 
 Subject diary dispensation 
 Assess AEs. 
Functional tests will be video recorded. 
Pulmonary function as assessed by spirometry at screening should be repeated if the test does 
not meet ATS/ERS criteria and/or the evaluator deems that a valid attempt to perform a 
correct maneuver has not been made by the subject. 
9.1.3 Visits 4 (Week 1, ±3 days) 
At Visit 4, after 1 week (± 3 days) of treatment, the following assessments will be performed: 
 Record concomitant medications; 
 Perform a physical examination; 
 Measure vital signs (blood pressure, pulse rate, and body temperature); 
 Measure weight; 
 Perform a 12-lead ECG (at 2,5 hour ±30 minutes  after drug intake);  
 Collect blood samples for hematology;  
 Assess AEs. 
9.1.4 Visits 5, 6 and 8 (Weeks 2, 3 and 6, ±3 days) 
Note: Visits 5, 6, and 8 may be performed by Investigator’s authorized personnel outside the 
site location (e.g., at the subject’s home by a local qualified nurse trained in the study 
protocol or at the subject’s General Practitioner’s practice) if the following conditions are 
met: 
 the Investigator is confident that there is no medical concern to do so; 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 71 of 120 
 all study procedures will be followed as per protocol and as per Good Clinical 
Practices (GCP), and with the same quality standard as if being at the site; 
 all required local regulation, insurance and contracting obligation are respected. 
The Visits 5, 6, and 8 will performed respectively 2, 3 and 6 weeks after the Randomization 
Visit (± 3 days), and the following assessment will be performed: 
 Collect blood samples for hematology (the sample will be shipped to the central 
laboratory); 
 Assess AEs; in case of the visit will be performed by the subject’s General 
Practitioner’s, the Investigator will call the subject’s parent/legal guardian to inquire 
if any AE is occurred. 
9.1.5 Visit 7 (Week 4, ±3 days) 
At Visit 7, after 1 month of treatment (± 3 days), the following assessments will be 
performed unless otherwise noted: 
 Record concomitant medications; 
 Perform a physical examination; 
 Measure vital signs (blood pressure, pulse rate, and body temperature); 
 Measure weight; 
 Perform a 12-lead ECG (at 2,5 hours ±30 minutes after drug intake);  
 Collect blood samples for hematology and biochemistry (only TSH, fT3, fT4);  
 Obtain PK blood sample;   
 Dispense and account for study drug ; 
 Subject diary dispensation and evaluation of drug compliance through diary; 
 Perform acceptability/palatability evaluation; 
 Assess AEs. 
9.1.6 Visits 9 (Week 8, ± 3 days)  
At Visit 9, after 2 months of treatment (± 3 days), the following assessments will be 
performed: 
 Record concomitant medications; 
 Perform a physical examination; 
 Measure vital signs (blood pressure, pulse rate, and body temperature); 
 Measure weight; 
 Perform a 12-lead ECG ( at 2,5 hours ± 30 minutes after drug intake);  
 Collect blood samples for:  

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 72 of 120 
o hematology; 
o blood chemistry; 
o coagulation tests (PT and aPTT); 
 Obtain a urine sample for urine analysis; 
 Dispense and account for study drug;  
 Subject diary dispensation and evaluation of drug compliance through diary;  
 Assess AEs. 
9.1.7 Visits 10 – 14 (Weeks 12-60, ± 7 days)  
The Visits 10, 11, 12, 13 and 14 will respectively happen after 12, 24, 36, 48 and 60 weeks 
after the Randomization Visit, with a visit window of ± 7 days. 
At Visit 10 – 14  (i.e., every 3 months), the following assessments will be performed unless 
otherwise noted: 
 Collect and record concomitant medications; 
 Perform a physical examination; 
 Measure vital signs (blood pressure, pulse rate, and body temperature); 
 Measure weight; 
 Measure height (only at Visits 11 and 13; i.e., after 6 and 12 months of treatment) ; 
 Perform a 12-lead ECG (at 2,5 hours ±30 minutes after drug intake); 
 Perform pulmonary function tests: FEV1, FVC, FEV1/FVC, and PEF (only at 
Visit 13);  
Pulmonary function as assessed by spirometry at visit 13 should be repeated if the test 
does not meet ATS/ERS criteria and/or the evaluator deems that a valid attempt to 
perform a correct maneuver has not been made by the subject. 
 Collect blood samples for:  
o hematology; 
o blood chemistry; 
o coagulation tests (PT and aPTT);  
 Collect DMD serum biomarkers (only at Visit 13); 
 Obtain a urine sample for urine analysis; 
 Perform Quality of Life tests (assessed by PODCI) (only at Visit 13; i.e., after 
12 months of treatment); 
 Perform time to 4SC 
 Perform NSAA and 6MWT; 
 Perform muscle strength tests;  
 Obtain PK blood sample (only at Visits 10, 11, and 13; i.e., after 3, 6, and 12 months 
of treatment, respectively); 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 73 of 120 
 Dispense and account for study drug;  
 Subject diary dispensation and evaluation of drug compliance through diary;  
 Assess AEs; 
 Perform MRI/MRS evaluation  (MR cohort only) (only at Visit 13; i.e., after 12 
months of treatment). 
 
At Visit 13, functional tests will be video recorded. 
9.1.8 Visit 15: End of Study Visit (also named “EOS Visit”, Week 72 ± 7 days), and early 
withdrawal visit  
At the end of the treatment (i.e.,  72 weeks after the Randomization Visit, ± 7 days) the EOS 
Visit (Visit 15) will be scheduled.  At EOS Visit the subject should take the morning dose at 
the site. 
Subjects who prematurely withdraw from the study for any reason will perform an Early 
Withdrawal Visit within two weeks after the last study drug dose intake. The Early 
Withdrawal Visit requirements are the same as the EOS Visit (Visit 15) described in this 
section. 
If the Early Withdrawal Visit or the EOS Visit is not done, the reason will be recorded in the 
CRF.  
At this Visit 15, the following assessments will be performed unless otherwise noted: 
 Collect and record concomitant medications; 
 Perform a physical examination (at V15 assessment for ankle ROM should be done) 
 Measure vital signs (blood pressure, pulse rate, and body temperature); 
 Measure weight; 
 Measure height; 
 Perform a 12-lead ECG (at 2,5 hours  ±30 minutes after drug intake);  
 Perform an ECHO; 
 Perform pulmonary function tests: FEV1, FVC, FEV1/FVC, and PEF; 
 Collect blood samples for:  
o hematology; 
o blood chemistry: 
o coagulation tests (PT and aPTT);  
 
Collect DMD serum biomarkers; 
 Obtain a urine sample for urine analysis; 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 74 of 120 
 Obtain PK blood sample. The remaining PK samples may be drawn during this visit 
in order to obtain all required PK samples; 
 Perform Quality of Life test (assessed by PODCI); 
 Perform time to 4SC 
 Perform NSAA and 6MWT; 
 Perform muscle strength tests  
 Perform cognitive function evaluation (test should be performed at the beginning and 
at the end of the study, at the same time of the day); 
 Perform acceptability/palatability evaluation; 
 Evaluation of drug compliance through diary;  
 Assess AEs; 
 Perform MRI/MRS evaluation (MR cohort only). (If the subject is discontinued from 
the study treatment, the subject will be asked to return for the early withdrawal visit 
to be performed within 2 weeks of the last dose of study drug.  In this case, the 
cognitive function evaluation and MRI/MRS may not be performed). 
 
Functional tests will be video recorded. 
The subject has to be asked to attend an unscheduled visit to repeat measurement of 
pulmonary function as assessed by spirometry if the test performed at visit 15 has not met 
ATS/ERS criteria and/or the evaluator has deemed that a valid attempt to perform a correct 
maneuver was not made by the  subject. 
At visit 15, the subject’s parent/legal guardian will be asked to consent in writing and subject 
to assent and/or consent in writing for his participation in the long-term  study. In case the 
subject or parent/legal guardian do not provide assent/consent, a final Follow-up visit will be 
performed.   
9.1.9 Follow up Visit (Week 76)( ± 7 days) 
The follow up visit will be performed 4 weeks after the last dose is administered (± 7 days) 
and only in case the subject or parent/legal guardian do not provide assent/consent to 
participate in long-term study.  
The following assessments will be performed:  
 Collect and record concomitant medications; 
 Perform a physical examination; 
 Measure vital signs (blood pressure, pulse rate, and body temperature); 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 75 of 120 
 Perform a 12-lead ECG;  
 Collect blood samples for:  
o hematology;  
o blood chemistry;  
o coagulation tests (PT and aPTT); 
 Obtain a urine sample for urine analysis; 
 Assess AEs. 
9.1.10 Unscheduled Visits 
The Investigator may, at his/her discretion, arrange for a subject to have an unscheduled 
assessment, especially in the case of AEs that require follow-up or an AE considered by the 
Investigator to be possibly related to the use of study drug.  The unscheduled visit page in the 
eCRF must be completed. If needed, these assessments may be performed at the subject’s 
home by a local qualified personell trained in the study protocol.  
9.2 
Study Conclusion  
The end of the trial is defined as the date of the last visit of the last subject undergoing the 
trial. 
10 EFFICACY ASSESSMENTS 
10.1 Primary Efficacy Assessment 
The primary efficacy assessment for this study is the time to climb 4 standard stairs (at 
18 months). 
The time to climb 4 standard-sized stairs is a TFT that represents stair climbing ability.  The 
test will be evaluated by qualified functional evaluators (i.e., physiotherapists) who will be 
different from the site personnel who will review subjects’ safety results; safety results must 
not be shared with site personnel.  The test will be performed in a standardized manner 
described in a specific site manual. 
In addition to the time to climb 4 standard-sized stairs recorded in seconds, functional 
adaptation employed by the subject during the test will be evaluated and graded by functional 
evaluators according to standardized scales as follows: 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 76 of 120 
1. Unable to climb up 4 standard stairs; 
2. Climbs 4 standard stairs “marking time” (climbs one foot at a time, with both feet on a 
step before moving to next step), using both arms on one or both handrails; 
3. Climbs 4 standard stairs “marking time” (climbs one foot at a time, with both feet on a 
step before moving to next step), using one arm on one handrail; 
4. Climbs 4 standard stairs “marking time” (climbs one foot at a time, with both feet on a 
step before moving to next step), not needing handrail; 
5. Climbs 4 standard stairs alternating feet, needs handrail for support; 
6. Climbs 4 standard stairs alternating feet, not needing handrail support. 
10.2 Secondary Efficacy Assessments (All Subjects) 
The secondary key efficacy assessments (all subjects) in the target population are: 
 Time to rise from floor; 
 Distance done in 6 walking minutes by 6MWT; 
 Physical function assessed by NSAA; 
 Muscle strength evaluated by knee extension, elbow flexion as measured by HHM. 
 Fat fraction of vastus lateralis muscles evaluated by MRS technique (MR cohort) 
The exploratory efficacy assessments are: 
 Time to walk/run 10 meters; 
 Quality of life (assessed by PODCI);  
 %-predicted  6MWT; 
 MRI parameters (e.g., fat fraction of thigh muscles, CSA of vastus lateralis and other 
thigh muscles, etc) only in the MR cohort; 
 Time to 10% persistent worsening in 6MWT (Baseline through end of study); 
 Proportion of subjects with ≥10% worsening in 6MWT at end of study; 
 Time to loss of standing (Baseline through end of study); 
 Proportion of subjects who loose ambulation during the study; 
 Evaluation of any correlation between the effect of Givinostat on disease progression and 
the type of DMD mutation, LTBP4 and Osteopontin genotype; 
 Evaluation of any possible DMD serum biomarker.  
As for the primary efficacy assessment, all the functional and strength assessments will be 
evaluated by qualified functional evaluators (i.e., physiotherapists) who will be different 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 77 of 120 
from the site personnel who will review subjects’ safety results. The safety results must not 
be shared with physiotherapists.  
To limit variability associated with functional evaluators ‘drift’ in performing trial 
assessment across the course of the study, to ensure compliance with functional evaluator 
manual procedures, and valid conduct of assessments, some screening, baseline, 12 month 
and final study visits will be videoed and reviewed for quality assurance across all subjects. 
The videos: will be uploaded to a central secure repository and reviewed only by an expert 
and independent team engaged to train and qualify the site functional evaluators. 
Time taken to stand from a supine position and time to walk/run 10 meters are TFTs.  Timed 
function tests provide a measure of functional capability in ambulatory subjects, which is 
complementary to the 6MWT. The TFTs will be performed in a standardized manner 
described in a specific site manual. 
Six-minute walking test: a modified version of the 6MWT recommended by American 
Thoracic Society (2002) for use in adults will be performed.  
North Star Ambulatory Assessment:  the 17 items of the NSAA, ranging from standing to 
running 10 meters, will be graded using the standard score card with each assessment rated as 
0 – unable to achieve independently, 1 – modified method but achieves goal independent of 
physical assistance from another, or 2 – normal with no obvious modification of activity. 
Muscle strength: using HHM, the muscle strength of knee extensor and elbow flexor will be 
measured following standardized procedures; bilateral assessments will be done, and 
3 measurements will be recorded from each muscle group on each side.   
Quality of Life (QoL): the QoL will be measured via the American Academy of Orthopaedic 
Surgeons Pediatric Musculoskeletal Function Instrument, also referred to as PODCI.  The 
PODCI will be administered to the parent/legal guardian of subjects.  The PODCI is 
comprised of several dimensions that assess upper extremity function, transfers and mobility, 
physical function and sports, comfort/pain (pain-free), and happiness.  There is also a scale 
for global functioning, which is a combination of the 3 function subscales and comfort.  

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 78 of 120 
MR Cohort 
The MRI and MRS will be centralized in a referred qualified site.  Therefore, some subjects 
will be asked to perform the examination at a site that is different from the study site. 
The MRI/MRS personnel involved will be different from the site personnel.  They will not 
review subjects’ safety results; safety results must not be shared with them.  Moreover, the 
MRI/MRS images will be centrally read by an Independent Central Review team.  A 
qualification process will be implemented in order to improve data quality and decrease 
inter-site variability and the test will be performed in a standardized manner described in a 
specific site manual. 
All subjects will perform the baseline MRI/MRS tests. –All 110 randomised subjects in the 
target population (i.e. Group A: subjects with a baseline vastus lateralis muscle fat fraction 
assessed by MRS  in the range >5 and ≤30%),  will be included in the MR cohort. 
The subjects will perform the Dixon MRI and MRS on the thigh muscles without receiving 
general anesthesia.  The MRI/MRS images will be read to evaluate the fat fraction of each 
muscle.  A cross sectional area of muscles will be evaluated as well. 
11 PHARMACOKINETICS  
11.1 Pharmacokinetic Sampling 
11.1.1 Blood Samples 
Blood samples for PK analysis of givinostat and its metabolites will be collected.    All of the 
PK sampling visits are  indicated in the Schedule of Assessments (Table 4).  There are 5 
visits where the PK samples can be taken: Visits 7 (Week 4), 10 (Week 12), 11 (Week 24), 
13 (Week 48), and 15 (Week 72).  
All subjects will have a total of 6 PK blood specimens drawn during the study: 
 Two samples drawn pre-dose, these 2 specimens must be drawn at 2 different visits; 
 One sample drawn between 0 and 2 hours post-dose; 
 One sample drawn between 2 and 4 hours post-dose; 
 One sample drawn between 4 and 6 hours post-dose; 
 One sample drawn between 6 and 10 hours post-dose. 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 79 of 120 
During Visits 7 (week 4), 10 (week 12), 11 (week 24), 13 (week 48) and 15 (week 72) at 
least one PK sample is collected for each subject. After the randomization, the site personnel 
will be informed at which time the PK samples will be drawn during these visits.  
On the day when the pre-dose PK blood is drawn, subjects should be instructed to take the 
morning dose at the site. 
For the PK draws, the parent/legal guardian must be reminded to provide the date and time of 
the last evening dose from the day before the visit, which will be recorded in the source 
documents and eCRF together with the date and time of the blood draws prior to the morning 
intake of the compound.  
For the post-dose blood draws, the date and time of the dose prior to the blood draws and the 
date and time of blood draws will be recorded in the source documents and eCRF.  
The date and time of the first dose will be recorded in the source documents and eCRF for 
each subject. 
In case the subject is withdrawn from the study prematurely, if not all PK samples were 
obtained prior to early withdrawal, the remaining PK samples may be drawn during the Early 
Withdrawal Visit  in order to obtain all required PK samples. 
Specific details regarding collection, handling, processing, storage, and shipment of PK 
samples can be found in a separate laboratory manual (found in the relevant section of the 
Investigator File). 
11.2 Pharmacokinetic Analytical Methodology 
The concentration of givinostat and its main metabolites will be determined from the plasma 
samples using a validated analytical method.  Details of the method validation and sample 
analysis will be included with the final Clinical Study Report (CSR).  
12 SAFETY ASSESSMENTS 
Safety and tolerability will be evaluated by monitoring hematology and blood chemistry, 
coagulation, urinalysis; by measurement of vital signs, physical examinations, weight, height, 
ECHO and ECG recording; and by respiratory function evaluation, cognitive function and 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 80 of 120 
acceptability/palatability evaluation and by AEs recording to be performed at protocol-
specified visits, as specified in the Schedule of Assessments, Table 6. 
12.1 Vital Signs 
Vital signs (body temperature, heart rate, systolic and diastolic blood pressure measurements) 
will be evaluated at the visits indicated in the Schedule of Assessments, Table 6.  All vital 
signs will be measured after the subject has been resting in a sitting position for at least 
5 minutes.  Blood pressure measurements are to be taken in the same arm for the duration of 
the study.  Body weight (without shoes) and height (without shoes) will be recorded at the 
visits indicated in the Schedule of Assessments, Table 6. 
Vital sign measurements will be repeated if clinically significant or machine/equipment 
errors occur.  Out-of-range blood pressure or heart rate measurements will be repeated at the 
Investigator’s discretion.  Any confirmed, clinically significant vital sign measurements must 
be recorded as an AE. 
12.2 Physical Examination 
A complete physical examination (head, eyes, ears, nose, and throat (HEENT), heart, lungs, 
abdomen, skin, lymph nodes, extremities and nervous system) will be performed at 
Screening (Visit 1).  Physical examinations will be performed by a physician.  In addition, 
medical history will be recorded at screening. 
A limited physical examination to verify continued subject eligibility and to follow up on any 
change in medical history will be performed at the visits indicated in the Schedule of 
Assessments, Table 6.  All changes not present at baseline or described in the past medical 
history and identified as clinically noteworthy must be recorded as AEs. 
12.3 Electrocardiogram 
A 12-lead resting ECG will be obtained at the visits indicated in the Schedule of 
Assessments, Table 6. 
At the Screening Visit, the Investigator will examine the 3 ECG traces for signs of cardiac 
disease that could exclude the subject from the study.  An assessment of normal or abnormal 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 81 of 120 
will be recorded.  If the ECG is considered abnormal, the abnormality will be documented on 
the CRF.  If an ECG demonstrates a prolonged QTcF interval (i.e.>450 msec) at the defined 
timepoints (see Schedule of Assessments, Table 6), the Investigator will obtain 2 more ECGs 
over a brief period (5 minutes between recordings), and then use the averaged QTcF value of 
the 3 ECGs.  If the averaged QTcF value meets the stopping criteria, the subject has to 
interrupt the study drug, the Medical Monitor  must be informed and the mean QTcF value 
must be confirmed by central reading.   
During the study, ECG should be performed at 2,5 hours ± 30 minutes after drug intake. 
The QTc has to be calculated with the Fridericia formula QTc = QT/RR1/3. 
Electrocardiograms will be repeated if clinically significant abnormalities are observed or 
artifacts are present. 
12.4 Echocardiogram 
Standard ECHOs will be conducted at the visits indicated in the Schedule of Assessments,  
Table 6, and more often if clinically indicated. 
12.5 Respiratory Function Test 
Forced expiratory volume at 1 second (FEV1), FVC, FEV1/FVC, and PEF, will be collected 
as per the site’s standard process at the visits indicated in the Schedule of Assessments, Table 
6 and more often if clinically indicated.  
At each assessment, three studies with maximal effort will be attempted by each subject, and 
the experienced technician performing the testing will make the determination if the effort 
will be acceptable.  All the study results will be recorded in the eCRF. 
12.6 Cognitive Function Test 
 
A general cognitive function test will be performed at the visits indicated in the Schedule of 
Assessments, Table 6 using the Raven coloured progressive matrices test. 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 82 of 120 
12.7 Acceptability/Palatability Evaluation 
At Visit 7 (i.e. at the end of the first month of treatment) and 15 (i.e. at the end of the study), 
the palatability of the oral suspension will be evaluated using the Five-Point Hedonic Scale 
palatability. 
The investigator will explain to the child that he would be asked "how much did you like the 
taste of this medicine?" and encourage to indicate his preference by pointing to the 
appropriate face that depicts five degrees of pleasure: 
5= like very much 
4= like a little 
3= not sure 
2= dislike a little 
1= dislike very much. 
The explanation will be repeated if the child did not understand. 
 
Figure 12-2:  Five Point Hedonic Scale - Face Descriptions 
 
In addition, the acceptability/ palatability will be also indirectly assessed in parents with two 
questions: 
1. "On the basis of reaction / facial expression of your child, do you think that the medication 
is: pleasant= 3; not sure= 2; or unpleasant= 1?" 
2. "Do you sometimes have problems in giving the medication to your child because he 
refuses to take it or throws it up? (Yes / No)" 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 83 of 120 
12.8 Laboratory Assessments 
Laboratory assessment samples, Table 7, will be obtained at designated visits as detailed in 
the Schedule of Assessments, Table 6. 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 84 of 120 
Table 7: 
Laboratory Assessment Samples 
Hematology 
Serum chemistry 
Urine analysis 
(dipstick) 
Coagulation 
 Hematocrit (Hct) 
 Hemoglobin (Hb) 
 Mean corpuscular 
hemoglobin (MCH) 
 Mean corpuscular 
hemoglobin 
concentration (MCHC) 
 Mean corpuscular 
volume (MCV) 
 Platelets count 
 Red blood cell (RBC) 
count  
 White blood cell (WBC) 
count  
 with differential  
 
 Albumin 
 Alanine aminotransferase 
(ALT) 
 Alkaline phosphatase (ALP) 
 Amylase 
 Aspartate aminotransferase 
(AST) 
 Bicarbonate 
 Blood Urea Nitrogen (BUN)  
 Calcium 
 Chloride 
 Cystatin C 
 Creatinine 
 Creatine kinase  
 C-reactive protein (CRP) 
 Gamma-glutamyl 
transpeptidase (GGT) 
 Glucose  
 Lactate dehydrogenase 
(LDH) 
 Potassium 
 Phosphorus 
 Sodium 
 Total bilirubin 
 Direct bilirubin 
 Total protein 
 Thyroid-stimulating 
hormone (TSH) 
 Tryglicerides 
 Total cholesterol 
 Low-Density Lipoprotein 
(LDL) 
 High-Density Lipoprotein 
(HDL) 
 fT3 (free T3 – the active part 
of triiodothyronine) 
 fT4 (free T4 – the active part 
of thyroxine) 
 Uric acid 
 Appearance 
 pH 
 Protein 
 Glucose 
 Ketone bodies 
 Indicators of 
blood and WBCs 
 Specific gravity 
 Urobilinogen 
 
 Prothrombin 
time (PT) 
 Activated partial 
thromboplastin 
time (PTT) 
Blood and urine samples will be analysed at a central laboratory facility.  Urine samples will 
be analyzed by dipstick, and a microscopic analysis will be performed if the results of 
dipstick indicate abnormalities to be further investigated.  All laboratory reports must be 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 85 of 120 
reviewed, signed, and dated by the Investigator.  A legible copy of all reports must be filed 
with the medical record (source document) for that visit.  Any laboratory test result 
considered by the Investigator to be clinically significant should be considered an AE.  
Clinically significant abnormal values occurring during the study will be followed until 
repeat test results return to normal, stabilize, or are no longer clinically significant.  
12.9 Adverse Events 
12.9.1 Definitions 
Adverse Events:  
An AE is “any untoward medical occurrence in a subject or clinical investigation subject 
administered a pharmaceutical product and which does not necessarily have a causal 
relationship with this treatment (International Conference on Harmonisation [ICH] E2A).”  
Study drug includes both the investigational drug under evaluation and the comparator drug 
or placebo.  Medical conditions that were present before starting study drug are only 
considered AEs if they worsen after the subject has started the study drug.  Abnormal 
laboratory values or test results constitute AEs only if they induce clinical signs or 
symptoms, are considered clinically significant, or require treatment.  All medical and 
psychiatric conditions (except those related to the indication under study) present at 
screening will be documented in the medical history CRF.  Changes in these conditions and 
new symptoms, physical signs, syndromes, or diseases should be noted on the AE CRF page 
during the rest of the study.  Clinically significant laboratory abnormalities should also be 
recorded as AEs.  Surgical procedures that were planned before the subject enrolled in the 
study are not considered AEs if the conditions were known before study inclusion; the 
medical condition should be reported in the subject’s medical history. 
Adverse Drug Reaction: 
In the pre-approval clinical experience with a new medicinal product: “all noxious and 
unintended responses to a medicinal product related to any dose should be considered an 
Adverse Drug Reaction (ADR).”  The phrase “responses to a medical product” means that a 
causal relationship between a medical product and an AE is at least a reasonable possibility, 
i.e., the relations cannot be ruled out. 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 86 of 120 
Regarding marketed medicinal products, a well-accepted definition of an adverse drug 
reaction in the post-marketing setting is found in WHO Technical Report 498 [1972] and 
reads as follows:  “A response to a drug which is noxious and unintended and which occurs 
at doses normally used in man for prophylaxis, diagnosis, or therapy of disease or for 
modification of physiological function.”  
Unexpected Adverse Drug Reaction - An unexpected ADR is an ADR, the nature or severity 
of which is not consistent with the applicable product information (i.e., Sections 7 and 8 of 
the current IB for ITF2357 Givinostat Hydrochloride Monohydrate). 
Serious Adverse Event: 
An SAE (experience) or reaction is any untoward medical occurrence that at any dose: 
 is fatal (results in the outcome death) 
 is life-threatening* 
 requires in-patient hospitalisation or prolongation of existing hospitalisation 
 results in persistent or significant disability/incapacity 
 is a congenital anomaly/birth defect 
 is medically significant or requires intervention to prevent one or other of the outcomes 
listed above 
*The term “life-threatening” refers to an event in which the subject is at risk of death at the time of the event; it 
does not refer to an event that hypothetically may cause death if it is more severe. 
In addition, any suspect of transmission of infective agents through study drug must be 
reported to the Sponsor as a SAE as medically significant event. 
Other important medical events that may not be immediately life-threatening or result in 
death or hospitalisation, based upon appropriate medical judgment, are considered SAEs if 
they are thought to jeopardize the subject and/or require medical or surgical intervention to 
prevent one of the outcomes defining a SAE.   
A pre-planned hospitalisation should not be considered an SAE. 
A Suspected Unexpected Serious Adverse Reaction (SUSAR) is referred to an ADR that 
complies with both the definitions of “serious” and “unexpected.” 
12.9.2 Adverse Event Reporting 
The Investigators or their designees are requested to collect and assess any spontaneous AE 
reported by the subject or their parent/legal guardian and to question the subject or their 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 87 of 120 
parent/legal guardian about AEs and under current illnesses at each visit during the treatment 
period and any follow-up visit performed to monitor any drug-related AE that is still ongoing 
beyond the last scheduled visit until recovery. The questioning of subject or their parent/legal 
guardian regarding AEs is generalized such as: “How have you been feeling since your last 
visit?”  
Any AE occurring from the Informed Consent signature up to the first study drug intake will 
be recorded on the medical history section of the CRF as baseline condition, while any AE 
occurring after a subject has intake the first study treatment up to the follow-up study visit, 
whether volunteered by the subject/parent/legal guardian, discovered during general 
questioning by the Investigators or detected through physical examination, laboratory test or 
other means will be recorded on the specific section of the CRF.  
Each AE will be described by:  
 seriousness; 
 duration (start and end dates); 
 severity; 
 relationship with the study drug; 
 action taken.  
The severity of AE should be assessed and graded according to the most recently published 
National Cancer Institute Common Terminology Criteria for AE (CTCAE v. 4.03, 
14th June 2010).  
The relationship with the study drug should be assessed as: 
 related to study drug; 
 not related to study drug; 
 unknown.  
The assessment of the relationship of an adverse event with the administration of study drug 
is a clinical decision based on all available information at the time of the completion of the 
CRF. 
An assessment of “Related” indicates that there is a reasonable suspicion that the AE is 
associated with the use of the study drug. 
An assessment of “Not related” would include the existence of a clear alternative 
explanation, or non-plausibility. 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 88 of 120 
An assessment “Unknown” indicates there is not a reasonable suspicion that the AE is 
associated with the use of the study drug and at the same time there is not the existence of a 
clear alternative explanation or non-plausibility.  In this case, Investigator has to collect all 
possible information in order to assess the relationship with the study drug, particularly in 
case of SAEs. 
Factors to be considered in assessing the relationship of the AE to study drug include: 
 The temporal sequence from study drug administration; 
 The recovery on discontinuation and recurrence on reintroduction; 
 The concomitant diseases; 
 The evolution of the treated disease; 
 The concomitant medication; 
 The pharmacology and PK of the study drug; 
 The presence of an alternative explanation. 
Abnormal Laboratory Findings and Other Objective Measurements: 
Abnormal laboratory findings and other objective measurements should not be routinely 
captured and reported as AEs as they will be collected and analysed separately in the eCRF.  
However, abnormal laboratory findings and other objective measurements that meet the 
criteria for an SAE, result in discontinuation of the study drug or require medical 
intervention, or are judged by the Investigator to be clinically significant changes from 
baselines values should be captured and reported on the AE pages of the eCRF. 
When reporting an abnormal laboratory finding on the AE pages of the eCRF, a clinical 
diagnosis should be recorded in addition to the abnormal value itself, if this is available (for 
example “anaemia” in addition to “haemoglobin = 10.5 g/dl”). 
Baseline Medical Condition: 
Medical conditions present at the screening visit, that do not worsen in severity or frequency 
during the study are defined as baseline medical conditions and are not AEs.  These medical 
conditions should be adequately documented on the appropriate page of the eCRF, i.e., the 
medical history page.  However, medical conditions present at the initial study visits that 
worsen in severity or frequency during the study should be recorded and reported as AEs. 
 
 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 89 of 120 
12.9.3 Serious Adverse Event Reporting 
Any SAE, including death from any cause that occurs after subject/parent/legal guardian 
have signed the Informed Consent and up to the follow-up visit (regardless of relationship to 
study drug/comparator) must be reported by the Investigators to the Sponsor within 24 hours 
of learning of its occurrence. 
Serious adverse event reports must be made whether or not the Investigator considers the 
event to be related to the investigational drug. 
Related SAEs must be collected and reported regardless of the time elapsed from the last 
study drug administration, even if the study has been closed.  
As soon as an AE becomes serious, it will be recorded in the AE section of the eCRF and in 
the SAE form that will be automatically opened if the answer to the question “Was adverse 
event serious?” in the AE section is “yes.” A paper SAE Form will be also available as 
backup. 
Initial completion and follow-up reporting updates of the SAE eCRF page within the 
Electronic Data Capture (EDC) system will automatically send the SAE report directly to the  
Syneos Health Global Safety and Pharmacovigilance (GSPV) via secure email.  
This automated e-mail alert process supports the Investigator in the notification of SAEs to 
the Syneos Health GSPV.  Sufficient details must be provided to allow for a complete 
medical assessment of the AE and independent determination of possible causality.  The 
Investigators are obliged to pursue and provide additional information as requested by 
Italfarmaco S.p.A.  Corporate Drug Safety, or its designee or the Medical Monitor of the 
study or Clinical Research and Development Director, or his designee.  
The Investigator must notify the Sponsor and his designee of the SAE by completing the 
SAE reporting form available within the eCRF or, as a backup ONLY in case of technical 
issues, by faxing the SAE reporting form at the number specified below, within 24 hours of a 
SAE; then, only in case of SAE notification by fax (backup system) the Investigator must 
confirm any SAE notifications by mailing to the mail address or phoning to the phone 
number specified below: 
Syneos Health Pharmacovigilance Email: SafetyPV@syneoshealth.com 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 90 of 120 
Syneos Health Pharmacovigilance Fax Numbers:   
North America:  866-880-9343 
All other countries:  +44-1628-461184 
If notification cannot be made via these means due to technical delivery problems, initial 
notification may be made by telephone, using the SAE Hotline number: 
888-750-8020 
The same procedure must be applied to the SAE follow-up information.  Preliminary reports 
of SAEs must be followed by detailed descriptions later on, including clear and anonymized 
photocopies of hospital case reports, consultant reports, autopsy reports, and other documents 
when requested and applicable.   
Appropriate remedial measures should be taken to treat the SAE and the response should be 
recorded.  Clinical, laboratory and diagnostic measures should be employed as needed in 
order to determine the etiology of the problem.  All SAEs will be followed until the 
Investigator and Sponsor agree the event is satisfactorily resolved. 
Any SAE that is not resolved by the end of the study or upon discontinuation of the subject’s 
participation in the study is to be followed until it either resolves, stabilizes, returns to 
baseline values (if a baseline value is available), or is shown to not be attributable to the 
study drug or procedures. 
All serious and unexpected AEs that are associated with the use of the study drug (SUSARs) 
will be notified by the Drug Safety Manager to the Ethic Committees or Institutional Review 
Board and competent authority within the required time and following procedures required 
by applicable laws.  It is imperative that the Sponsor be informed as soon as possible, so that 
reporting can be done within the required time frame.  
12.9.4 Overdose 
In general, a drug overdose in a clinical study is defined as the accidental or intentional use 
of a drug or medicine in an amount exceeding the protocol defined dose.  The Investigator 
must immediately notify the Sponsor of any occurrence of overdose with study drug.  In this 
study, if an AE is associated with (“results from”) the overdose of givinostat/placebo, the AE 
is reported as a SAE, even if no other criteria for seriousness are met. 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 91 of 120 
If a dose of givinostat/placebo meeting the protocol definition of overdose is taken without 
any associated clinical symptoms or abnormal laboratory results, the overdose is reported as 
a non-serious Event of Clinical Interest, using the terminology “accidental or intentional 
overdose without adverse effect.” 
Any instance of overdose (suspected or confirmed, with and without an AE) must be reported 
to the Sponsor within 24 hours and, only in case of AEs, it must be fully documented as a 
SAE.  Details of any signs or symptoms and their management should be recorded in the 
SAE Form including details of any antidote or systematic treatment administered.  Any signs 
or symptoms of over-dosage will be treated symptomatically.  
Any other situations putting the subject at risk of an adverse reaction, such as misuse and 
abuse, medication errors, suspect of transmission of infective agents must be reported to the 
Sponsor within 24 hours and be fully documented as a SAE. 
12.9.5 Pregnancy reporting 
Since it is possible to randomize adolescent fertile trial male subjects in this trial, the subject 
must be informed by the investigator that if it is suspected that his partner becomes pregnant 
during the study treatment or within 3 months days after the study treatment, he should 
inform the site personnel immediately of this pregnancy. 
If the Investigator is made aware that the partner of a subject who is participating to the study 
become pregnant, he/she is required to report within 24 hours the pregnancy, using the 
Pregnancy Notification Form available in the Investigator Study File, to Syneos Health 
Pharmacovigilance by mailing to the mail address or faxing numbers specified below:  
 Syneos Health Pharmacovigilance Email:  
SafetyPV@syneoshealth.com 
 Syneos Health Pharmacovigilance Fax Numbers:   
North America:  866-880-9343 
All other countries:  +44-1628-461184 
If notification cannot be made via these means due to technical delivery problems, initial 
notification may be made by telephone, using the SAE Hotline number: 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 92 of 120 
 888-750-8020 
Whenever possible, such pregnancy should be followed until termination, any premature 
termination should be reported, and the status of the mother and child should be reported to 
the sponsor after delivery. 
13 STATISTICAL ANALYSIS 
A Statistical Analysis Plan (SAP) will be prepared prior to the first planned interim analysis 
to provide full details on the methods described here and provide a complete description of 
the data presentations required for this study.  Changes to the statistical analysis planned in 
this protocol will be described in the SAP along with the rationale for the changes.  
The statistical evaluation will be performed using the latest available version of the Statistical 
Analysis Software (SAS®) (SAS Institute, Cary, NC).   
All data will be listed, and summary tables will be provided.  Summary statistics will be 
presented by dose group.  For continuous variables, data will be summarized with the number 
of subjects (N), mean, SD, median, minimum, and maximum by treatment group.  For 
categorical variables, data will be tabulated with the number and proportion of subjects for 
each category by treatment group. 
13.1 Overall Statistical Strategy 
This trial design a single planned interim analysis.  The interim will be governed by an 
IDMC. The interim analysis will be performed when the first N=50 subjects randomised in 
the target population have reached the 12 month time point.  The purpose of this interim is to 
solely assess futility on VL MFF and execute a blinded sample size re-estimation procedure, 
there will be no formal analyses for efficacy and no early stopping for efficacy and 
hence no alpha spend. 
13.2 Determination of Sample Size 
The sample size was originally calculated to provide 90% power and a 1-sided alpha of 2.5% 
to detect a true difference between givinostat and placebo in the target population in 4SC 18 
month change from baseline of 3 seconds, assuming a common SD of 6 seconds.  The 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 93 of 120 
estimated SD is based on publicly available Phase 3 study data on ataluren and drisapersen in 
subjects with DMD in addition to internal Italfarmaco data.    
The pre-planned interim analysis was performed in January 2020; it was concluded by the 
IDMC that futility on VLFF was not met and the trial should continue; hence the pre-planned 
blinded sample size re-assessment was performed.  The blinded within treatment SD for the 
change in 4CS from baseline to 18 months was estimated to be 3.094 seconds, approximately 
half of that assumed in the original power calculation. Based on this SD estimate, the revised 
sample size (utilizing a 2:1 randomisation scheme) N= 102 was calculated to provide 90% 
power and a 1-sided alpha of 2.5% to detect a true difference between givinostat and placebo 
in the target population, in 4SC 18 month change from baseline, of 2 seconds. With an 
estimated drop-out rate of 8%, a total of 110 subjects in the target population (Group A) will 
be randomized. 
For the MR cohort, the blinded SD estimate was 5.941%, being in line with the 6% SD 
assumed in the original power calculation, hence all the subjects in the target population will 
be included in the MR cohort.  
A total of 110 male ambulant subjects will be randomised in the target population (Group A). 
Up to 50 subjects (about 35% of the overall population) outside of the target may also be 
recruited into the study (Group B). The overall subjects population (Group A + Group B) will 
provide supportive data. 
13.3 Analysis Population 
13.3.1 Intent-To-Treat Population 
The Intent-to-Treat (ITT) target population will include all subjects in the target population 
who are randomised, irrespective of any deviation from the protocol or premature 
discontinuation.  The treatment group assignment will be designated according to initial 
randomisation.  The ITT target population will serve as the basis for the formal analysis of 
efficacy.  The overall ITT population will include all subjects in both the target and off-traget 
populations (Group A + Group B) who are randomised, irrespective of any deviation from 
the protocol or premature discontinuation.  The overall ITT population will be used for 
supportive efficacy analyses.  

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 94 of 120 
13.3.2 Safety Population 
The target Safety Population will include all randomised subjects in the target population 
who receive at least one dose of study drug.  The treatment group assignment in this 
population will be defined by the treatment actually received.  This population will be used 
for the evaluation of safety in the target population.   The overall Safety Population will 
include all randomised subjects in both the target and off-target population who receive at 
least one dose of study drug. The overall Safety Population will be used for supportive 
evaluations of safety.  
13.4 Demographic and Baseline Characteristics 
Demographic data and other baseline characteristics including medical history will be 
analysed based on the target safety population.  Summary statistics will be provided for all 
collected variables.  Continuous variables will be summarized by descriptive statistics, 
including mean, SD, median, minimum, and maximum.  Details of endpoint analyses will be 
described in the SAP. 
13.5 Investigational Medicinal Products 
The duration (days) of exposure of givinostat/placebo will be calculated for each subject in 
the target and overall populations, and will be summarized descriptively including the mean, 
SD, median, minimum, and maximum by treatment group and overall. 
In addition, the daily dosage (mg) of givinostat will be summarized for each subject in the 
target and overall populations, and will be summarized descriptively including the mean, SD, 
median, minimum and maximum. 
Reason for treatment discontinuation and number of subjects treated beyond 
protocol-specified discontinuation criteria will also be summarized in the target and overall 
populations.  Summaries will be based on the respective safety population. 
13.6 Prior and Concomitant Therapy 
Prior treatments, defined as those taken within 6 months prior to screening, should be 
recorded in the source documents as prior medications.  

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 95 of 120 
Concomitant treatments are defined as treatments taken after study drug administration.  
Prior and concomitant medications will be classified using the WHO-DRL drug dictionary 
(using the most recent version) and summarised in the target and overall populations.  
Summaries will be based on the respective safety population. 
13.7 Efficacy Analysis 
All formal efficacy analyses will be performed on the ITT target population; efficacy 
analyses in the overall population will be supportive and informal.  Descriptive statistics for 
qualitative data will include frequency tabulation and presentation of percentages.  
Descriptive statistics for quantitative data will include mean and SD or geometric mean, 
coefficient of variation, median and interquartile range.  
13.7.1 Analysis of the Primary Efficacy Endpoint 
The change in 4SC from baseline to 18 months will be evaluated in the target population.  
The data will be analyzed using an Analysis of Covariance (ANCOVA) model with the 
change in 4SC from baseline to 18 months as the dependent variable and with terms for 
baseline 4SC value as a covariate and randomised treatment, concomitant steroid use and age 
at baseline as independent class variables. Least squares means will be estimated for 
givinostat and placebo. The treatment effect, being the difference in Lsmeans, will be 
presented along with the associated 95% confidence interval and the p-value. Significance 
will be achieved if the 1-sided p-value is ≤0.025.   
13.7.2 Analysis of Key Secondary Efficacy Endpoints 
Analysis of Key Secondary Endpoints  
Formal analyses of functional key secondary endpoints (i.e., cumulative loss of function in 
the NSAA, change in 6MWT, NSAA, time to rise from floor and muscle strength by knee 
extension and elbow flexion) and Vastus lateralis MFF will take place in the target 
population at 18 months and will be achieved using the same approach as described for the 
primary /endpoint. Possible need for log transformation of these variables will be assessed 
prior to unblinding by assessment of ANCOVA model residuals without a treatment effect 
term.  

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 96 of 120 
13.7.3 Analysis of Exploratory Efficacy Endpoints 
Exploratory efficacy endpoints will be supportive only and not subject to alpha control; 
therefore nominal p-values will be presented. 
The mean change from baseline to 18 months will be compared between givinostat and 
placebo in the target population for: 
 Time to walk/run 10 meters; 
 Quality of life assessed by Paediatric Outcomes Data Collection Instrument (PODCI);  
 %-predicted 6MWT; 
These endpoints will be analyzed using methods in line with those described for the primary 
and key secondary endpoints.   
The fraction of subjects achieving the following endpoints at 18 months will be compared 
between givinostat and placebo in the target population: 
 Proportion of subjects with ≥10% worsening in 6MWT at end of study; 
 Proportion of subjects who loose ambulation during the study. 
These endpoints will be analysed using a logistic regression model with terms for 
randomised treatment, concomitant steroid use and age at baseline.  The odds for each 
treatment group will be extracted along with the odds ratio, associated 95% confidence 
interval and p-value.  
The following endpoints will be compared between givinostat and placebo in the target 
population using Cox proportional hazards modelling: 
 Time to 10% persistent worsening in 6MWT (Baseline through end of study); 
 Time to loss of standing (Baseline through end of study); 
The model will include terms for randomised treatment, concomitant steroid use and age at 
baseline.The hazard ratio will be extracted, along with the associated 95% confidence 
interval and p-value.  
Moreover, exploratory analyses will be done in the target population to explore whether the 
effects of givinostat versus placebo administered chronically may be related to the type of 
DMD mutation, LTBP4 and Osteopontin genotype or to the biomarkers.   

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 97 of 120 
13.8 Pharmacokinetic Analysis 
Nonlinear mixed effect models will be used for the evaluation of the population PK profile.  
The population PK analysis will be performed using NONMEM software (Version VI 
or later).   
The evaluation will be performed for describing the PK of givinostat and its major 
metabolites (ITF2374 and ITF2375) in the subject population and for identifying the relevant 
demographic and pathophysiological covariates. Separate PK models for givinostat and its 
metabolite will be developed.  
Additionally, the relationship of givinostat PK exposure to efficacy and safety endpoints in 
the target population will be explored as exploratory analyses.  
The Population PK approach will be based on the development of the following 3 models: 
1. Identification of the structural model that best describes the PK data in absence of 
covariates;  
2. Random Effect Models: defining the inter-individual variability and the residual 
error.  Different forms of residual error (additive, multiplicative or both) will be 
explored; 
3. Covariate Model: identifying the relevant demographic and pathophysiological 
covariates affecting the PK profile of the compound.  The selection of the covariates 
will be performed using an appropriate statistical methodology.  
Population PK procedures and analyses will be detailed in a separate “Population PK data 
analysis plan.” 
13.9 Safety Analysis 
Safety data will be evaluated descriptively in both the target and overall patient populations.  
The following parameters will be summarized: rates of discontinuation, AEs, and laboratory 
abnormalities. Adverse event data will be coded using the most updated version of Medical 
Dictionary for Competent Activities (MedDRA) dictionary. Adverse events will be 
summarized by treatment group for the number of subjects reporting the AE and the number 
of AEs reported.  Summaries will be performed for treatment-related AEs (TEAEs), SAEs, 
AEs that lead to withdrawal, severity of TEAEs, and relationship of TEAEs to study drug.  

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 98 of 120 
They will be presented by MedDRA System Organ Class (SOC) MedDRA Preferred Term 
and treatment group.  
Serious adverse events and AEs leading to discontinuation will be listed separately. 
A by-subject AE data listing including verbatim term, coded term, treatment group, severity, 
and relationship to treatment will be provided. 
Summary statistics will be presented for changes in vital signs, weight, height and BMI, in 
ECG parameters, in ECHO parameters, in respiratory function parameters, and cognitive 
function parameters.  Laboratory test values will be summarised similarly but will also 
include tabulation of the number of subjects shifting from within the reference range at 
baseline to outside of the reference range on randomised treatment. 
13.10  Interim Analysis  
A single interim analysis is planned and will be performed by the IDMC in the target 
population.  An IDMC charter will be prepared to describe the role, function and operations 
of the IDMC and the rules to be used when reviewing interim data.  
13.10.1 
Interim Analysis 
The interim analysis will be performed when the first N=50 subjects randomised in the target 
population have reached the 12 month time point.  In this interim analysis, the IDMC will 
evaluate the effects of givinostat versus placebo on the vastus lateralis MFF (VL MFF) in 
terms of futility.  Futility will be considered if the mean change from baseline to 12 months 
in VLMFF in the givinostat group is equal to or worse than that seen in the placebo group 
since the biologic plausibility of a subsequent treatment effect on 4SC time would be greatly 
diminished.  The IDMC will only communicate to the Sponsor whether the study should 
proceed or it should be stopped having met the futility criteria.  
If the IDMC indicates that the study should proceed, a blinded sample size re-estimation will 
be conducted for MFF and 4SC in the target population as follows:    
 To maintain the blind on the primary endpoint, the within treatment SD for the 
change from baseline will be estimated as  𝝈̂𝒘𝒊𝒕𝒉𝒊𝒏= √𝝈̂𝒐𝒗𝒆𝒓𝒂𝒍𝒍
𝟐
−(
𝜟
𝟐)
𝟐
 where 𝝈̂𝒐𝒗𝒆𝒓𝒂𝒍𝒍  
is the overall SD for the change from baseline in 4SC based on the n=50 subjects in 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 99 of 120 
the interim and 𝛥 is the originally hypothesized treatment effect, i.e., 𝛥= 3 seconds.  
Dependent upon the blinded SD estimate, the sample size may be decreased or 
increased to maintain 90% power. Any increase in sample size for 4SC will be 
limited to 1.5 times maximum of the initial target population sample size, i.e., to a 
maximum of 1.5 × 192 = 288 subjects.  For a 20% increase in the SD, this degree of 
increase in sample size will maintain 90% power, and for a 40% increase in SD 
power will be maintained at 80%. 
 
 With respect to VL MFF, a similar approach will be applied; the within treatment SD 
for the change from baseline will be estimated as  𝝈̂𝒘𝒊𝒕𝒉𝒊𝒏= √𝝈̂𝒐𝒗𝒆𝒓𝒂𝒍𝒍
𝟐
−(
𝜟
𝟐)
𝟐
 where 
𝝈̂𝒐𝒗𝒆𝒓𝒂𝒍𝒍  is the overall SD for the change from baseline in VL MFF and 𝛥 is the 
originally hypothesized treatment effect, i.e. 𝛥= 3.63% (i.e., 55% of 6.6%).  Dependent 
upon the blinded SD estimate, the sample size may be decreased or increased to 
maintain 90% power. Any increase in sample size required to assess MFF will also be 
limited to 1.5 times the required target population sample size stated in the preceding 
power calculation, to a maximum of 1.5 × 99 = 150 subjects.  
 
At the interim futility analysis, there will be no efficacy assessment, no unblinded analysis of 
the primary endpoint and, hence, no alpha spend nor early stopping of the study for efficacy.  
As noted above in Section 13.2, the interim analysis took place in January 2020; futility was 
passed and the blinded sample size reassessment followed.  The estimated SD for 4SC was 
approximately half of that assumed in the original power calculation.  Consequently, it was 
determined that a total of N=102 patients would be sufficient to test the hypothesis that 4SC 
was improved by at least 2 seconds with givinostat compared placebo. With allowance for a 
small dropout rate, a total of 110 male ambulant subjects will be randomised in the target 
population (Group A). Up to 50 subjects (about 35% of the overall population) outside of the 
target may also be recruited into the study (Group B). The overall subjects population (Group 
A + Group B) will provide supportive data. 
For the MR cohort, the blinded SD estimate was 5.941%, being in line with SD assumed in 
the original power calculation for VL MFF, hence all the subjects in the target population 
will be included in the analysis of the MR cohort. 
 
 
 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 100 of 120 
13.10.2 
Final  Analysis 
The final analysis will be performed when N=110 patients in the target population subjects 
have achieved 18 months follow-up.  The p-value applicable to the final analysis of 4SC will 
be p≤0.025 1-sided.    
13.11 Independent Data Monitoring Committee  
The IDMC will be established by the Sponsor to review accumulating safety data at regular 
intervals throughout the study and monitor overall study conduct.  The IDMC will review, 
evaluate, and categorise safety findings every 3 months during the study and will be 
responsible for oversight of the planned interim analysis as described in Section 13.10.  
Members will include at least 3 person, but are not limited to, a chairman, a clinician experts 
in DMD and a biostatistician, who are not participating in this study and do not have 
affiliation with the Investigators or the Sponsor.  The IDMC can recommend in writing to the 
Sponsor whether to continue, modify, or stop the clinical study on the basis of safety 
considerations.   
An IDMC charter will be prepared to describe the role, function and operations of the IDMC 
and the rules to be used when reviewing interim data. 
14 STUDY MANAGEMENT 
14.1 Approval and Consent 
14.1.1 Regulatory Guidelines 
The Investigator will ensure that this study is conducted in full conformity with the principles 
of the “Declaration of Helsinki” or with the laws and regulations of the country in which the 
research is conducted, whichever affords the greater protection to the individual.  
The study must fully adhere to the principles outlined in “Guideline for Good Clinical 
Practice” ICH Tripartite Guideline or with local law if it affords greater protection to the 
subject.  
For EU/EEA countries this study will be performed in accordance with EU and country 
regulation in force. 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 101 of 120 
Moreover, this study will be performed in accordance to all relevant federal regulations, as 
set forth in Parts 50 “Protection of Human Subjects”, 56 “Institutional Review Boards”, 312 
“Responsibilities of Sponsors and Investigators”, Subpart D “GCP”, of Title 21 of the Code 
of Federal Regulations (CFR), and in compliance with Good Clinical Practice (GCP) 
guidelines. 
This study will also be carried out in accordance with SOPs of Italfarmaco S.p.A. and/or its 
designee. 
The Investigator agrees, when signing the protocol, to adhere to the instructions and 
procedures described therein and thereby to adhere to the principles of GCP to which it 
conforms. 
14.1.2 Institutional Review Board/Independent Ethics Committees 
The protocol, informed consent form, assent form, recruitment materials, and all participant 
materials will be submitted to the Independent Ethics Committee (IEC) or Institutional 
review Board (IRB) for review and approval.  This study will be undertaken only after 
approval of the protocol, informed consent form, assent form and all other materials 
described above, have been obtained from the appropriate IEC or IRB and a copy of the 
signed and dated approval has been received by Italfarmaco S.p.A.  The name and 
occupation of the chairman and the members of the IRB/IEC must be supplied to Italfarmaco 
S.p.A. or its designee.  The IRB/IEC must be informed of all subsequent protocol 
amendments and should be asked whether a re-evaluation of the ethical aspects of the study 
is necessary. 
If applicable, interim reports on the study and reviews of its progress will be submitted to the 
IRB/IEC by the Investigator at intervals stipulated in their guidelines.  At the completion or 
termination of the study, the Investigator must submit a close-out letter to the IRB/IEC and to 
Italfarmaco S.p.A. 
14.1.3 Independent Data Monitoring Committee 
An IDMC will be utilized in this study to ensure external objective medical and/or statistical 
review of safety issues in order to protect the ethical and safety interests of subjects and to 
protect the scientific validity of the study.  The IDMC also has the responsibility to monitor 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 102 of 120 
risk versus benefit considering factors external to the study when relevant information 
becomes available. 
The members of the IDMC act as advisors to the Sponsor to monitor subject safety and study 
progress. The IDMC will have the responsibility to provide the Sponsor with 
recommendations related to the protection of the subject’s safety, including stopping or 
amending the study protocol, the consent/assent forms, and the IB. 
During the study, the IDMC will review, evaluate and categorise safety findings every three 
months and will be responsible for the interim analyses (see section 13.10.10), which could 
result in recommendations to the Sponsor.  The IDMC will meet at predefined times and 
more frequently as needed. 
The IDMC will be also responsible to review any protocol amendments. 
The IDMC will operate under a written charter that includes a well-defined standard 
operating procedure.  The charter will be prepared to describe the role, function, and 
operations of the IDMC and the rules to be used when reviewing interim data. 
All members should have no financial, scientific, or other conflicts of interest with the study. 
IDMC meeting/phone call will include both an open and closed session, while the 
meeting/phone call with the Sponsor and Investigators will always be blinded session. 
14.1.4 Subject Informed Consent  
Prior to the beginning of the study, the Principal Investigator (PI) must have the IRB/IEC 
written approval/favourable opinion of the written Informed Consent/ Assent Form and any 
other written information to be provided to subject and legally accepted representative. The 
approved subject information letter/Informed Consent/Assent Form must be filed in the study 
files (clinical Trial Master File [TMF] and Investigator File [IF]).  For each study subject, a 
written Informed Consent Form the legally accepted representative will be obtained prior to 
any protocol related activities.  Informed assent or consent, if applicable, may be obtained 
from subjects who are capable of providing assent/consent.  As part of this procedure, the PI 
or a designated representative must explain orally and in writing the nature, duration, and 
purpose of the study, and the action of the drug in such a manner that the subject, the parent 
and, if applicable, appointed guardian are aware of the potential risks, inconveniences, or 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 103 of 120 
adverse effects that may occur.  Subjects and their legally accepted representatives should be 
given ample time and opportunity to inquire about the details of the study prior to deciding 
whether to participate in the study.  It is the responsibility of the Investigator to ensure that 
all questions about the study are answered to the satisfaction of the subjects and their legally 
accepted representatives.  
Subjects and their legally accepted representatives should be informed that subjects may 
withdraw from the study at any time.  They will receive all information that is required by 
local regulations and ICH guidelines.  The PI or a designated representative will provide the 
sponsor or its representative with a copy of the IRB/IEC approved ICF prior to the start of 
the study. 
The ICF should be signed and dated by the subject’s legally accepted representative and the 
Investigator on the same day.  If the subject and/or legally accepted representative are not 
able to read, an impartial witness should be present during the informed consent discussion, 
and the witness must co-sign and date the informed consent form.  The subject’s legally 
accepted representative and/or impartial witness should receive a copy of the signed 
documents.  
For details of the information provided, refer to the ICF. 
14.1.5 Discontinuation of the study by the Sponsor 
The Sponsor has the right to terminate this study at any time.  Reasons for terminating the 
study may include the following: 
 unsatisfactory subject enrolment;   
 inaccurate or incomplete quality or quantity of data recording; 
 incidence or severity of adverse drug reactions in this or other studies with study drug 
indicating a potential health hazard to subjects; 
 poor adherence to protocol and regulatory requirements; 
 plans to modify or discontinue the development of the study drug. 
14.1.6 Data Handling  
 
Data on subjects collected on eCRFs during the trial will be documented in an anonymous 
fashion and the subject will only be identified by the subject number. All the information 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 104 of 120 
required by the protocol should be provided and any omissions require explanation.  All 
eCRFs must be completed expeditiously after the subject’s visit. 
Any data to be recorded directly on the eCRFs (to be considered as source data) will be 
identified at the start of the study.  The Investigator must maintain source documents for each 
subject in the study.  Data reported on the eCRF that are derived from source documents 
should be consistent with the source documents, or the discrepancies must be explained. 
Clinical data will be entered on eCRFs, a 21 CRF Part 11 compliant, for transmission to the 
Sponsor.  Data on eCRFs transmitted via the web-based data system must correspond to and 
be supported by source documentation maintained at the study site, unless the study site 
makes direct data entry to the databases for which no other original or source documentation 
is maintained.  In such cases, the study site should document which eCRFs are subject to 
direct data entry and should have in place procedures to obtain and retain copies of the 
information submitted by direct data entry.  All study forms and records transmitted to the 
Sponsor must carry only coded identifiers such that personally identifying information is not 
transmitted.  The primary method of data transmittal is via the secure, internet-based EDC 
system.  Access to the EDC system is available to authorized users via the study’s Internet 
web site, where an assigned username and password are required for access.  
Any changes made to data after collection will be made through the use of Data Clarification 
Forms.  Case Report Forms will be considered complete when all missing and/or incorrect 
data have been resolved.  
14.2 Source Documents 
Source documents contain all information in original records and certified copies of original 
records of clinical findings, observations, data or other activities in a clinical study necessary 
for the reconstruction and evaluation of the study. All source documents should be completed 
in a neat, legible manner to ensure accurate interpretation of data. 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 105 of 120 
14.3 Record Retention 
The Investigator must arrange for retention of study records at the site. The nature of the 
records and the duration of the retention period must meet the requirements of the relevant 
regulatory authority.   
In addition, because this is an international study, the retention period must meet the 
requirements of the most stringent authority.   
 The Sponsor and the Investigator shall archive the content of the clinical trial master file for 
at least 25 years after the end of the clinical study.  However, the medical files of subjects 
shall be archived in accordance with national law. 
The content of the clinical trial master file shall be archived in a way that ensures that it is 
readily available and accessible, upon request, to the competent authorities. 
Any transfer of ownership of the content of the clinical trial master file shall be documented. 
Any alteration to the content of the Investigator file shall be traceable and the Investigator 
should take measures to prevent accidental or premature destruction of these documents.  
14.4 Monitoring 
The study will be monitored to ensure that it is conducted and documented properly 
according to the protocol, GCP, and all applicable regulatory requirements.  
A site visit will be held prior to initiation of subject enrolment.  The protocol, eCRFs, study 
drug supplies and relevant procedures will be explained to the Investigators and his/her staff 
in detail at the site visit.  On-site monitoring visits will be made at appropriate times during 
the study. 
Clinical monitors must have direct access to source documentation in order to check the 
completeness, clarity, consistency of the data recorded in the eCRFs/CRFs for each subject 
and the adherence to the protocol and to GCP.  The clinical monitors will also check the 
progress of enrolment and the handling of study medication to ensure that study medication 
is being stored, dispensed, and accounted for according to specifications. 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 106 of 120 
The Investigator will make available to the clinical monitor source documents and medical 
records necessary to complete eCRFs/CRFs.  No information in these records about the 
identity of the subjects will leave the study centre.  In addition, the Investigator and key trial 
personnel will work closely with the clinical monitor and, as needed, provide them 
appropriate evidence that the conduct of the study is being done in accordance with 
applicable regulations and GCP guidelines.  
Monitoring standard procedures require full verification for the presence of informed 
consent/assent, adherence to the inclusion/exclusion criteria, documentation of SAEs and the 
recording of primary efficacy and safety variables.  The Investigator is responsible for 
completing the CRFs expeditiously to capture all the relevant information, while the monitor 
is responsible for reviewing them and clarifying any data queries. 
14.5 Quality Control and Quality Assurance 
The Sponsor or its designee will perform the quality assurance and quality control activities 
of this study; however, responsibility for the accuracy, completeness, and reliability of the 
study data presented to the Sponsor lies with the Investigator generating the data. 
The Sponsor will arrange audits as part of the implementation of quality assurance to ensure 
that the study is being conducted in compliance with the protocol, Standard Operating 
Procedures, GCP, and all applicable regulatory requirements.  Audits will be independent of 
and separate from the routine monitoring and quality control functions.  Quality assurance 
procedures will be performed at study sites and during data management to assure that safety 
and efficacy data are adequate and well documented.  
A Regulatory Authority may also wish to conduct an inspection (during the study or even 
after its completion).  If an inspection is requested by a Regulatory Authority, the 
Investigator must inform Italfarmaco S.p.A. immediately that this request has been made. 
14.6 Protocol Amendment and Protocol Deviation  
14.6.1 Protocol Amendment 
Any change or addition to this protocol requires a written protocol amendment that must be 
approved by Italfarmaco S.p.A. 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 107 of 120 
Amendments can be classified as substantial when impact one of the following criteria:  
 The safety or physical or mental integrity of the subject; 
 The scientific value of the study; 
 The conduct or management of the study; 
 The quality or safety of any IMP used in the study. 
Substantial amendments require the authorization to the Competent Authority and the 
positive opinion of the relevant IRB/IEC before implementation. 
In case of urgent safety measures to protect the subject against any immediate hazard, these 
measures may be taken without prior authorization from the Competent Authority or 
favourable opinion of the IRB/IEC.  In this case, the Competent Authority and IRB/IEC will 
be informed as soon as possible using the fastest means of communication followed by a 
written report. 
Amendments classified as non-substantial require only notification to the IRB/IECs involved. 
14.6.2 Protocol Deviations 
Should a protocol deviation occur, the Sponsor must be informed as soon as possible.  
Protocol deviations and/or violations and the reasons they occurred will be included in the 
CSR.  Reporting of protocol deviations to the IRB/IEC and in accordance with applicable 
Regulatory Authority mandates is an Investigator responsibility. 
14.7 Ethical Considerations 
This study will be conducted in accordance with the accepted version of the Declaration of 
Helsinki and/or all relevant federal regulations, as set forth in Parts 50, 56, 312, Subpart D, of 
Title 21 of the CFR, in accordance with European and country regulations in force and in 
compliance with GCP guidelines. 
The IRB/IEC will review and approve this protocol, the informed consent form, the assent 
form, the recruitment materials, and all participant materials.    
14.8 Financing and Insurance 
Prior to the study commencing, the Sponsor (or its designee) and the Investigator (or the 
institution, as applicable) will agree on costs necessary to perform the study.  This agreement 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 108 of 120 
will be documented in a financial agreement that will be signed by the Investigator (or the 
institution signatory) and the Sponsor (or its designee).  
The Investigator is required to have adequate current insurance to cover claims for 
negligence and/or malpractice.  The Sponsor will provide insurance coverage for the clinical 
study as required by national regulations. 
14.9 Publication Policy/Disclosure of Data and Confidentiality  
The Investigator must assure that subjects’ anonymity will be maintained and that their 
identities will be protected from unauthorized parties.  On eCRFs or other documents 
submitted to the Sponsor, subjects should not be identified by their names, but by an 
identification code.  The Investigator should keep an enrolment log showing codes, names 
and addresses. 
By signing the protocol, the Investigator agrees to keep all information provided by 
Italfarmaco S.p.A. in strict confidence and to request similar confidentiality from his/her staff 
and the IRB/IECs.  Study documents provided by Italfarmaco S.p.A. (protocols, IBs, eCRFs, 
and other material) will be stored appropriately to ensure their confidentiality.  The 
information provided by Italfarmaco S.p.A. to the Investigator may not be disclosed to others 
without direct written authorization from Italfarmaco S.p.A., except to the extent necessary to 
obtain informed consent from subjects who wish to participate in the study.  For USA sites, 
the Investigator agrees to comply with all applicable federal, state, and local laws and 
regulations relating to the privacy of subject health information, including, but not limited to, 
the Standards for Individually Identifiable Health Information, 45 CFR, Parts 160 and 164 
(the Health Insurance Portability Accountability Act of 1996 [HIPAA] Privacy Regulation).  
The Investigator shall ensure that study subjects authorize the use and disclosure of protected 
health information in accordance with HIPAA Privacy Regulation and in a form satisfactory 
to the Sponsor.  
Both the use of data and the publication policy are detailed within the clinical study 
agreement.  Intellectual property rights (and related matters) generated by the Investigator 
and others performing the clinical study will be subject to the terms of a clinical study 
agreement that will be agreed upon between the Institution and the Sponsor or their designee.  

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 109 of 120 
With respect to such rights, the Sponsor or its designee will solely own all rights and interests 
in any materials, data, and intellectual property rights developed by Investigators and others 
performing the clinical study described in this protocol, subject to the terms of any such 
agreement.  In order to facilitate such ownership, Investigators will be required to assign all 
such inventions either to their Institution or directly to the Sponsor or its designee, as will be 
set forth in the clinical study agreement. 
Italfarmaco S.p.A assures that the key design items of the Protocol will be published in a 
publicly accessible database such as “Clinicaltrials.gov.”  Moreover, upon completion of the 
study and finalization of the study report, the results of this study will be submitted for 
publication or posted in a publicly accessible data base.   
15 REFERENCES 
1. 
Mendell, J. R., C. Shilling, et al. (2012). “Evidence-based path to newborn screening 
for Duchenne muscular dystrophy.” AnNeurol 71(3): 304-313. 
2. 
Peverelli, L., et al. (2015). “Histologic muscular history in steroid-treated and 
untreated patients with Duchenne dystrophy.” Neurology. 
3. 
Forbes, S. C., R. J. Willcocks, et al. (2014). “Magnetic resonance imaging and 
spectroscopy assessment of lower extremity skeletal muscles in boys with Duchenne 
muscular dystrophy: a multicentre cross sectional study.” PLoS One 9(9): e106435. 
4. 
Bushby, K., R. Finkel, et al. (2010). “Diagnosis and management of Duchenne 
muscular dystrophy, part 2: implementation of multidisciplinary care.” Lancet Neurol 
9(2): 177-189). 
5. 
Manzur, A. and M. Pike (2009). “Glucocorticoid corticosteroids for Duchenne 
muscular dystrophy.” Cochrane Database Syst Rev. 
6. 
Choudhary C, Kumar C, Gnad F, Nielsen ML, Rehman M, Walther T, Olsen JV, 
Mann M. Lysine acetylation targets protein complexes and co-regulates major 
cellular functions. Science. (2009); 325:834-40. 
7. 
Guha, M. (2015). “HDAC inhibitors still need a home run, despite recent approval.” 
Nat Rev Drug Discov 14(4): 225-226. 
8. 
Azuara, V., P. Perry, et al. (2006). “Chromatin signatures of pluripotent cell lines.” 
Nat Cell Biol 8(5): 532-538. 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 110 of 120 
9. 
Bernstein, B. E., T. S. Mikkelsen, et al. (2006). “A bivalent chromatin structure marks 
key developmental genes in embryonic stem cells.” Cell 125(2): 315-326. 
10. 
Ervasti, J. M. (2007). "Dystrophin, its interactions with other proteins, and 
implications for muscular dystrophy." Biochim Biophys Acta 1772(2): 108-117. 
11. 
Colussi, C., et al. (2008). “HDAC2 blockade by nitric oxide and histone deacetylase 
inhibitors reveals a common target in Duchenne muscular dystrophy treatment.” Proc 
Natl Acad Sci U S A 105(49): 19183-19187. 
12. 
Consalvi, S., et al. (2011). “Histone deacetylase inhibitors in the treatment of 
muscular dystrophies: epigenetic drugs for genetic diseases.” Mol Med 17(5-6): 457-
465. 
13. 
Minetti, G. C., et al. (2006). “Functional and morphological recovery of dystrophic 
muscles in mice treated with deacetylase inhibitors.” Nat Med 12(10): 1147-1150. 
14. 
Saccone, V., et al. (2014). “HDAC-regulated myomiRs control BAF60 variant 
exchange and direct the functional phenotype of fibro-adipogenic progenitors in 
dystrophic muscles.” Genes Dev 28(8): 841-857. 
15. 
Leoni, F., Fossati, G., Lewis, E., Lee, J., Porro, G., Pagani, P., Modena, D., Moras, 
M., Pozzi, P., Reznikov, L., et al. 2005. The histone deacetylase inhibitor ITF2357 
reduces production of pro-inflammatory cytokines in vitro and systemic inflammation 
in vivo. Mol Med 11:1-15. 
16. 
Joosten, L. A., F. Leoni, et al. (2011). “Inhibition of HDAC activity by ITF2357 
ameliorates joint inflammation and prevents cartilage and bone destruction in 
experimental arthritis.” Mol Med 17(5-6): 391-396.) 
17. 
Boldrin L, Zammit PS, Morgan JE. Satellite cells from dystrophic muscle retain 
regenerative capacity. Stem cell research. 2015;14(1):20-9. 
18. 
Tierney MT, Aydogdu T, Sala D, Malecova B, Gatto S, Puri PL, et al. STAT3 
signaling controls satellite cell expansion and skeletal muscle repair. Nature 
medicine. 2014;20(10):1182-6. 
19. 
Doles JD, Olwin BB. The impact of JAK-STAT signaling on muscle regeneration. 
Nature medicine. 2014;20(10):1094-5. 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 111 of 120 
20. 
Kerr, J. S., S. Galloway, et al. (2010). “Nonclinical safety assessment of the histone 
deacetylase inhibitor vorinostat.” Int J Toxicol 29(1): 3-19. 
21. 
Population PK/PD analysis to assess Thrombocytopenia of Givinostat (ITF2357) in 
Clinical studies (Report 0428-2012-R1).   
22. 
Goemans, N., et al. (2013). “Ambulatory capacity and disease progression as 
measured by the 6-minute-walk-distance in Duchenne muscular dystrophy subjects 
on daily corticosteroids.” Neuromuscul Disord 23(8): 618-623. 
23. 
McDonald, C. M., et al. (2013). “The 6-minute walk test and other endpoints in 
Duchenne muscular dystrophy: longitudinal natural history observations over 48 
weeks from a multicenter study.” Muscle Nerve 48(3): 343-356. 
24. 
Mercuri E, Pichiecchio A, Counsell S, Allsop J, Cini C, Jungbluth H, Uggetti C, 
Bydder G. A short protocol for muscle MRI in children with muscular dystrophies. 
Eur J Paediatr Neurol. 2002;6(6):305-7. 
25. 
McDonald CM et al., “The 6-minute walk test and other clinical endpoints in 
duchenne muscular dystrophy: reliability, concurrent validity, and minimal clinically 
important differences from a multicenter study.” Muscle Nerve 48(3): 357-368. 
26. 
Manzur AY, K. T., Pike M, Swan A (2009). “Glucocorticoid corticosteroids for 
Duchenne muscular dystrophy.” Cochrane Database Syst Rev. Jan 23. 
27. 
Bushby, K. and E. Connor (2011). “Clinical outcome measures for trials in Duchenne 
muscular dystrophy: report from International Working Group meetings.” Clin 
Investig (Lond) 1(9): 1217-1235. 
28. 
Willcocks RJ, Arpan IA, Forbes SC, et al. Longitudinal measurements of MRI-T2 in 
boys with Duchenne muscular dystrophy: effects of age and disease progression. 
Neuromuscular disorders : NMD 2014;24:393-401 
29. 
Willcocks RJ, Rooney WD, Triplett WT, Forbes SC, Lott DJ, Senesac CR, Daniels 
MJ, Wang DJ, Harrington AT, Tennekoon GI, Russman BS, Finanger EL, Byrne BJ, 
Finkel RS, Walter GA, Sweeney HL, Vandenborne K. Multicenter prospective 
longitudinal study of magnetic resonance biomarkers in a large duchenne muscular 
dystrophy cohort. Ann Neurol. 2016 Feb 19. doi: 10.1002/ana.24599. [Epub ahead of 
print] PubMed PMID: 26891991 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 112 of 120 
30. 
Wren TA, Bluml S, Tseng-Ong L, Gilsanz V. Three-point technique of fat 
quantification of muscle tissue as a marker of disease progression in Duchenne 
muscular dystrophy: preliminary study. AJR American journal of roentgenology. 
2008;190(1):W8-12 
31. 
Bonati U, Hafner P, Schadelin S, Schmid M, Naduvilekoot Devasia A, Schroeder J, et 
al. Quantitative muscle MRI: A powerful surrogate outcome measure in Duchenne 
muscular dystrophy. Neuromuscular disorders: NMD. 2015;25(9):679-85 
32. 
Pane M, Mazzone ES, Sormani MP, Messina S, Vita GL, et al. (2014) 6 Minute Walk 
Test in Duchenne MD Patients with Different Mutations: 12 Month, Changes. PLoS 
ONE 9(1): e83400. doi:10.1371/journal.pone.0083400. 
33. 
Henricson E, Abresch R, Han JJ, Nicorici A, Goude Keller E, Elfring G, Reha A, 
Barth J, McDonald CM. Percent-predicted 6-minute walk distance in duchenne 
muscular dystrophy to account for maturational influences. Version 2. PLoS Curr. 
2012 Jan 25 [revised 2012 Feb 2];4:RRN1297. PubMed PMID: 22306689 
34. 
Bushby K, Finkel R, Birnkrant DJ, Case LE, Clemens PR, Cripe L, Kaul A, Kinnett 
K, McDonald C, Pandya S, Poysky J, Shapiro F, Tomezsko J, Constantin C; DMD 
Care Considerations Working Group. Diagnosis and management of Duchenne 
muscular dystrophy, part 1: diagnosis, and pharmacological and psychosocial 
management. 
Lancet 
Neurol. 
2010 
Jan;9(1):77-93. 
doi: 
10.1016/S1474-
4422(09)70271-6. Epub 2009 Nov 27. Review. PubMed PMID: 19945913. 
35. 
Ricotti V, Ridout DA, Scott E, Quinlivan R, Robb SA, Manzur AY, Muntoni F; 
NorthStar Clinical Network. Long-term benefits and adverse effects of intermittent 
versus daily glucocorticoids in boys with Duchenne muscular dystrophy. J Neurol 
Neurosurg Psychiatry. 2013 Jun;84(6):698-705. doi: 10.1136/jnnp-2012-303902. 
Epub 2012 Dec 18. PubMed PMID: 23250964. 
36. 
Bello L, Gordish-Dressman H, Morgenroth LP, Henricson EK, Duong T, Hoffman 
EP, Cnaan A, McDonald CM; CINRG Investigators. Prednisone/prednisolone and 
deflazacort regimens in the CINRG Duchenne Natural History Study. Neurology. 
2015 Sep 22;85(12):1048-55. 

Italfarmaco S.p.A.  
  DSC/14/2357/48 
Givinostat   
  Protocol Version8.0  
08 April 2020 
Page 113 of 120 
16 APPENDICES 
 

Italfarmaco S.p.A. 
DSC/14/2357/48 
Givinostat 
Protocol Version8.0 
 
 08 April 2020 
 
Page 114 of 120 
16.1  Combined list of drugs that prolong QT and/or cause torsades de Pointes (TDP)  
Source:  Arizona Center for Education and Research on Therapeutics.  Link: http://www.crediblemeds.org/everyone/composite-list-
all-qtdrugs/. List last revised: 12 September 2018.  Accessed 9 October 2018. 
CredibleMeds® has reviewed available evidence for the drugs on the following list and placed them in one of three designated 
categories: Known Risk of TdP (KR), Possible Risk of TdP (PR) or have a Conditional Risk of TdP (CR). The full description of these 
categories can be found on the CredibleMeds.org website. 
 
 
 
 
 
 

Italfarmaco S.p.A. 
DSC/14/2357/48 
Givinostat 
Protocol Version8.0 
 
 08 April 2020 
 
Page 115 of 120 
 

Italfarmaco S.p.A. 
DSC/14/2357/48 
Givinostat 
Protocol Version8.0 
 
 08 April 2020 
 
Page 116 of 120 
 

Italfarmaco S.p.A. 
DSC/14/2357/48 
Givinostat 
Protocol Version8.0 
 
 08 April 2020 
 
Page 117 of 120 
 
 

Italfarmaco S.p.A. 
DSC/14/2357/48 
Givinostat 
Protocol Version8.0 
 
 08 April 2020 
Page 118 of 120 
16.2 Drugs knows to be a substrate of OCT2 transporter  
OCT2 transporter = Organic Cation Transporter 2 
Source: http://www.straighthealthcare.com/organic-cation-transporter-2.html 
Accessed October 9th, 2018. 
 
Generic Name 
Brand 
Names 
(Partial 
List) 
OCT2 interaction 
Amantadine 
 
Substrate 
Amiloride 
Midamor® 
Substrate 
Cimetidine 
Tagamet® 
Substrate 
Creatinine 
 
Substrate 
Dofetilide 
Tikosyn® 
Substrate 
Dopamine 
 
Substrate 
Famotidine 
Pepcid® 
Substrate 
Memantine 
Namenda® 
Substrate 
Metformin 
Glucophage® 
Substrate 
Oxaliplatin 
Eloxatin® 
Substrate 
Pindolol 
Visken® 
Substrate 
Procainamide 
 
Substrate 
Ranitidine 
Zantac® 
Substrate 
Trimethoprim 
Bactrim® 
Substrate 
Varenicline  
Chantix® 
Substrate 
 
 
 
 
 
 

Italfarmaco S.p.A. 
DSC/14/2357/48 
Givinostat 
Protocol Version8.0 
 
 08 April 2020 
Page 119 of 120 
16.3 Drugs known to be P-glycoprotein inhibitors 
Source: https://www.straighthealthcare.com/p-glycoprotein.html 
Accessed July 26th, 2019. 
 
 P-glycoprotein inhibitors 
o Amiodarone (Cordarone®)  
o Atorvastatin (Lipitor®)  
o Azithromycin (Zithromax®)  
o Boceprevir (Victrelis®) - Drug PI states possible inhibitor  
o Bromocriptine (Cycloset®, Parlodel®, etc.) 
o Captopril (Capoten®)  
o Carvedilol (Coreg®)  
o Clarithromycin (Biaxin®)  
o Cobicistat (part of Stribild®)  
o Conivaptan (Vaprisol®)  
o Cyclosporine (Neoral®, Gengraf®, Sandimmune®)  
o Daclatasvir (Daklinza™)  
o Diltiazem (Cardizem®, Cartia®, Dilacor®, Diltia®)  
o Doxazosin (Cardura®)  
o Dronedarone (Multaq®)  
o Erythromycin (E.E.S®, Ery-tab®)  
o Felodipine (Plendil®)  
o Fluvastatin (Lescol®)  
o Glecaprevir (Mavyret™)  
o Indinavir (Crixivan®)  
o Itraconazole (Sporanox®)  
o Ketoconazole (Nizoral®)  
o Ledipasvir (Harvoni™)  
o Linagliptin (Tradjenta®)  
o Lopinavir and ritonavir (Kaletra®)  
o Lovastatin (Mevacor®)  
o Meperidine (Demerol®)  
o Methadone  
o Nelfinavir (Viracept®)  

Italfarmaco S.p.A. 
DSC/14/2357/48 
Givinostat 
Protocol Version8.0 
 
 08 April 2020 
Page 120 of 120 
o Nicardipine (Cardene®)  
o Paritaprevir (Viekira Pak™, Technivie™)  
o Pentazocine (Talwin®)  
o Pibrentasvir (Mavyret™)  
o Progesterone  
o Quercetin (supplement)  
o Quinidine  
o Ranolazine (Ranexa®)  
o Reserpine  
o Ritonavir (Norvir®)  
o Saquinavir (Invirase®)  
o Sarecycline (Seysara™) 
o Simeprevir (Olysio®)  
o Simvastatin (Zocor®)  
o Suvorexant (Belsomra®) - in vitro data  
o Tacrolimus (Prograf®)  
o Tamoxifen   
o Telaprevir (Incivek®)  
o Ticagrelor (Brilinta®)  
o Velpatasvir (Epclusa®)  
o Verapamil (Calan®,Covera-HS®, Isoptin®, Verelan®)  
o Vorapaxar (Zontivity®) (weak inhibitor)  
o Voxilaprevir (Vosevi™)