A Phase I-IIa Study of Safety, Tolerance, Pharmacokinetics, Dosimetry and Benefice of Early Nuclear Medicine Imaging of 99mTc-rhAnnexin V-128 in Patients With Rheumatoid Arthritis or Ankylosing Spondylitis
Phase: PHASE1
Conditions: Rheumatoid Arthritis, Ankylosing Spondylitis
Sponsor: Advanced Accelerator Applications

Services de Médecine Nucléaire 
Et de Rhumatologie 
Clinical trial study 
Protocol Amendment n°4; 16 December 2014 
Replaces Protocol Amendment 3; 08 April 2014 
A Phase I-IIa study of safety, tolerance, pharmacokinetics, 
dosimetry and benefice of early nuclear medicine imaging of 99mTc-
rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing 
spondylitis 
Study number: 1002  / NCT number: NCT02328027
Study Phase: I-IIa 
Principal investigator 
Prof. J. Prior, PhD, MD, Head of Nuclear Medicine, CHUV, 1011 Lausanne, Switzerland 
Signature: ……………………………………………………………………. 
Co-investigators 
, MD 
, 
, PhD, 
, 
, PhD, 
, 
, MD, 
, 
Prof. 
, MD, 
, 
Patients coming from department of  
Prof. 
, MD, 
, 
 
Signature: ……………………………………………………………………. 
Sponsor 
Advanced Accelerator Applications Switzerland S.A., 4 rue du Tour de l’Ile, 1204 Geneva 
Investigational Medicinal Product (IMP) 
Kit for the Preparation of Tc-99m Recombinant Human Annexin V-128 for Injection 
Manufacturer of Product 
 Italy 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 2 of 67 
 
 
 
 
PV Responsible: 
 
Advanced Accelerator Applications 
Tel : 
  
Fax : 
 
E-mail: 
 
Contacts for Safety Reporting: 
 
Advanced Accelerator Applications 
Tel:
  
Fax: 
 
Mobile : 
  
E-mail: 
 
Contacts for Clinical Development: 
 
 
Advanced Accelerator Applications 
Tel: 
 
E-mail: 
  
 
 
 
Advanced Accelerator Applications 
Tel :
  
Fax:
E-mail: 
 
 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 3 of 67 
STUDY ACKNOWLEDGMENT 
Protocol N°1002/Protocol Amendment n°4, 16 December 2014 
 
1. I have carefully read this protocol entitled “A Phase I-IIa study of safety, tolerance, 
pharmacokinetics, dosimetry and benefice of early nuclear medicine imaging of 99mTc-rhAnnexin 
V-128 in patients with rheumatoid arthritis or ankylosing spondylitis”, and agree that it contains all 
the necessary information required to conduct the study. I agree to conduct this study as outlined 
in the protocol. 
2. I understand that this study will not be initiated without approval of the appropriate Institutional 
Review Committee/Ethics Committee and that all administrative requirements of the governing 
body of the institution will be complied with fully. 
3. I confirm that I will conduct the study in accordance with the International Conference on 
Harmonisation (ICH) Good Clinical Practice (GCP) guidelines and the provisions of the Helsinki 
Declaration; copies of these documents have been given to me by the Sponsor. 
4. I will also ensure that sub-investigator(s) and other relevant members of my staff have access to 
copies of this protocol, the ICH GCP guidelines, and the Helsinki Declaration to enable them to 
work in accordance with the provisions of these documents. 
5. Written informed consent will be obtained from all participating subjects in accordance with 
institutional and ICH Guidelines for Good Clinical Practice. 
6. I will enroll patients who meet the protocol criteria for entry and who can be followed up in 
accordance with this protocol. 
7. I understand that my signature on each completed Case Report Form indicates that I have 
carefully reviewed each page and accept full responsibility for the contents thereof. 
8. I understand that the information presented in this study protocol is confidential and I hereby 
assure that no information based on the conduct of the study will be released without prior 
consent from the Sponsor unless this requirement is superseded by the Health Authority and/or 
the European Medicines Agency. 
 
_______________________________________________ 
   _______________ 
Investigator’s Name and Signature 
 
 
Date 
 
_______________________________________________ 
   _______________ 
AAA Switzerland, CEO, Name and Signature                                                                        Date 
 
 
_______________________________________________ 
   _______________ 
 
AAA, Head of BD and Pre-clinical Development, Name and Signature 
 
 
Date 
 
_______________________________________________ 
   _______________ 
AAA, Head of Clinical Development, Name and Signature 
 
                            Date  
 
 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 4 of 67 
SYNOPSIS 
Investigational 
Medicinal Product 
Kit for the Preparation of Tc-99m Recombinant Human Annexin V-128 for 
Injection 
Title of the study 
A Phase I-IIa Study of safety, tolerance, pharmacokinetics, dosimetry and 
benefice of early nuclear medicine imaging of 99mTc-rhAnnexin V-128 in 
patients with rheumatoid arthritis or ankylosing spondylitis 
Study centre 
Nuclear Medicine Department, CHUV, 1011 Lausanne, Switzerland 
Sponsor 
Advanced Accelerator Applications Switzerland S.A., 4 rue du Tour de l’Ile, 
1204 Geneva 
Subject’s 
Indication 
Rheumatoid Arthritis (RA) or Ankylosing Spondylitis (AS) 
Objectives 
Primary Objectives: 
 
To determine the safety and tolerability of imaging with 99mTc-
rhAnnexin V-128.  
 
Secondary Objectives: 
 
To determine the biodistribution, pharmacokinetics and radiation 
dosimetry of 99mTc-rhAnnexin V-128 
 
 
To demonstrate the time-dependent distribution and localization of 
99mTc-rhAnnexin V-128 both in RA and AS patients 
 
 
To determine ability of early imaging with 99mTc-rhAnnexin V-128 to 
evaluate the presence of lesions before and after short term treatment 
of  either RA or AS patients  
Rationale 
Annexin V is an endogenous human protein that binds to phosphatidylserine, a 
molecule expressed only on the surface of apoptotic cells. Technetium-99m 
(Tc-99m) is a medical isotope widely used in diagnostic imaging.  99mTc-
labelled annexin V has demonstrated the ability to image cellular apoptosis 
and necrosis of, among others, rheumatoid arthritis or ankylosing spondylitis 
conditions. 
Planned number of 
patients 
20 evaluable patients (patients who have completed Day 56 assessments) will 
be included in the study with either rheumatoid arthritis or with ankylosing 
spondylitis. 
Ten enrolled patients, independently from the group (RA or AS), will take part 
in adosimetric and pharmacokinetics (PK) sub-study, after providing written 
approval.  
Out of the first 6 enrolled patients, at least 3 patients must take part in the sub-
study. 
Study design and 
Methodology 
This is a monocentric, open label, Phase I-IIa study 
Subjects who have signed the informed consent and are eligible to participate 
in the study will be subjected to the following assessments: 
 
At screening, patients will have a physical examination, vital signs, 
blood analysis (haematology, coagulation, chemistry and immunology), 
urine analysis, a bone scintigraphy if not already performed within 8 
weeks before rhAnnexin V-128 administration, an ECG, a pregnancy 
test for women with childbearing potential, BASDAI, BASFI, BASMI for 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 5 of 67 
patients with AS, DAS28 Disease Activity Score assessments for 
patients with RA. 
 
On Day 1, patients will have whole body scintigraphies with 99mTc-
rhAnnexin V-128, vital signs assessment and an ECG. A pregnancy 
test will also be performed prior to rhAnnexin V-128 administration. The 
first 3 patients (who will not take part in the sub-study) will be imaged 
at 60 min and at 2 hrs after administration. Next enrolled patients will 
be imaged at a time in line with the results of the image acquisition in 
the first 3 patients who will have participated in the sub-study. 
Additional images, blood and urine samples will be taken for the 10 
patients participating in the dosimetric and PK study. 
 
At Day 2, patients will be called over the phone to inquire if they 
experienced allergic reactions such as edema or rash. Patients who 
will participate in the PK and dosimetric sub-study will be interviewed in 
face to face on site meeting during the visit on Day 2. For these last 
patients, blood/urine analysis, whole body scintigraphy with 99mTc-
rhAnnexin V-128 will be repeated 24 hours later for the dosimetric and 
pharmacokinetics analyses. Vital signs and ECG will also be assessed.  
 
At Day 30+/- 3 days, all patients will have immunological evaluations 
as well as blood (haematology and biochemistry) and urine analysis, 
ECG and vital signs. 
 
At 6 weeks (Day 42) ± 2 weeks, a whole body scintigraphy with 99mTc-
rhAnnexin V-128 at a time in line with the results of the image 
acquisition in the first 3 patients who will have participated in the sub-
study, ECG, physical examination, vital signs, blood/urine analyses, a 
pregnancy test for women with childbearing potential, BASDAI, BASFI, 
BASMI for patients with AS, DAS28 Disease Activity Score 
assessments for patients with RA will be performed in all patients.  
 
At Day 43, patients will be called over the phone to inquire if they 
experienced allergic reactions such as edema or rash. 
 
 At 8 weeks (Day 56) ± 2 weeks, vital signs and immunological 
evaluation will be performed. 
 
At Day 90+/- 2 weeks, all patients will have immunological evaluations, 
ECG, physical examination and vital signs, blood and urine analysis, 
BASDAI, BASFI, BASMI for patients with AS, DAS28 Disease Activity 
Score assessments for patients with RA. 
Treatment 
The single dose vial (rhAnnexin V-128: 0.40 mg) will be reconstituted with 740 
MBq (20 mCi) of 99mTc. The labelling reaction requires 90 minutes and the 
reconstituted radiolabelled product is stable for 6 h. For the purpose of this 
study, it is recommended to administer the reconstituted solution within 4 
hours after completion of the labelling reaction.The drug is administered at a 
dose of 250 MBq as a single intravenous bolus over 10-20 seconds at Day 1 
and at 6 weeks (42 days) +/- 2 weeks after the first administration. 
Inclusion/ 
exclusion criteria 
Inclusion criteria 
1. Patients diagnosed with RA based on ACR/EULAR 2010 criteria with a 
score ≥ 6, OR 
Patients diagnosed with AS based on the ASAS criteria. Patients with 
RA must have serology assessment performed and documented at the 
time of enrolment. 
2. Patient with RA active disease (DAS > 2,6) and the introduction of a Bi-
DMARD treatment should be indicated.  
RA patients must at least be treated with DMARD (methotrexate, 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 6 of 67 
leflunomide and sulfasalazine) or combination of these treatments for 
at least 3 months. Treatment will be pursued while on study.  
OR 
RA patients must have been previously treated with Bi-DMARD before 
initiation of the new Bi-DMARD treatment. The non-response of the 
previous Bi-DMARD treatment must be documented. 
OR 
Patients with ankylosing spondylitis with insufficiently controlled 
disease while under NSAID and indication for Bi-DMARD. These 
patients must be under NSAID for at least 3 months and under the 
same NSAID for at least 1 month prior to enrolment.  
3. ≥ 18 years old 
4. Karnofsky ≥ 80%  
5. Negative pregnancy test for women with childbearing potential,  
6. For women with childbearing potential, use of two reliable means of 
contraception (e.g., hormonal contraceptive, patch, vaginal ring, 
intrauterine device, associated with other barrier method of 
contraception such as the use of condoms) throughout their 
participation to the study 
7. Absence of ECG anomaly 
8. Written ICF signed 
Exclusion criteria 
1. Pregnancy or lactation 
2. Liver impairment (ALT, AST or Bilirubin > 2 ULN) at screening visit or 
baseline  
3. Kidney impairment (serum creatinine > 1.5 mg/dL) 
4. History of congestive heart failure (NYHA III & IV) 
5. History of malignant disease within 5 years  
6. History of any disease or relevant physical or psychiatric condition or 
abnormal physical finding which may interfere with the study objectives 
at the investigator judgment 
7. Know hypersensitivity to the investigational drug or any of its 
components 
8. Participation to another clinical trial within 4 weeks before study 
inclusion except for patients who have participated or who are 
currently participating in an interventional study without any study drug 
administration. 
 
Study duration and assessments: maximum 4 months (+/- 2 weeks) including the screening period 
 
Dosimetry 
 
 
 
 
 
 
 
 
 
 
 
The quantitative in vivo biodistribution of the 99mTc-rhAnnexin V-128 will be 
determined through whole-body planar imagings. In addition, a SPECT/CT will 
be performed on the abdominal/pelvis regions at 3 hours post administration for 
the first 3 patients included in the sub-study in order to generate relevant 
dosimetry data after extrapolation for the reconstruction with OLINDA software. 
Depending upon the results in those 3 patients, the SPECT/CT on the 
abdominal/pelvis regions will be performed at 5 hours post administration 
Reconstruction will be done using iterative reconstruction incorporating CT-
based attenuation correction and dual-energy-window scatter correction. 
Dynamic planar imaging will be acquired during the first 10 minutes followed by 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 7 of 67 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pharmacokinetics 
 
 
 
 
 
whole body planar images at 30min, 60 min, 2hrs, 4 hrs and 24 hrs post-
injection for the first 3 patients included in the sub-study. Depending upon the 
results in those 3 patients, the timeframe for dosimetry measurements and PK 
will be confirmed or modified with a time-point at 3 hrs (instead of 2 hrs) and 6 
hrs (instead of 4 hrs) for the following 7 enrolled patients in the sub-study. 
. 
Radiation dose to the organ of interests (particularly the kidneys), effective 
dose equivalent and effective dose will be calculated following the MIRD 
committee guidelines using the OLINDA/EXM software. 
 
Blood and urine collection and counting: 
Venous blood samples will be drawn for each subject at screening, Day 30, 
Day 42 and Day 90 for lab analysis (Haematology, biochemistry).  
For patients included into the subgroup of PK and dosimetric study, blood 
sample will also be collected for lab analysis (Haematology, biochemistry) at 
Day 2. For the first 3 patients, a further 10 ml of venous blood samples will be 
drawn at nominal times of 0, 5, 10, 15, 30, 60 minutes as well as 2 hrs, 4hrs 
and 24 hrs post administration. Depending upon the results in those 3 patients, 
the timeframe for dosimetry measurements and PK will be confirmed or 
modified with a time-point at 3 hrs (instead of 2 hrs) and 6 hrs (instead of 4 
hrs) for the following 7 enrolled patients in the sub-study. 
The following whole blood and serum aliquots will be prepared as described in 
Appendix 2, for radioactivity measurements, and PK. 
For immunogenicity assays, venous blood samples will be drawn for each 
subject at screening, at Day 30 ± 3 days, at Day 56 ± 14 days and Day 90 ± 14 
days. 
Total quantity of collected blood samples for patients (participating or not in the 
PK and dosimetric sub-study) is described in Appendix 3.  
 
Urine sample will be collected within 24 hrs prior to 99mTc-rhAnnexin V-128 
administration, preferable just prior to its administration (0 h sample) to achieve 
bladder emptying. Urine collections will be obtained and volume recorded, 
possibly in the time intervals 0-1 h, 1 h – 4 hrs, 4 hrs -16 hrs, 16 hrs – 24 hrs 
post administration. Dual 2 mL aliquots of urine from each period will be 
counted in a gamma counter at local laboratory. Urine samples (10 mL) will 
also be analyzed by SEC-HPLC technique at local laboratory.   
 
Blood clearance fractions and effective half-life estimates from multi-term non-
compartmental 
exponential 
analysis 
will 
be 
calculated 
from 
serial 
measurements of radioactivity in the whole blood and serum. 
 
 
Pharmacokinetic analysis will be also performed based on rhAnnexin V-128 
serum concentration determined by ELISA method. 
As mentioned above, venous blood samples of 10 ml volume each will be 
taken from the first 3 patients at nominal times of 0, 5, 10, 15, 30, 60 minutes 
as well as 2 hrs, 4hrs and 24 hrs post administration. Depending upon the 
results in those 3 patients, the timeframe fordosimetry measurements and PK 
samples will be confirmed or modified with a time-point at 3 hrs (instead of 2 
hrs) and 6 hrs (instead of 4 hrs) for the following 7 enrolled  patients in the sub-
study. The blood will be processed and aliquoted as described in Appendix 2. 
Two aliquots of at least 0.6 mL of serum per time-point will be frozen at -80°C. 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 8 of 67 
 
 
 
 
 
Immunogenicity 
assessments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Safety and 
tolerability 
After complete decay of radioactivity, one out of two serum samples per time-
point will be shipped to the central laboratory and analyzed by ELISA to 
determine the rhAnnexin V-128 concentration in serum (method detailed in the 
Laboratory Manual). 
 
Assays for anti-rhAnnexin V-128 IgG and IgM antibodies will be performed in 
serum samples by ELISA. For this purpose 10mL blood samples will be 
collected at baseline, at Day 30 ± 3 days and at Day 56 ± 14 days. An 
additional sample is required 3 months after the first administration of the 
99mTc-rhAnnexin V-128 (Day 90 ± 14 days) in case of positive anti-Annexin 
antibodies outcome in previous examinations. Serum will be prepared, divided 
into six aliquots and frozen (-80°C) until complete decay. Three out of six 
serum samples per time-point will be then shipped to the centralized 
laboratory, where the analysis for anti-rhAnnexin V-128 antibodies will be 
performed (methods detailed in the Laboratory Manual). 
24 hours after each treatment injection (at Day 2 and Day 43), each patient will 
be interviewed over the phone (in face to face meeting at Day 2 for patients 
who will participate into the PK and dosimetric sub study) in order to inquire if 
they experienced signs or symptoms of allergic reactions (edema, rash). If this 
is the case, Adverse Event(s) should be reported and recorded in the Case 
Report Form. 
 
Adverse events will be collected in the Case Report Form (CRF). 
 
 
 
 
 
 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 9 of 67 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 10 of 
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99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 11 of 
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99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 12 of 
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99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 13 of 
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99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 14 of 
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Visit schedule – Table 1 
 
1 Only for patients participating to the dosimetric and PK substudies.  
2 Venous blood samples of 10 ml volume each will be taken from the first 3 patients at nominal times of 0, 5, 10, 15, 30, 60 minutes and 2 hrs, 4hrs 
and 24 hrs post administration as described in Appendix 2 for radioactivity measurements, and PK. Depending upon the results in those 3 patients, 
timeframe of radioactivity measurements and PK will be confirmed or modified with a time-point at 3 hrs (instead of 2 hrs) and 6 hrs (instead of 4 hrs) 
as required for the following 7 enrolled patients in the sub-study. The whole blood and serum samples (bullet points 1 and 2) will be counted in an 
auto-gamma counting system at the CHUV/NUC laboratory. 
3 Anti-rhAnnexin V-128 IgG and IgM antibodies will be performed in serum samples by ELISA. For this purpose 10mL blood samples will be 
collected at baseline, Day 30 (±3 days), Day 56 (±2weeks) and Day 90 (±2weeks) post  administration of test agent (sample at 90 days is required 
only in case of positive anti-annexin antibodies outcome in previous examinations). Serum will be prepared, divided into six aliquots and frozen (-
80°C) until complete decay. Three out of six serum samples per time-point will be then shipped to the central laboratory. 
4 One urine sample will be collected within 24 hrs prior to 99mTc-rhAnnexin V-128 administration, preferable just prior to the administration of study 
Study Procedures 
Screening   
(±4 weeks) 
Day 
1 
24 
hours1 
 
Day 30 
±3 
days 
Day 42 
±2weeks 
Day 56 
±2weeks 
Day 90 
±2weeks 
Written informed 
consent 
x 
 
 
 
 
 
 
Inclusion/exclusion 
criteria 
x 
 
 
 
 
 
 
Medical history  
x 
 
 
 
 
 
 
Concomitant 
medications 
including RA and AS 
treatment  
x 
x 
x 
x 
x 
x 
 
x 
Disease assessment 
(BASDAI, BASFI, BASMI 
for AS for AS patients,  
DAS28 scales including 
Ultrasound assessments 
for RA patients) 
x 
 
 
 
x 
 
x 
Physical examination  
x 
 
 
 
x 
 
x 
Vital signs (BP and 
HR) 
x 
x 
x 
x 
x 
x 
x 
Lab analysis 
(haematology, 
biochemistry; urine) 
x 
 
x 
x 
x 
 
x 
Venous/urine 
sampling  
(PK and dosimetry)2 
 
X1 
x 
 
 
 
 
Immunogenicity by 
ELISA3 
x 
 
 
x 
 
x 
x 
Urine SEC-HPLC 
analysis1,4 
 
x 
x 
 
 
 
 
Pregnancy test 
x 
x 
 
 
x 
 
 
Standard 12-lead 
ECG 
x 
x 
x 
x 
x 
 
x 
rh-Annexin V-128 
administration6 
 
x 
 
 
x 
 
 
Bone scintigraphy7 
x 
 
 
 
 
 
 
Whole Body 
scintigraphic 
imaging5 
 
x 
x 
 
x 
 
 
Adverse Events 
x 
x 
x 
x 
x 
x 
x 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 15 of 
67 
drug (0 h sample) to achieve bladder emptying. Quantitative urine collections will be obtained (and volume recorded) possibly in the time intervals 
0-1 h, 1 h – 4 hrs, 4 hrs – 16 hrs, and 16 hrs – 24 hrs post administration. Dual 2 mL aliquots of urine from each period will be counted in a gamma 
counter at the CHUV/NUC laboratory.  
Urine samples (10 mL aliquot) will be analysed as a function of time by SEC-HPLC technique at the local laboratory in order to gain information on 
the chemical status of 99mTc-rhAnnexin V-128 and on the presence of 99mTc-rhAnnexin V-128-related species. 
5 The first 3 patients participating to the dosimetric and PK sub-study will be imaged post administration at 30min, 60 min, 2 hrs, 4 hrs and 24 hrs 
after the first administration.  Depending upon the results in those 3 patients, timeframes of the radioactivity measurements and PK will be 
confirmed or modified with a time-point at 3 hrs (instead of 2 hrs) and 6 hrs (instead of 4 hrs) as required for the following 7 enrolled patients in the 
sub-study. The other first 3 patients (not taking part to the sub-study) will be imaged on Day 1 at 60 min and at 2 hrs after administration. Next 
patients will be imaged at a time defined on the basis of the data collected in the first 3 patients participating to the dosimetric and PK sub-study. 
On  Day 42 ± 2 weeks, all patients will be imaged at a suitable time, defined on the basis of the data collected on the first 3 patients participating to 
the dosimetric and PK sub-study. 
624 hours after each treatment injection, each patient will be contacted to inquire if they experienced signs or symptoms of allergic reactions 
(edema, rash). 
7The bone scintigraphy must be performed at screening except for patients who already had a bone scintigraphy within 8 weeks prior to 99mTc-
rhAnnexin V-128 administration. In that case, the bone scintigraphy report must be collected (after patient anonymity) and will be reviewed. 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 16 of 
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LIST OF ABBREVIATIONS  
 
AE 
ACD 
ACR 
ALAT 
ALT 
Anti-CCP AB 
AP 
AS 
ASAS 
ASAT 
AST 
BASDAI 
BASFI 
BASMI 
Bi-DMARD 
BUN 
CHUV 
CRF 
CRO 
CRP 
CT 
CV 
DAS28 
DMARD 
DMC 
DNA 
DBP 
ECG 
EDTA 
ELISA 
ESR 
EULAR 
Adverse Event 
Anticoagulant Citrate Dextrose Solution 
American College of Rheumatology 
Alanine Aminotransferase 
Alanine Transaminase  
Anti-cyclic citrullinated peptide antibodies 
Alkaline Phosphatase 
Ankylosing Spondylitis 
Assessment of Spondylo-Arthritis Society 
Aspartate Aminotransferase 
Aspartate Transaminase 
Bath Ankylosing Spondylitis Disease Activity Index 
Bath Ankylosing Spondylitis Functional Index 
Bath Ankylosing Spondylitis Metrology Index 
Biological Disease Modifying Anti-Rheumatic Drug 
Blood Urea Nitrogen 
Centre Hospitalier Universitaire Vaudoix 
Case Report Form 
Clinical Research Organisation 
C-Reactive Protein 
Computed Tomography 
Cardiovascular 
Disease Activity Score 
Disease Modifying Anti-Rheumatic Drug 
Data Monitoring Committee 
Deoxyribonucleic Acid 
Diastolic Blood Pressure 
Electrocardiogram 
Ethylenediaminetetraacetic Acid 
Enzyme-Linked Immunosorbent Assay 
Erythrocyte Sedimentation Rate 
European League Against Rheumatism 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 17 of 
67 
FDA 
FDG 
Gamma-GT 
GCP 
GE 
GI 
GP 
Hb 
HPLC 
HR 
HYNIC 
IBD 
ICF 
ICP-MS 
ICH 
ICP-OES 
ICRP 
IEC 
IL-6 
IMP 
INR 
IRB 
ITLC 
LDH 
MIRD 
MCV 
MedDRA 
MRI 
NSAID 
NOAEL 
OFSP 
PBS 
PK 
PS 
Food and Drug Administration 
Fluorodesossi- Glucose 
Gamma-Glutamyl Transpeptidase  
Good Clinical Practice 
General Electric 
Gastrointestinal 
General Practitioner 
Hemoglobin 
High-Performance Liquid Chromatography 
Heart Rate 
Hydrazino-Nicotinamide 
Inflammatory Bowel Disease 
Informed Consent Form 
Inductively Coupled Plasma Mass Spectrometry 
International Conference on Harmonisation 
Inductively Coupled Plasma Optical Emission Spectrometry 
International Commission on Radiological Protection 
Independent Ethics Committee 
Interleukine-6 
Investigational Medicinal Product 
International Normalised Ratio 
Institutional Review Board 
Instant Thin Layer Chromatography 
Lactate Dehydrogenase 
Medical Internal Radiation Dose 
Mean Corpuscular Volume 
Medical Dictionary For Regulatory Activities 
Magnetic Resonance Imaging 
Non Steroidal Anti-Inflammatory Drug 
No Observed Adverse Effect Level 
Office Fédéral de la Santé Publique 
Phosphate Buffered Saline 
Pharmacokinetics 
Phosphatidylserine 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 18 of 
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PT 
PTT 
PV 
QA 
QC 
RA 
RBC 
RCP 
ROI 
RR 
SAE 
SBP 
SEC-HPLC  
SOP 
SPECT 
TBR 
TLC 
TNF 
US 
UV/Vis 
WBC 
WFI 
WHO 
VOI 
 
Prothrombin Time 
Partial Thromboplastin Time 
Pharmaco Vigilance 
Quality Assurance 
Quality Control 
Rheumatoid Arthritis 
Red Blood Cell 
Radiochemical Purity 
Region of Interest 
Respiratory Rate 
Serious Adverse Event 
Systolic Blood Pressure 
Size-Exclusion HPLC 
Standard Operating Procedure 
Single-Photon Emission Computed Tomography 
Target to background ratio 
Thin Layer Chromatography 
Tumour Necrosis Factor 
United States 
Ultraviolet/Visible 
White Blood Cell 
Water For Injection 
World Health Organization 
Volumes Of Interest 
 
 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 19 of 
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Table of Contents 
LIST OF ABBREVIATIONS ............................................................................................................................... 16 
Anti-CCP AB ................................................................................................................................................... 16 
1 
INTRODUCTION ........................................................................................................................................ 21 
Background and rationale ................................................................................................................................. 21 
99mTc-rhAnnexin V-128 Risk-Benefit Assessment ........................................................................................... 22 
2 
STUDY OBJECTIVES AND HYPOTHESIS ........................................................................................... 24 
3 
STUDY DESIGN ......................................................................................................................................... 25 
Study Outline .................................................................................................................................................... 25 
Study duration and End of Study ...................................................................................................................... 25 
4 
PATIENTS SELECTION ........................................................................................................................... 25 
Inclusion Criteria............................................................................................................................................... 25 
Exclusion Criteria ............................................................................................................................................. 26 
Number of patients ............................................................................................................................................ 26 
Screening Failures and Drop Outs patients ....................................................................................................... 27 
Discontinuation Criteria for Individual Patients ............................................................................................... 27 
Prohibition and Restrictions .............................................................................................................................. 28 
5 
STUDY MEDICATION AND TREATMENT ............................................................................................ 28 
Packaging and Labelling ................................................................................................................................... 28 
Handling of Study Medication .......................................................................................................................... 29 
Precautions and recommendation for use .......................................................................................................... 29 
Study Medication Dose, Mode of Administration, Batch Number ................................................................... 30 
6 
ASSESSMENTS ......................................................................................................................................... 30 
Clinical assessment ........................................................................................................................................... 31 
Imaging ............................................................................................................................................................. 32 
Immunogenicity assessments ............................................................................................................................ 32 
Pharmacokinetics (blood and urine) .................................................................................................................. 33 
SEC-HPLC urine assessment ............................................................................................................................ 33 
Dosimetry .......................................................................................................................................................... 33 
7 
DATA MONITORING COMMITTEE (DMC) ........................................................................................... 35 
8 
STATISTICAL METHODS ........................................................................................................................ 35 
Sample size ....................................................................................................................................................... 35 
Demographics and Other Subject Characteristics ............................................................................................. 36 
Concomitant Medications ................................................................................................................................. 36 
Laboratory Tests ............................................................................................................................................... 36 
Vital Signs and ECG ......................................................................................................................................... 36 
Physical Examination ........................................................................................................................................ 36 
Safety ................................................................................................................................................................ 36 
Dosimetry .......................................................................................................................................................... 37 
Pharmacokinetics and immunology .................................................................................................................. 37 
9 
ADVERSE EVENTS AND OTHER SAFETY ASPECTS ...................................................................... 37 
Definition of Adverse Events ............................................................................................................................ 37 
Definition of Serious Adverse Events ............................................................................................................... 37 
Criteria for Causal Relationship to the Clinical Study Medication ................................................................... 38 
Investigator Reporting Requirements ................................................................................................................ 38 
Reporting of Serious Adverse Events ............................................................................................................... 38 
Follow-up of Adverse Events ............................................................................................................................ 39 
Procedure in Case of Pregnancy ....................................................................................................................... 39 
New Safety Information Affecting the Conduct of the Study ........................................................................... 40 
10 TERMINATION OF THE STUDY ............................................................................................................. 40 
11 OPERATIONAL, ETHICAL, AND ADMINISTRATIVE CONSIDERATIONS ..................................... 40 
Clinical Study Monitoring................................................................................................................................. 41 
12 QUALITY ASSURANCE ............................................................................................................................ 46 
Appendix 1 ............................................................................................................................................................ 47 
Appendix 2 ............................................................................................................................................................ 57 

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Appendix 4 ............................................................................................................................................................ 61 
Appendix 5 ............................................................................................................................................................ 64 
 

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1 INTRODUCTION 
 
Background and rationale 
Apoptosis and necrosis are the two major cell death processes. Apoptosis is an energy-dependent 
process of cell death with activation through an internal and regulated suicide program. Necrosis 
differs from apoptosis and is accidental cell death induced by a variety of chemical or physical insults. 
Necrosis is characterized by progressive swelling of the cell, denaturation of proteins in the cytoplasm 
and disruption of the plasma membrane integrity usually associated with an inflammatory response 
[1]. In contrast, apoptosis proceeds by a cascade of events including externalisation of 
phosphatidylserine (PS), shrinkage of the cytoplasm, condensation of nuclear proteins, degradation of 
DNA and fragmentation of the cell [2]. Apoptosis is a form of programmed cell death and useful to the 
organism as a means of selectively removing unwanted cells. However, apoptosis occurs excessively 
in disease states including acute myocardial infarction, stroke and inflammatory conditions [3, 4].  
Annexin V, an endogenous human protein with a molecular weight of 36 kDalton (320 aa), is produced 
by the epithelial cells of many tissues and blood cells (placenta, umbilical vessels, liver, spleen, 
kidney, heart, uterus, skeletal muscle, erythrocytes, leukocytes, endothelial cells, and platelets). 
Physiologically it plays a role in binding cells undergoing apoptosis/necrosis and acts as an “eat me” 
signal for macrophage phagocytosis.  This function is mediated by the high affinity binding (Kd = 7 nM) 
of Annexin V to phosphatidylserine (PS). PS is a phospholipid physiologically present in the inner 
leaflet of cell membrane and maintained in this position by a series of enzymes (floppase/flippase). 
Apoptosis plays a critical role in the pathogenesis of a number of disorders (including cerebral and 
myocardial ischemia, autoimmune and neurodegenerative diseases, viral illness, organ and bone 
marrow transplant rejection, and tumor response to chemotherapy and radiation), leading to the 
activation of proteolytic enzymes (caspases) and to the changes of plasma membrane structure. As a 
result, there is rapid redistribution of PS from the inner membrane leaflet to the outer membrane leaflet 
of apoptotic cells, exposing the anionic head group of PS to Annexin V binding. Such changes occur 
within 30-120 min of apoptotic signalling in vitro. The externalization of PS is a general feature of 
apoptosis occurring prior to membrane bleb formation, deoxyribonucleic acid (DNA) degradation and 
nuclear condensation. On the other hand, PS is also accessible for Annexin V binding in necrotic cells 
because of disruption of the plasma membrane.  
Rheumatoid arthritis (RA) is associated with apoptosis caused by the influx of autoimmune cells which 
stimulates an inflammatory synovitis that is a hallmark of early RA [5-7]. Rheumatoid Arthritis is a 
chronic relapsing incurable disease of unknown aetiology that affects at least 2% of the adult 
population in the U.S. and Europe [8].  There are few specific preclinical and clinical biomarkers of RA. 
Anti-CCP (cyclic citrullinated peptide) antibodies are a good example of that kind of biomarker. They 
can be found in patients many months before patients clinically develop RA [9, 10]. 
In contrast to established disease, diagnosis of early RA is problematic. Therefore classification 
criteria are used to identify RA as early as possible; those criteria are a mix of clinical, biological and 
immunological data.   All current imaging techniques including conventional (plain film) radiography, 
MRI, 99mTc-DPD bone scans, and F-18 FDG-PET cannot directly evaluate preclinical (pre-articular 
phase) RA limiting the information on this stage of disease [11-15]. In the modern rheumatology, 
rheumatologists are regularly using ultrasound examinations of joints to evaluate infraclinical synovitis 
or erosions, which could not be seen on conventional radiography; both of them – synovitis and 
erosions - are found in RA. Ultrasounds are used to improve and to complete the quality of the clinical 
assessment of RA.  

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Diagnosis of early stage RA prior to the erosive bone changes, which are a radiographic hallmark of 
the disease is difficult with a sensitivity of as low as 50%.  Many clinicians now believe that early 
institution of anti-RA therapy may reduce the severity of the disease and, in some cases, may even 
prevent the recurrence of the symptoms.   
The first step in the treatment of the disease is to introduce as soon as possible a disease-modifying 
anti-rheumatic drug (DMARD) to prevent the development of a destructive arthritis that could lead to 
the loss of function of a joint. Methotrexate, leflunomide and sulfasalazine belong to that category of 
medication; unfortunately they all need a couple of weeks until they can act as an anti-inflammatory 
drug, therefore glucocorticoids or non steroidal anti-inflammatory drugs (NSAID) are prescribed in the 
very first steps of the treatment of RA to control inflammation; both categories will be step down in a 
second time. If DMARDs fail to achieve what they are aiming at, biological treatments – anti-tumor-
necrosis factor (TNF) therapies, anti-CD 20 positive lymphocytes treatments, anti-interleukine 6 or 
abatacept - can be added as second line agents[16].  
Ankylosing spondylitis (AS) is a chronic, disabling rheumatic disease characterized by inflammatory 
back pain, restricted spinal mobility, and frequently peripheral arthritis, enthesitis, and extra-articular 
manifestations like acute anterior uveitis. Patients fulfil classification criteria for AS if characteristic 
radiological changes of the sacroiliac (SI) joints are present, together with defined clinical symptoms, 
physical findings and the presence of HLA-B27. 
An earlier diagnosis of ankylosing spondylitis is required because there is still a 5-7 year delay 
between first symptoms and diagnosis, and new effective treatments are available for active disease. 
Radiographic diagnosis is complicated by the slow evolution of radiological changes in many patients. 
Thus, sacroiliac radiographs may be normal in the early phase of disease and may stay normal in 
some patients for many years. Hence, two sets of criteria that allow earlier diagnosis in patients with 
predominant axial and peripheral manifestations were developed: the ASAS criteria[17]. 
In AS, there are different therapeutical options depending on the extension of the disease. In case of 
AS limited to axial skeleton, different NSAIDs are used as first line agents associated to 
physiotherapy. For AS with isolated appendicular skeleton manifestations, therapeutical strategies as 
in RA can be tried. Anti-TNF drugs are second line agents for diseases with axial and appendicular 
skeleton manifestations[18]. 
 
99mTc-rhAnnexin V-128 Risk-Benefit Assessment 
99mTc-labelled Annexin V radiopharmaceuticals have been developed for imaging apoptosis [19]. 
RhAnnexin V-128 is a protein produced by recombinant techniques in Escherichia coli. It has been 
prepared by Dr. John Tait as a mutant of Annexin V (wild type, human Annexin), in which six amino 
acids have been added to the amino terminus of rh-Annexin V to form an endogenous 99mTc-binding 
site. Published data in preclinical studies in mice show that 99mTc-rhAnnexin V-128 has only 6-8% 
renal localization at 1 hour post intravenous injection compared to 45-50% renal localization of 99mTc-
HYNIC-Annexin V [20].  Moreover, 99mTc-rhAnnexin V-128 shows almost twice the target-to-
background localization at apoptotic targets in vivo as demonstrated by 99mTc-HYNIC-Annexin V. 
Annexin V binds with high affinity to phosphatidylserine exposed on the cell surface as an early step in 
the apoptotic cascade [19]. 99mTc-hydrazino-nicotinamide (HYNIC) Annexin V has been developed 
and used in Phase II clinical studies in patients with acute myocardial infarction [21-23], in patients 
with lymphoma [24], head and neck carcinoma [25, 26] and in patients with non-small-cell lung cancer 
receiving chemotherapy [27]. 99mTc-HYNIC-Annexin V has limitations including high uptake in the 
kidney resulting in a large patient radiation dose and significant abdominal scatter [28].  
New improved Annexin V-based imaging agents have been developed [20, 29] and have improved 
biodistribution profiles with less renal uptake compared to 99mTc-HYNIC-Annexin V and similar 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
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detection of apoptosis [24, 25]. This advantage of decreased renal retention of the radiolabelled 
mutant Annexin compound with decreased abdominal background and renal dosimetry needs to be 
demonstrated in humans. 
Preclinical characterization of 99mTc-rhAnnexin V-128 safety profile indicated that the product can be 
safely administered, both from the point of view of the proposed radioactive dose (250 MBq) and also 
considering the total drug substance (protein) present in a 250 MBq dose (0.4 mg). In particular, the 
radiation safety assessment performed based on extrapolations from animal biodistribution and 
dosimetry data showed that, for the proposed injected dose of 250 MBq, the estimated kidney 
absorbed dose in human is around 40 mGy, which is below the level recommended by FDA for the 
single dose per organ (0.05 Sv, as generally recognized as safe in the FDA Guidance for Industry and 
Researchers, 2010) and considerably lower than the threshold for nephrotoxicity reported in literature, 
that is 14 Gy (corresponding to 14 Sv for 99mTc) when delivering radiation dose in 2 fractions, as 
reported by Emami et al., 1991, for tolerance dose 5/5 (the probability of 5% complications within 5 
years of irradiation) reported in literature [30]. These estimated kidney absorbed doses are also lower 
than those achieved with some technetiated diagnostics currently used in the Nuclear Medicine 
practice (e.g. 99mTc MoAb antiCEA has kidney as critical organ with an absorbed dose in mGy/MBq of 
0.1-0.4 (that is 100-400 mGy for an injected dose of 1000 MBq). 
The estimation of effective dose for total human body, from an injected dose of 250 MBq, is 2.8 mSv, 
that is far below the FDA single-study limit of 30 mSv for research subjects, as per FDA Guidance for 
Industry and Researchers, 2010  [31]. 
Therefore, animal data from biodistribution/dosimetry studies and extrapolation of human kidney 
absorbed and total body effective dose, along with the current Nuclear Medicine practice concerning 
technetiated diagnostics, support the proposed single dose of 250 MBq of 99mTc Annexin V-128  for 
the Phase I-IIa study. 
Regarding the toxicity profile of the non-radiolabelled protein, a package of pre-clinical studies was 
designed in order to investigate the potential toxicity of rhAnnexin V-128. Preliminary 7-days toxicity 
studies conducted in rats and dogs, showed that rhAnnexin V-128, administered intravenously once 
daily, was well tolerated up to the highest tested dose, that is 450 fold (in rats) and 200 fold (in dogs) 
the proposed human dose. 
The main repeat-dose toxicity studies were conducted in rats and dogs as well, and consisted of 2-
weeks daily intravenous administrations of rhAnnexin V-128, at doses that were approximately 25, 50 
and 100 times the intended human dose. The toxicity profile was in general favourable, with some 
treatment-related findings in the spleen (germinal centres hyperplasia) and in the liver (periportal 
eosinophilic cell infiltration) in the rats at the intermediate and high dose, and some periportal 
subchronic inflammation in the dog liver at the high dose. These signs were in general reversible after 
2 weeks recovery period. The No-Observed-Adverse-Effect-Level (NOAEL) was defined to be 0.2 
mg/kg/day in rats (25 fold the intended human dose) and 0.4 mg/kg/day in dogs (50 fold the intended 
human dose). 
These findings meet the safety margins recommended in the relevant guideline[32], which indicates 
that the mass dose intended to be used in the Phase I studies should be at least 100 times lower than 
the NOAEL found in the acute toxicity studies in the rat and at least 25 times lower than the NOAEL 
found in the repeated toxicity studies in rat and dog. 
 
As described in sections 5.3.1 and 5.3.2 of the investigator Brochure, it is worth noticing that no 
adverse reaction, including any sign of allergic or anaphylactic reaction, was reported in animals 
during in vivo phase of any of the toxicity studies performed in rats and dogs. As a reference the dose 
range tested in animals was within 25 to 450 times the intended human dose (section 5.3 of the IB). 
 
In addition to the in vivo toxicology studies mentioned above, the safety of rhAnnexin V-128 was 
evaluated in a whole blood cytokine release ex-vivo assay (section 5.3.3 of the investigator Brochure). 
The results showed that rhAnnexin V-128 did not induce any cytokine release. 
 
An open label, single dose, Phase I clinical study of safety, tolerability, pharmacokinetics and nuclear 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
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medicine imaging of 99mTc-rhAnnexin V-128 intravenous administration of 370 MBq single intravenous 
bolus in 12 healthy adult volunteers has been conducted. A series of images for up to 24 hours from 
the time of injection and blood samples were obtained from time of screening, dosing day and 24 
hours after injection, with follow up visits at 72 hrs, 7 days and 30 days post injection.  A physical 
examination was conducted 72 hrs, 7 days and 30 days post administration of 99mTc - rhAnnexin V-
128.  No abnormal findings have been noted after administration of the studied imaging product and 
during the observation period. No immunology response has been reported in any of the 12 treated 
subjects (15 and 30 days post administration). The Phase I Clinical Trial Report is in preparation. 
 
2 STUDY OBJECTIVES AND HYPOTHESIS 
 
This Phase I-IIa study will be undertaken to determine the safety, tolerability, biodistribution and ability 
of early imaging with 99mTc-rhAnnexin V-128 to predict response to treatment. Patients with diagnosed 
rheumatoid arthritis (10 patients) or ankylosing spondylitis (10 patients) will be imaged on Day 1 and 
after a suitable interval time (6 weeks +/- two weeks) post-first administration of the imaging product. 
Ten patients, independently from the group (RA or AS), will participate to a dosimetry and PK sub-study 
after written approved consent. These patients will have additional images and blood sampling at Day 1 
and 24 hrs after administration of 99mTc-rhAnnexin V128. In these patients urines will be also analysed 
as a function of time by SEC-HPLC. 
Out of the first 6 patients, at least 3 patients must be enrolled in the dosimetric and PK sub-study.  
 
 
The Study objectives are: 
 
Primary Objectives: 
 
To determine the safety and tolerability of imaging with 99mTc-rhAnnexin V-128.  
 
Secondary Objectives: 
 
To determine the biodistribution, pharmacokinetics and radiation dosimetry of 99mTc-rhAnnexin 
V-128 
 
 
To demonstrate the time-dependent distribution and localization of 99mTc-rhAnnexin V-128 both 
in RA and AS patients 
 
To determine ability of early imaging with 99mTc-rhAnnexin V-128 to evaluate the presence of 
lesions before and after short term treatment of either RA or AS patients 
 
Study hypothesis:  
99mTc-rhAnnexin V-128 could be used as an adjunct for the diagnosis of early stage rheumatoid 
arthritis and ankylosing spondylitis and for the assessment of response to treatment of these diseases.   
Study justification:  
For the patient, the availability of an in vivo biomarker of early RA and AS with high sensitivity and 
specificity in the early stages of the disease could support the timely initiation of disease-modifying 
treatment, and could allow improved control of risk and cost on a patient-by-patient basis of the anti-
rheumatic agents now in clinical use. 

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3 STUDY DESIGN 
 
Study Outline 
 
This is a monocentric, open label, Phase I-IIa study. 
Patients who have signed the informed consent and are eligible for study participation according to the 
inclusion and exclusion criteria will receive a single intravenous bolus of 99mTc-rhAnnexin V-128 on Day 
1 and a single intravenous bolus of 99mTc-rhAnnexin V-128 6 weeks later (+/- 2 weeks).  
All patients will start a new RA or AS treatment on Day 2.  
In order to minimize the risks for the study population, patients will be enrolled with a minimum of 2-
week interval. 
Details on study assessments are provided in Protocol Section 6 and Table1. 
 
 
Study duration and End of Study 
 
Study duration is of 4 month +/- 2 weeks (including the screening period).  
Eligible patients will receive two injections: one on Day 1 and a second administration 6 weeks +/- 2 
weeks later.  The end of the study is defined as the moment that the last enrolled patient has 
completed 18 days follow-up after completing the second 99mTc-rhAnnexin V-128 administration An 
additional blood sample for immunological assay is required 3 months after the first administration of 
the 99mTc-rhAnnexin V-128 (Day 90 ± 14 days) in case of positive anti-Annexin antibodies outcome in 
previous examination. 
 
4 PATIENTS SELECTION 
 
Approval for the study will be obtained from the Research Ethics Committee in Lausanne, Swissmedic 
and the OFSP. All patients will provide written informed consent prior to the initiation of any study 
procedures. 
 
Inclusion Criteria  
1. Patients diagnosed with RA based on ACR/EULAR 2010 criteria (score ≥ 6),   
OR 
Patients diagnosed with AS based on the ASAS criteria. Patients with RA must have serology 
assessment performed and documented.at the time of enrolment. 
2. Patient with RA active disease (DAS > 2,6) and the introduction of a Bi-DMARD treatment 
should be indicated. RA patients must at least have been treated with DMARD (methotrexate, 
leflunomide and sulfasalazine) or combination of these treatments for at least 3 months. 
Treatment will be pursued while on study. 
OR 
RA patients must have been previously treated with Bi-DMARD before initiation of the new Bi-
DMARD treatment. The non-response of the previous Bi-DMARD treatment must be 
documented. 
OR 
Patients with ankylosing spondylitis with insufficiently controlled disease while under NSAID 
and indication for Bi-DMARD. These patients must be under NSAID for at least 3 months and 

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under the same NSAID for at least 1 month prior to enrolment. 
3. ≥ 18 years old 
4. Karnofsky ≥ 80%  
5. Negative Pregnancy test for women with childbearing potential 
6. For women with childbearing potential, use of two reliable means of contraception (e.g., 
hormonal contraceptive, patch, vaginal ring, intrauterine device, associated with other barrier 
method of contraception such as the use of condoms) , throughout their participation in the 
study 
7. Absence of ECG anomaly 
8. Written ICF signed 
 
Exclusion Criteria 
1. Pregnancy or lactation 
2. Liver impairment (ALT, AST or Bilirubin > 2 ULN) at screening visit or baseline  
3. Kidney impairment (serum creatinine > 1.5 mg/dL) 
4. History of congestive heart failure (NYHA III & IV) 
5. History of malignant disease within 5 years  
6. History of any disease or relevant physical or psychiatric condition or abnormal physical finding 
which may interfere with the study objectives at the investigator judgment 
7. Known hypersensitivity to the investigational drug or any of its components 
8. Participation to another clinical trial within 4 weeks before study inclusion except for patients 
who have participated or who are currently participating in an interventional study without any 
study drug administration. 
 
 
Number of patients 
 
Twenty evaluable patients (patients who have completed Day 56 assessments) will be recruited 
diagnosed either with Rheumatoid Arthritis (RA) or Ankylosing spondylitis (AS). Patients will be 
recruited with a ratio of 1:1 RA:AS. 
 
Details on treatment of the patients:  
 
Patients with RA will be diagnosed based on ACR/EULAR10 and will thereafter be evaluated with DAS 
28. Patients with AS will be diagnosed based on the ASAS criteria. Each patient will be anonymized 
and identified with a patient ID number. 
 
A unique subject identification number (Patient ID) will be assigned at the start of the Screening Period 
to each subject who signs the informed consent form until the study termination of the patient. This 
number will identify the subject throughout the study.  
Patient IDs will include the 2-digit country code number (SW) and a 3-digit subject number (ex: SW001 
for first subject In). 
 
In both groups of patients – i.e. RA and AS patients – the introduction of a Bi-DMARD treatment should 
be indicated at the moment of inclusion in the study. The Bi-DMARD therapy should start on Day 2 of 
the study. RA patients must have been treated at least with one DMARD (methotrexate, leflunomide 
and sulfasalazine) or a combination of them in the last 3 months – before inclusion - and this/these 
DMARD(s) will be continued in this study. Otherwise, RA patients must have been previously treated 
with Bi-DMARD before administration of the new Bi-DMARD treatment. The non-response of the 
previous Bi-DMARD treatment must be documented.  
AS patients must at least have been treated with NSAID in the last 3 months before inclusion and they 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
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should be under the same NSAID treatment during the last 4 weeks before inclusion.  
For RA patients, anti-tumour necrosis factor (TNF) antibodies, anti-interleukine 6 (IL-6) antibodies and 
abatacept therapies are to be considered and are authorized in Switzerland as first line Bi-DMARD 
agents in RA. On the contrary, anti-CD 20 positive lymphocytes antibodies can only be used, if one 
anti-TNF therapy failed. 
In the AS patients group, only anti-TNF antibodies can be considered, if NSAID are not sufficient. 
 
Ten patients enrolled in the study will be asked to participate in a dosimetry and PK sub-study, 
irrespective of the group they are part of (RA or AS).  
 
Screening Failures and Drop Outs patients 
For the purpose of this study, an “enrolled patient” is a patient who has signed the informed consent 
and meets all inclusion and exclusion criteria to participate in the study.  
A “screening failure” is a patient who has signed the informed consent, but who does not meet all 
selection criteria and has not received any study medication as part of this protocol. 
For patients not considered eligible after the screening period, the reason for not being eligible must be 
documented. No additional assessments are needed. 
A “drop-out” is a patient who has received the study medication and withdrawn consent during the 
participation in the trial. A “drop-out” may also be a patient who has been “lost to follow-up” and is 
presumed to have withdrawn consent prior to the end of the trial procedures. However, in the case 
where a patient who has signed the informed consent and has received study medication as part of this 
protocol, but who is (later) found not to meet all selection criteria, this will be considered a “protocol 
violation”. 
 
Discontinuation Criteria for Individual Patients 
The patient is free to withdraw from the study for any reason and at any time without giving reason for 
doing so and without penalty or prejudice. It is also possible that the Sponsor or Swissmedic request 
termination of the study if there are concerns about conduct or safety. 
A patient may be withdrawn from the study if: 
 
A serious adverse event (SAE) occurs. 
 
The patient fails to comply with the evaluations or other requirements of the study. 
 
The patient starts treatment with one of the medications disallowed. The final decision to 
withdraw a patient who starts treatment with disallowed medication will be made by the 
Sponsor following consulting of the Investigator. 
 
A patient must be withdrawn from the study if: 
 
The Investigator considers it, for safety reasons, to be in the best interest of the patient. 
 
The patient withdraws his/her consent. 
 
The patient is pregnant. 
 
If withdrawal occurs for any reason, the Investigator must determine the primary reason for a patient’s 
withdrawal from the study. The date and reason for discontinuation must be documented in the CRF.  
For patients who are lost to follow-up (i.e., those patients whose status is unclear because they fail to 
appear for study visits without stating an intention to withdraw), the Investigator should show ‘due 
diligence’ by documenting in the source documents steps taken to contact the patient, e.g., dates of 
telephone calls, registered letters, etc. 
 
 

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Prohibition and Restrictions 
Previous Annexin V-based agents, such as 99mTc-BTAP-rhAnnexin V and 99mTc-HYNIC-rhAnnexin V, 
have been used in several clinical trials as a tool for both diagnosis and follow up of drug therapy in 
oncological, autoimmune, transplanted and cardiopatic patients. No significant effects on vital signs, 
coagulation parameters or measured haematology or chemistry values have been observed. 
Existing Phase I study data in healthy volunteers, indicates that 99mTc-HYNIC-rhAnnexin V is a safe 
radiopharmaceutical [28].  
The good safety profile of 99mTc-rhAnnexin V-128 has been confirmed by the extensive package of 
bioanalytical, immunological and other preclinical studies performed by the Sponsor which indicate 
adequate safety margin for use in man at the concentrations and doses foreseen in this study. 
Furthermore, no adverse reactions were observed in a Phase I study in 12 healthy volunteers who 
have been administered 370 MBq of 99mTc-rhAnnexin V-128. 
The most important required restriction for study patients is pregnancy. 
Imaging is performed ambulatory. After imaging, patient may go back home or go back to work without 
particular precaution for him or his relatives. 
 
Any concomitant medication deemed necessary for the welfare of the subject during the study may be 
given at the discretion of the Investigator.  However, it is the responsibility of the Investigator to ensure 
that details regarding the medication are recorded in full in the case report form, including any changes 
that have occurred during the study. 
5 STUDY MEDICATION AND TREATMENT 
Packaging and Labelling 
 
The full name of the Investigational New Drug is “Kit for the Preparation of Tc-99m Recombinant 
Human Annexin V-128 for Injection”.  
The kit will be prepared, packaged and released according to Sponsor Standard Operating Procedures 
(SOPs), Good Manufacturing Practice (GMP) guidelines, ICH Good Clinical Practice (GCP) guidelines, 
and applicable local laws/regulations. 
The investigational product will be supplied by Sponsor as a sterile, single vial lyophilised kit for 
reconstitution with 99mTc solution eluted from a generator.  
A single dose vial contains 0.4 mg of rhAnnexin V-128. The kit also contains stannous chloride 
(reducing agent), sodium α-D-Glucoheptonate dihydrate (transchelating agent), gentisic acid sodium 
salt hydrate (radiation stability enhancer), hydroxyprolpyl-β-cyclodextrin (solubilizer), sodium 
metabisulfite (antioxidant) and trehalose dihydrate (lyoprotectant and cake-forming agent). Lactic acid 
is also present as buffering agent. The kit composition details are reported in the table below. 
Composition of the Kit for the preparation of 99mTc-rhAnnexin V-128 for injection 
Component 
Amount mg/ vial 
Function 
Reference to Standards 
rhAnnexin V-128 
0.400 
Drug Substance 
In-house 
Sodium -D-Glucoheptonate 
dihydrate 
3 
Transchelating agent 
In-house 
Gentisic acid sodium salt hydrate 
0.020 
Radiation Stability 
Enhancer 
In-house 
D(+)-Trehalose dihydrate 
50 
Lyoprotectant/Cake 
forming agent 
Ph. Eur. 07/2010:2297 
Sodium metabisulfite 
0.020 
Lyoprotectant 
Ph. Eur. 01/2008:0849 
Hydroxypropyl-β-Cyclodextrin 
5 
Solubilizing agent 
Ph. Eur. 01/2009:1804 

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Stannous chloride dihydrate 
0.010 
Reducing agent 
Ph. Eur. 01/2008:1266 
 Lactic acid 
5.406 
Buffering agent 
Ph. Eur. 01/2008: 0458 
Sodium hydroxide 
1.320 
pH regulation agent 
Ph. Eur. 01/2008: 0677 
 Nitrogen 
qs 
Inert blanket 
Ph. Eur. 01/2008:1247 
 
 
Handling of Study Medication 
 
99mTc-rhAnnexin V-128 must be administered at the investigational site.  
The study medication must be stored, handled and administered only by qualified/authorized personnel 
and must be prepared in accordance with pharmaceutical quality requirements, and radiation safety 
regulations. 
Based on the stability tests performed (Appendix 1), the Annexin Kit can be stored upon receipt at  5°C 
± 3°C at least up to 6 months..  
A single dose vial containing 0.4 mg of lyophilized rhAnnexin V-128 will be reconstituted with 2 mL ± 
0.2 mL containing 740 MBq ± 74 MBq (20 mCi ± 2 mCi) of 99mTc eluted from the generator. Stability 
studies have demonstrated radiochemical purity at 6 h from labelling greater than 90%, which is in line 
with current specifications of the Kit for the preparation of 99mTc-rhAnnexin V-128 for injection. The 
administration volume (corresponding to 250 MBq) is calculated according to the estimated time of 
injection, on the basis of the physical decay of the radionuclide (half-life = 6.02 h). For the purpose of 
this study, it is recommended to administer the reconstituted solution within 4 hours after completion of 
the labelling reaction.  
 
IMP Packaging and Storage  
 
The site personnel will maintain shipping, dispensing, and collection logs.  All investigational product 
will be stored and inventoried according to the protocol instructions and applicable state, regional and 
federal regulations and will be stored in a secure, locked location with limited authorized access at the 
investigational site. 
  
Precautions and recommendation for use 
 
Technetium-99m eluate should be obtained from a commercially available Mo-99/Tc-99m generator, 
approved by regulatory authorities, that has been eluted within the past 24 hrs.  The radiopharmacist 
will be directed to use the eluate within one hour of milking the generator.    
Drug inventory and accountability records for the “Kits for preparation of Technetium 99mTc-rhAnnexin 
V-128 for injection” will be kept by the Investigator/the radiopharmacist, and must be documented 
throughout the study.  
On ongoing basis the Investigator/radiopharmacist agrees to conduct a study medication supply 
inventory and to record the results of this inventory on the IMP Reconciliation Form. It must be possible 
to reconcile delivery records with those of used and unused medication. Any discrepancies must be 
accounted for. Appropriate forms of deliveries and returns must be signed by the responsible person. 
Used/unused “Kits for preparation of Technetium 99mTc-rhAnnexin V-128 for injection” will be locally 
discarded after monitoring by the Clinical Research Associate.  
Refer to Appendix 1 for detailed instruction on the Radiolabelled Imaging Product 99mTc-rhAnnexin V-

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
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128, Cautionary notes, Analytical and Biological Controls, Stability and Shelf Life. 
 
Study Medication Dose, Mode of Administration, Batch Number 
The "Kit for preparation of 99mTc-rhAnnexin V-128 for injection" consists of 1 patient dose.  
The single dose vial (0.40 mg rh-Annexin V-128) will be reconstituted with 2 mL ± 0.2 mL containing 
740 MBq ± 74 MBq (20 mCi ± 2 mCi) of 99mTc. The labelling reaction requires 90 minutes and the 
reconstituted radiolabelled product is stable for 6 h. For the purpose of this study, it is recommended 
to administer the reconstituted solution within 4 hours after completion of the labelling reaction, 
Patients will receive 2 administrations of  99mTc-rhAnnexin V-128 , one on day 1 and one on day 42 
(±14 days). 
When investigational product is received at the site, the Investigator, Pharmacist or authorized 
designee shall check for accurate delivery and acknowledge receipt by signing and dating the 
documentation provided by the Sponsor and returning it to the Sponsor or designee. A copy of this 
documentation shall be retained for the Investigator file. 
The dispensing of the investigational product shall be carefully recorded on an investigational product 
accountability form provided and an accurate accounting must be available for verification by the 
Clinical Research Associate at each monitoring visit.  
 
Unused investigational product must not be discarded or used for any purpose other than the present 
study.  
The Clinical Research Associate will periodically collect the Drug Accountability Forms and will check 
all investigational product (both unused and used) before making arrangements for authorizing their 
destruction at the investigational site. 
6 ASSESSMENTS 
 
Assessments will take place in the Nuclear Medicine Department and in the Rheumatology department 
CHUV, Lausanne, Switzerland. 
Subjects will be evaluated for safety and tolerability in accordance with Table 1 and the following Visits 
Schedule:  
 Voluntary written informed consent will be obtained from every subject prior to the initiation of any 
study-related procedures. 
 Each subject’s demography:  gender, ethnicity, weight, height, medical history, and relevant 
baseline characteristics will be recorded at screening visit.  
 Inclusion/exclusion criteria will be checked at Screening. 
 Women of childbearing potential must have negative urine pregnancy test at screening and before 
each 99mTc-rhAnnexin V-128 administration. 
 All patients will have a baseline DPD-99m-Tc bone scan prior to any treatment. Patients will also 
perform a 3 hours post injection whole body scan as described below (Imaging section). The 99mTc-
DPD bone and whole body scan are not required in case the patients already performed them within 
8 weeks prior to the 99mTc-rhAnnexin V-128 administration. 
 Vital signs will be taken at all study visits.  
 ECGs will be recorded at all study visits except for Day 56 visit to measure the different ECG 
intervals (RR, PR, QRS, and a more extended QT evaluation according to ICH E14, and heart rate, 
HR). A single ECG will be taken supine, after 5 minutes rest, and not immediately after a meal. The 
parameters will be measured as a mean value of minimally 3 beats. The Investigator will note in 
the CRF whether the ECG is normal or abnormal, as well as the clinical relevance of abnormal 
ECGs. Clinically relevant abnormalities will be recorded on the Adverse Event page of the CRF. 
 Physical examination will be conducted at Screening, Day 42 and Day 90. 

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 BASDAI, BASFI, BASMI for AS, DAS28 Disease Activity Score assessments for RA will be 
performed at baseline, Day 42 and Day 90. 
 Blood samples for haematology, coagulation, biochemistry and urinalysis will be obtained at 
screening, at Day 30, Day 42 and Day 90, as described in the table below. For PK subgroup of 
patient’s blood samples will also be collected pre-injection, 24 hours post injection as described 
above. 
 All medications taken from 2 weeks prior to the first administration date through the end of study are 
to be recorded as medical history and concomitant medications, included therapies for RA and AS 
 Any adverse events post-injection will be followed until resolution. 24 hours after each treatment 
injection (at Day 2 and Day 43), each patient will be contacted by phone (except at Day 2 for 
patients participating in the PK and dosimetric sub-study who will be interviewed during in site visit) 
in order to inquire if they experienced signs or symptoms of allergic reactions (edema, rash). 
 
 
In more details, all patients will undergo the following assessments: 
 
General laboratory analysis will be performed and blood samples collected at screening, on Day 30, 
Day 42 and Day 90 Table 2 summarizes general laboratory analysis to be performed. 
 
Haematology 
Coagulation 
Blood Chemistry 
Urinalysis 
 WBC with differential 
 Platelets 
 Hb 
 MCV 
 Haematocrit 
 PT 
 PTT 
 INR 
 BUN 
 Serum creatinine 
 Creatinine Clearance 
 Uric acid 
 Albumin 
 Total bilirubin 
 AP 
 AST/ASAT 
 ALT/ALAT 
 Gamma-GT 
 Sodium 
 Potassium 
 LDH 
 GlycoHb 
 fT4 
 CRP 
 Calcium 
 Glucose 
 RBC/hpf 
 WBC/hpf 
 Casts/lpf 
 Protein by dipstick test 
 Pregnancy test  
(at screening, if applicable 
and before injection of study 
product) 
 
 
  
Clinical assessment 
For RA diagnosed patients a clinical evaluation will be made at the screening visit, at Day 42 and Day 
90. The DAS-28 (3items: tender joints, swollen joints and ESR) will be calculated. For AS beside the 
clinical evaluation including the search for enthesopathy – using the Maastricht Score -, assessments 
with BASDAI, BASFI and BASMI will be made.  
The clinical assessment will be completed by the measurement of biological markers of inflammation 
(ESR, CRP and CBC).  
 
Ultrasound assessment 
For RA patients only, an ultrasound examination of the 28 joints included in the DAS 28 will be made at 
screening, Day 42 and Day 90. Synovitis, power-doppler activity and erosions will be checked. 
 

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Imaging 
Bone scintigraphy: all patients will have a baseline DPD-99m-Tc bone scan prior to any treatment.. 
Standard quality control of the camera will be performed every day before patient imaging. Patient will 
be injected with 9MBq/Kg of DPD-99m-Tc. Peak will be centered on 140KeV with a 20% windowing; a 
LEHR collimator will be used. It will be a triple phase bone scan including angiogram, blood pool 
imaging (10 minutes after injection) and 3 hours delayed imaging. Angiogram will be centered on the 
most symptomatic joint and/or and associated inflamed tendinous structures; acquisition will be started 
immediately after DPD-99m-Tc intravenous injection. Then 16 frames of 15 seconds will be acquired 
(128x128 matrix; zoom 1). Blood pool images will be acquired 10 minutes after injection and will be 
centered on the most symptomatic joint. A complement of imaging could be performed at this time 
centered on another joint. It will be images of 2 minutes (256x256 matrix, zoom 1). Delayed images will 
be performed 3h post injection. They will be focused on the same joints visualized on blood pool 
images, with the same acquisition parameters. Centered images will be completed by a whole body 
scan (10cm/min, 1024x256 matrix; zoom 1).  SPECT images could be acquired 3h after injection 
centred on the most symptomatic joints (60 projections of 10 seconds, 128x128 matrix, zoom 1). On 
planar images, region of interest will be drawn on symptomatic joints and non symptomatic joints and 
ratios of activity will be measured. All patients will be subjected to early and delayed planar anterior and 
posterior images centered on the hands and the feet. On SPECT images, VOI will be drawn on 
symptomatic joints. 
 
99mTc-rhAnnexin V-128 administrations:patients will be injected intravenously with 250 MBq of 99mTc-
rhAnnexin V-128 and thenthewhole body planar imagings (GE Infinia Hawkeye IV camera, (8 cm/min, 
1024x256 matrix; zoom 1) will be performed and repeated acquisitions on symptomatic joints. Standard 
quality control of the camera will be performed every day before patient imaging. Peak will be centered 
on 140KeV with a 20% windowing; a LEHR collimator will be used.  A dual-SPECT would be acquired 
centered on the thorax and abdomen at 1h after injection centered (2*60 projections of 10 seconds 
each, 128x128 matrix, zoom 1). The use of the whole-body and SPECT data for dosimetry will be 
discussed further in the Dosimetry section 
 
Semi-quantitative assessment of inflammatory joints will be performed in terms of TBR as well as by 
calculating the relative uptake between pre and post treatment in ROI/VOIs.  ROI and VOI defined and 
use in the different scintigraphies will strictly have the same pixel size and localization; they will be 
measured in counts.  
 
In case a suspected anomaly is found at imaging, it would be reported to the rheumatologist and the 
patient’s general practitioner.  
 
 
 
Immunogenicity assessments  
Assays for Anti-rhAnnexin V-128 IgG and IgM antibodies will be performed in serum samples by ELISA 
at screening visit (before test agent administration at the latest) at Day 30 (+/- 3 days) and at Day 56 
(+/- 2 weeks), i.e. 2 weeks after second injection. An additional sample is required 3 months after the 
first administration of the 99mTc-rhAnnexin V-128 (Day 90 ± 14 days) in case of positive anti-annexin 
antibodies outcome in previous examinations.  
For this purpose, 10 mL of blood will be collected per sample. 
Serum will be prepared (following the same procedure as that used for PK samples – see Appendix 2), 
divided into six aliquots and frozen (-80°C) until complete decay. Three out of six serum samples per 
time-point will be then shipped to the local laboratory, where the analysis for anti-rhAnnexin V-128 
antibodies will be performed (methods detailed in the Laboratory Manual). 
 

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Patients participating to the dosimetry and PK studies will undergo the following 
additional assessments:  
 
Pharmacokinetics (blood and urine) 
 
Venous blood samples of 10 ml each will be taken just before administration of 99mTc-rhAnnexin V-128 
and then at the following time-points: 5, 10, 15, 30, 60 min, 2 hrs, 4 hrs and 24 hrs post the first  
rhAnnexin V-128 administration for the first 3 patients included in the sub-study. Depending upon the 
results in those 3 patients, the timeframe for dosimetry measurements and PK will be confirmed or 
modified with a time-point at 3 hrs (instead of 2 hrs) and 6 hrs (instead of 4 hrs) for the following 7 
enrolled patients in the sub-study. The following whole blood or serum aliquots will be prepared as 
described in Appendix 2: 
1) 2 x 1 mL of whole blood will be used for radioactivity measurements 
2) 2 x 1 mL of serum  aliquots will also be used for  radioactivity measurements 
3) 2 x 0.6 mL at least of serum aliquots to be frozen at -80°C, will be used for pharmacokinetics 
measurements. After complete decay of radioactivity, one out of 2 aliquots/time-point will be 
shipped to the centralized laboratory and analyzed by ELISA to determine the rhAnnexin V-128 
concentration in serum (See the Laboratory Manual for further instruction). 
 
The whole blood and serum samples (bullet points 1 and 2) will be counted in a gamma counting 
system (CHUV/NUC laboratory) and compared to the count rate from a representative percentage of 
the injected activity inside the same counter. 
Blood clearance fractions and effective half-life estimates from multi-term non-compartmental 
exponential analysis will be calculated from serial measurements of radioactivity in whole blood and 
serum. Pharmacokinetic analysis will be also performed based on rhAnnexin V-128 serum 
concentration determined by ELISA method. 
 
Urine samples will be collected as follows (see also Appendix 2). One sample will be collected within 24 
hrs prior to 99mTc-rhAnnexin V-128 administration, preferably just prior to the administration of study 
drug (0 h sample) to achieve bladder emptying. Quantitative urine collections will be obtained (and 
volume recorded) possibly in the time intervals 0-1 h, 1 h – 4 hrs, 4 hrs – 16 hrs, and 16 hrs – 24 hrs 
post administration. Dual 2 mL aliquots of urine from each period will be counted in a gamma counter at 
the CHUV/NUC laboratory. The mean between the two 99mTc radioactivity measurements and the 
measured volume of urine will be used to calculate the amount of 99mTc excreted in that period and the 
cumulative percent injected dose (radioactivity).  
 
SEC-HPLC urine assessment  
 
Urine samples will be also analysed as a function of time by SEC-HPLC technique at local laboratory, 
in order to gain information on the chemical status of 99mTc-rhAnnexin V-128 and on the presence of 
99mTc-rhAnnexin V-128-related species. For this purpose, 10 mL aliquot from each urine sample will be 
analyzed through SEC-HPLC (CHUV/NUC laboratory).  
 
Dosimetry 
 
Administration of the 99mTc-rhAnnexin V-128 will be as a single bolus via an intravenous catheter in an 
antecubital vein followed by a saline flush. All images will be acquired with a GE Infinia Hawkeye 4 
dual-head integrated SPECT/CT gamma camera with low-energy high-resolution collimators. The 

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energy acceptance window for the 99mTc photopeak will be 140 keV (+/- 10%).  
 
The quantitative in vivo biodistribution of the 99mTc-rhAnnexin V-128 will be determined through whole-
body planar imaging following the recommended procedures provided in MIRD Pamphlet No 16 [20]. 
Reconstruction will be done using iterative reconstruction incorporating CT-based attenuation 
correction and dual-energy-window scatter correction. Dynamic planar imaging will be acquired during 
the first 10 minutes centered on the thorax. Then whole body planar images post administration will be 
acquired at 30 min, 60 min, 2 hrs and 4 hrs at Day 1 and at 24 hrs post-injection for the first 3 patients 
of the sub-study.  Depending upon the results in those 3 patients, timeframe for dosimetry 
measurements and PK will be confirmed or modified with a time-point at 3 hrs (instead of 2 hrs) and 6 
hrs (instead of 4 hrs) for the following 7 enrolled patients in the sub-study. In addition, a SPECT/CT will 
be performed on the abdominal/pelvis regions at 3 hours post administration for the first 3 patients in 
order to generate relevant dosimetry data after extrapolation for the reconstruction with OLINDA 
software. Depending upon the results in those 3 patients, the SPECT/CT on the abdominal/pelvis 
regions will be performed at 5 hours post administration. Patient’s bladder should be voided before this 
acquisition. A 99mTc source of known activity will be imaged before the first acquisition with the patient 
[33].The activity of this source will be measured in a dose calibrator prior to imaging and used to 
determine the imaging system calibration factor for converting reconstructed image counts into an 
activity concentration. In all patients, the source regions will be the brain, lungs, heart, liver, spleen, 
gastrointestinal (GI) tract, kidneys and urinary bladder contents and volumes of interest (VOIs) will be 
drawn around these. An additional VOI will be drawn around the whole body. The salivary glands, 
thyroid gland and gall-bladder will be defined as 190 source regions when visible and VOIs drawn 
about them. The difference between the number of counts in the whole-body VOI and the sum of those 
in the specified VOIs will define the number of counts in the “remainder” category. In addition, a VOI will 
be drawn over the quadriceps femoris (to provide a measure of soft tissue uptake and washout as 
describe below). Background will be estimated from a separate SPECT acquisition with no activity 
present in the field of view. We assume the VOI set about the GI tract will demonstrate a rapid and non-
specific uptake by soft tissue which will clear (in parallel with observed washout from soft tissues) to be 
replaced by activity in the contents arising from hepatobiliary transport. In order to isolate the activity 
within the GI tract contents, the washout of activity from the GI tract tissues will be modelled by the 
measured washout of activity from the VOI set over the quadriceps femoris, rescaled to that of the 
gastrointestinal tract at the time of the first image acquisition, when there was no activity in the 
gastrointestinal tract contents, and then subtracted from the activity measured in the GI tract VOI. This 
procedure provides the activity due to the GI contents alone. 
For each source region, the measured activity at each time point will be normalized to that 
administered, decay-corrected to the time of injection, and least-squares-fit by an analytical function. 
Physical decay of 99mTc will then be introduced to these analytical fits of the normalized activities and 
the function integrated to yield the cumulated activity normalized to the amount of administered activity 
(numerically equivalent to the residence time). The cumulated activity in the combined urinary bladder 
contents and voided urine will be calculated using a dynamic urinary bladder model [33] for a 3.5 hour 
urinary bladder voiding interval [34]. The cumulated activity in the gastrointestinal tract [35] with the 
assumption that all activity enters the duodenum via the hepatobiliary transport will be calculated. 
 
Radiation dose to the organ of interests (particularly the kidneys), Effective Dose Equivalent (ICRP 30), 
Effective Dose (ICRP 60) will also be calculated. 
 
The internal radiation dosimetry for the adult human will be calculated through the normalized 
cumulated activities for each patient provided as input to OLINDA. The derived ensemble of organ 
absorbed doses will then be used to calculate the Effective Dose per unit administered activity [36] with 
the following modifications: 1) gonadal absorbed dose will be taken to be the arithmetic mean of the 
testicular and ovarian absorbed doses [34]; 2) absorbed dose to the thymus will be used as a surrogate 
for the absorbed dose to the oesophagus [36]; and 3) absorbed dose to the wall of the upper large 
intestine will be removed from the remaining organs category and the mean absorbed dose to the colon 

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wall, given by the mass-weighted absorbed doses to the walls of the upper and lower large intestine, 
used in the Effective Dose [36]. 
Because of the non-specific uptake by the walls of the GI tract, further dosimetry analysis of these 
tissues will be performed. While the MIRD schema specifies the walls of the GI tract compartments as 
target regions, they are not specified source organs. As such, their photon contributions to the 
dosimetry will be assimilated within those categorized as “remaining tissues”. However, the “self 
dosing” to the GI tract walls due to non-penetrating particulate radiations from 99mTc uptake within the 
walls will be estimated from the measured GI tract wall cumulated activities using decay data 
summarized by Stabin [37] and downloaded from the RADAR website. These masses of the three GI 
tract compartments’ walls (small, upper large and lower large intestine) will be taken from [38]. The 
organ absorbed doses and Effective Doses for the individual patients will be averaged. 
7 DATA MONITORING COMMITTEE (DMC) 
 
Ten patients, independently from the group (RA or AS), will participate in the dosimetry and PK sub-
study. Out of the first 6 patients, at least 3 patients will be enrolled in the PK and dosimetric sub-study. 
Preliminary data will be analyzed as soon as these 3 patients have completed the sub-study. 
Depending upon the results in those 3 patients, the time schedule for imaging acquisition and PK will 
be confirmed or revised.  
Results of dosimetry, PK and immunologic assessments will be monitored by the DMC to assess safety 
and adequacy of rhAnnexin V-128 technical performance. The data monitoring committee consists of 
two Site clinicians (one of them being a Nuclear Medicine Physician). These clinicians are not trial 
investigators.  The main function of the committee will be to determine if there is a premature high 
evidence of an excess of adverse events or the presence of adequate/inadequate technical 
performance in this patients group.  
DMC will advise on the safety of study patients and the patients yet to be recruited to the study as well 
as maintaining validity and scientific merit of the study. The DMC will review examinations of safety 
data and promptly give recommendations to continue, continue with modification, or terminate the 
study. 
The DMC report will be sent to the Sponsor and the ethics committee as well as competent authorities  
Preliminary results can be used by Sponsor for publication purpose, before the end of the main trial. 
 
8 STATISTICAL METHODS 
 
The statistical analysis of the present study will be performed in accordance with the principles stated in 
the Consensus-Guideline E9 (Statistical Principles for Clinical Trials) of the International Conference on 
Harmonisation (ICH). 
 
Sample size 
 
The number of patients in this study is not based on statistical power considerations. The planned 
sample includes 20 patients with Day 56 assessments which are believed to provide sufficient data to 
assess the general safety and tolerability of 99mTc-rhAnnexin V-128. Patients will be recruited with a 
ratio of 1:1 RA:AS. 
Any patient who has not completed Day 56 assessment will be replaced by a patient from the same 
group (RA or AS). It is expected that about 10% of patients will not complete their Day 56 assessments; 
therefore, approximately 23 patients will be recruited. 
In addition, 10 patients enrolled in the study will be asked to participate in a dosimetry and PK study, 
irrespective of the group they are part of (RA or AS). 
Out of the first 6 patients, at least 3 patients must take part in the dosimetric and PK sub-study. 

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Demographics and Other Subject Characteristics 
 
Demographic and other baseline data will be summarized descriptively. Categorical data will be 
presented as frequencies and percentages. For continuous data, mean, standard deviation, median, 
minimum, and maximum will be presented. All background and demographic/RA-AS diagnosis data will 
be listed in detail. 
 
Concomitant Medications 
 
Concomitant medications (including treatments for the underline disease) will be coded using World 
Health Organization (WHO) dictionary. Type and incidence of concomitant medications will be 
tabulated (generic terms). 
 
Laboratory Tests 
 
Laboratory tests (haematology, coagulation, blood chemistry and urinalysis) will be monitored before 
and during the study days mentioned in the study chart.  A total volume of 100ml will be collected 
during the study. For each patient participating to the dosimetric and PK sub-study a total of 205 ml will 
be drawn throughout the study. 
 
Descriptive statistics including shift tables will be generated for all laboratory tests performed i.e. the 
actual values and the changes from pre-injection by cross-tabulations (with classes for below, within, 
and above normal range).  
Laboratory data will be analysed with respect to the normal ranges of values provided by the local 
laboratory and with respect to pre-defined levels of change in these values.   
Abnormal laboratory test results will be tabulated. 
 
Vital Signs and ECG 
 
Vital signs will be taken at each study visits, while twelve-lead ECG will be performed. 
Descriptive statistics (N, mean, median, minimum, maximum, 95% confidence interval for the mean, 
etc.) of the observed values as well as for the changes from baseline value will be created. Frequency 
tabulations with values within, below or above the normal ranges will be made. 
ECG parameters will include heart rate (HR), RR interval, PR interval, QRS width and QT interval.  
QT intervals will be corrected for heart rate. ECG results will also be evaluated by means of descriptive 
statistics (mean, median, 95% confidence interval for the mean, etc.) and frequency tabulations.  
Graphical presentations might be created to facilitate the interpretation. 
 
Physical Examination 
 
Physical examination results will be tabulated; abnormalities will be listed. 
 
Safety 
 
The statistical analysis of safety data will be mainly descriptive in nature.  
 
Adverse Events 
 
All original AEs terms will be coded using the Medical Dictionary for Regulatory Activities (MedDRA). 
System organ classes and preferred terms will be used in the analyses. 
Type and incidence of AEs, as well as severity and relatedness to the study medication will be 

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tabulated. Special attention will be given to those patients who prematurely discontinue the study or the 
study medication due to an AE, or who experience a severe AE or an SAE. 
 
Dosimetry 
 
Descriptive statistics for the dosimetry parameters will be reported.  
Dosimetry data for liver, spleen, kidneys, testes, and whole body will be determined using image 
quantification according to the methodology presented in MIRD Pamphlet No. 16 [39]. 
 
Pharmacokinetics and immunology 
 
PK/immunology analysis plan and report will be created.  
 
9 ADVERSE EVENTS AND OTHER SAFETY ASPECTS 
Definition of Adverse Events 
 
An AE is defined as any untoward medical occurrence in a patient and which does not necessarily have 
a causal relationship with the study medication. An AE can therefore be any unfavourable and 
unintended sign (including an abnormal laboratory finding), symptom, or disease, temporally associated 
with the use of a study medication, whether or not causally related to the study medication.  
AEs will be reported from signing the informed consent onwards until the last study-related procedure. 
If the information of an untoward medical occurrence is collected before starting the intake of study 
medication, this information will be listed as a pre-treatment AE during statistical analysis. 
 
Definition of Serious Adverse Events 
 
An SAE is any untoward medical occurrence that at any dose: 
 
Results in death;  
 
Is life-threatening; 
Note: “life-threatening” refers to an event in which the patient is at risk of death at the time of 
the event; it does not refer to an event which hypothetically might have caused death if it was 
more severe; 
 
Results in persistent or significant disability/incapacity; 
 
Results in congenital anomaly or birth defect; 
 
Requires in-patient hospitalisation or leads to prolongation of hospitalisation.  
Hospitalisation or prolongation of hospitalisation will not be considered as SAE in the following 
cases: 
o 
Hospitalisation planned before the patient inclusion, 
o 
Hospitalisation less than 24 h 
o 
Hospitalisation needed for the routine follow-up of the patient disease. 
Medical and scientific judgment should be exercised in deciding whether expedited reporting is 
appropriate in other situations, such as important medical events that may not be immediately life-
threatening or result in death or hospitalization but may jeopardize the patient or may require 
intervention to prevent one of the other outcomes listed in the definition above. These events, 
including those that may result in disability, should also usually be considered serious. Examples of 
such events are intensive treatment in an emergency room or at home for severe allergic reactions 
that do not result in hospitalization. 
The Investigator must report all SAEs by sending a completed SAE Reporting Form (Appendix 5) to 
the Safety Officer designee within 24 h of becoming aware of the event. 
All SAEs must be addressed to Advanced Accelerator Applications EuQPPV,  
 with 
the following contact details:   

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Tel:
;  
Fax: 
 
Mobile : 
;  
E-mail: 
 
 
 
Criteria for Causal Relationship to the Clinical Study Medication 
 
The investigator should express his / her opinion as to the causality of the SAE in section 12 of the 
SAE Reporting Form:  
12. Possible Causes of the Serious Adverse Event 
 
Check off all that apply 
Specify 
Pre-existing / underlying disease 
 
 
Study treatment 
 
 
Other treatment 
 
 
Protocol-related procedure 
 
 
Other (e.g., accident, new / intercurrent illness) 
 
 
 
Investigator Reporting Requirements 
 
Throughout the study, the study staff will question the patient in a non-directive way as to the 
occurrence of AEs. The patient will also be instructed, when signing the informed consent, as from 
that moment, to contact the Investigator to report any study medication or non-study medication-
related adverse or unusual event that occurs during participation to the study. 
The study staff will record all these events in the patient’s medical records and e-CRF, whether 
observed by the Investigator, the investigational staff, or spontaneously reported by the patient. 
The Investigator will provide a complete description of the event in standard medical terminology, the 
date of onset and termination, severity, relationship to the study medication, action taken regarding the 
study medication, any treatment given, the outcome, and whether or not the event is considered an 
SAE. If known, the Investigator should report the underlying illness or disorder rather than the 
individual signs and symptoms. 
 
Reporting of Serious Adverse Events 
 
In the case of an SAE, the Investigator must immediately (at the earliest possible time point within 24h 
of awareness) complete the SAE section of the CRF, reporting all information that is required by the 
Regulatory Authorities and contact the delegated Safety Officer designee, if needed. The name and 
contact details of the delegated Safety Officer designee will be available in the Investigator File (and 
will be updated when needed).   
The minimum information required for immediate reporting is the event description, the patient ID, the 
study medication concerned, and the identifiable reporter (Investigator or designee). Even if not all the 
facts are known, an initial report should be made. The Investigator must provide follow-up information 
as soon as possible. If requested by the delegated Safety Officer designee, documents relevant to the 
diagnosis, treatment, and course of the event must be submitted (e.g. technical investigation reports, 
histology findings, hospital discharge documents). All documents must be anonymized with respect to 

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the patient’s personal data identification.  
When the Investigator determines that there is not more information likely to be available, a final report 
should be provided. 
The Sponsor or delegated CRO will assume responsibility for appropriate reporting of AEs to 
Swissmedic and Independent Ethics Committee(s)/Institutional Review Board(s) (IEC/IRB) according 
to local laws and regulations. 
SAEs will be collected following the patient written consent to participate in the study. The collection of 
SAE information will continue to be reported by the Investigator for each patient until 30 days after the 
last study medication administration. 
 
Follow-up of Adverse Events 
 
All AEs occurring during the study are to be followed up until resolved or judged to be no longer 
clinically significant, or until they become chronic to the extent that they can be fully characterized. An 
assessment should be made at the last study-related visit for each patient. Certain long-term AEs 
cannot be followed until resolution within the settings of this protocol. In these cases follow-up will be 
the responsibility of the treating physician. 
Since it is unpredictable how long such a follow-up might take, data from this follow-up generated after 
the patient’s last study-related visit will be recorded by the Investigator. Full details regarding this 
follow-up will be described in the Clinical Study Report, if necessary. 
If during AE follow-up the case has progressed to the level of “SAE”, or if a new SAE whose 
relationship to the study medication could not be ruled out is observed, the situation must be reported 
immediately by the Investigator becoming aware of the information (considering that the “date of SAE 
onset” is the date of the first manifestations of that AE). 
 
Procedure in Case of Pregnancy 
 
Prior to clinical study enrolment, women of childbearing potential must be advised of the importance of 
avoiding pregnancy during clinical study participation and the potential risk factors for an unintentional 
pregnancy. For all women to whom the study has been proposed, it will be ensured they are using two 
reliable means of contraception (e.g., hormonal contraceptive, patch, vaginal ring, intrauterine device, 
associated with other barrier method of contraception such as the use of condoms). During the clinical 
study, all women of childbearing potential should be instructed to contact the Investigator immediately 
if they suspect they might be pregnant (e.g. missed or late menstrual period). 
The Investigator must report any pregnancy associated with investigational product exposure including 
conceptions occurring until 30 days after the last study medication administration. The report should 
be carried out within 24 hours of pregnancy confirmation by sending a completed Pregnancy 
Reporting Form to the Safety Officer designee. 
Appropriate pregnancy follow-up procedures should be considered if indicated. The Investigator must 
report follow-ups within 24 hours of the receipt of any new information on the course of the pregnancy, 
including perinatal and neonatal outcome, by sending a completed Pregnancy Reporting Form to the 
Safety Officer designee. 
When the outcome of the pregnancy, delivery, and newborn fulfill the criteria of SAEs [e.g., 
spontaneous abortion, induced abortion, stillbirth, death of newborn, congenital anomaly (including 
anomaly in a miscarried fetus)], the Investigator should respond in accordance with the reporting 
procedure for SAEs described in section 9.5. Additional information regarding the outcome of 
pregnancy (which is categorized as an SAE) is mentioned below. 
Death of a newborn within 1 month after birth should be reported as an SAE regardless of its 
relationship with the study medication.  
If an infant dies more than 1 month after birth, it should be reported if a relationship between the death 
and intrauterine exposure to the study drug is judged as reasonably related by the Investigator, 
provided that the date of conception was prior to injection of the product or within one month of 

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monitoring the patient. 
If the date of conception is more than a month after the injection, all cases of child deaths are not 
included. 
In case of a delivery of a living newborn, the newborn’s condition is evaluated at birth. The miscarried 
fetus is evaluated by visual examination unless test results which indicate a congenital anomaly are 
obtained prior to miscarriage. 
 
New Safety Information Affecting the Conduct of the Study 
 
When new information, including “Dear Doctor Letters” but not limited to that, necessary for 
conducting the clinical study properly will lead to a protocol amendment, the Sponsor should inform all 
Investigators involved in the clinical study, the head of the study site, ethics committees, and 
Regulatory Authorities of such information, and when needed, should amend the patient information 
and let the patient sign the updated version of the Patient Information. 
10 TERMINATION OF THE STUDY 
 
Early termination of the study can occur in the following cases: 
 
 
When the Sponsor is aware of information on matters concerning the quality, efficacy, and 
safety of the study drugs, as well as other important information that may affect proper 
conduct of the clinical study, the Sponsor may discontinue the clinical study and send a 
written notice of the discontinuation along with the reasons to the investigator and applicable 
authorities.  
 
If the investigator intends to discontinue participation in the study, the investigator must 
immediately inform the Sponsor of the discontinuation and the reason for it. 
 
The Sponsor reserves the right to discontinue the study at any time for failure to meet 
expected enrolment goals. 
11 OPERATIONAL, ETHICAL, AND ADMINISTRATIVE 
CONSIDERATIONS 
 
Study personnel  
 
All study staff will be informed of the study protocol through meeting and internal study initiation. Their 
task will be supported by internal SOPs specific to the study. 
The study nurse will be asked to collect blood and urine samples and to ship/send them to the 
appropriate laboratory. 
 
Data collection 
 
The study will be monitored by Advanced Accelerator Applications according to the current SOP for 
the monitoring of studies. Shortly before the study starts, the Study Monitor will meet with the 
Investigator and Investigational Staff involved reviewing the procedures regarding study conduct and 
recording of data in the CRF. During the study, the Investigator will permit the Study Monitor to verify 
the progress of the study at the centre as frequently as necessary. The Investigator will make the 
electronic data screens available, provide missing or corrected data, and sign the CRFs. Key data 
transcribed into the CRF will be reviewed against the source documents. Personal information will be 
treated as strictly confidential and will not be made publicly available. Any inconsistency between the 
source data and the data recorded in the CRF will be corrected. 
The Sponsor will ensure that appropriate Quality Control (QC) steps are included into the different 

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clinical processes to guarantee adequate protection of the study patients and quality of the data. 
An independent Quality Assurance (QA) department, Regulatory Authorities and/or IECs/IRBs may 
review this study. This implies that auditors/inspectors have the right to inspect the study centre(s) at 
any time during and/or after completion of the study and have access to source documents, including 
the patient’s file. By participating in this study, the Investigator(s) agree(s) to this requirement. 
For any data transfer, measures will be undertaken to protect patient data handed over against 
disclosure to unauthorized third parties and patient confidentiality will be maintained at all times. 
 
Data Review 
 
All data relating to the study must be recorded in the CRFs provided by the Sponsor. These CRFs 
should always reflect the latest observations on the patient’s participation in the study. Therefore, 
CRFs are to be completed as soon as possible after (or during) the patient’s visit. To avoid inter-
observer variability, every effort should be made to ensure that the study determinations are 
completed by the same individual who made the initial ones at baseline. The Investigator must verify 
that all data entries in the CRFs are accurate and correct.  
The monitor will review the CRFs and evaluate them for completeness and consistency. The CRF will 
be compared with the source documents to ensure that there are no discrepancies between critical 
data. All entries, corrections and alterations are to be made by the responsible Investigator or his/her 
designee. The monitor cannot enter data in the CRFs.  
 
Data Clarification 
 
If corrections to a CRF are needed, the responsible monitor or data manager will raise a query. The 
appropriate investigational staff will answer queries. 
 
Source Documents 
 
Source data must be available at the study centre to document the existence of the study patients and 
substantiate the integrity of the study data collected. They must include the original documents relating 
to the study, as well as the medical treatment and medical history documentation of the patient. 
The source medical records should at least include the following information for each patient: 
 
Patient identification (name, date of birth, gender);  
 
Documentation of eligibility criteria, i.e. medical and medication history, physical examination; 
 
Participation in study (including study number); 
 
Study discussed, signed and dated ICF; 
 
Dates of all visits; 
 
Images/scans and reports; 
 
Documentation that protocol-specific procedures were performed; 
 
Study medication administration time and date; 
 
Receipt, dispensation and destruction of used/unused study medication; 
 
Record of all AEs and other safety parameters; 
 
Record of all previous and concomitant therapies; 
 
Date of study completion or reason for early discontinuation (if applicable). 
The following documents are considered as source documents as well: nurse records and worksheets. 
The author of an entry in the source documents must be identifiable. Direct access to source 
documentation (medical records) must be allowed for the purpose of verifying that the data recorded 
on the CRF are consistent with the original source data. 
 
Clinical Study Monitoring 
 
Advanced Accelerator Applications or designee is responsible for periodic monitoring of the study to 

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ensure that patients’ human rights, safety, and well-being are protected, that the study is properly 
conducted in adherence to the current protocol and ICH GCP, and that the data reported by the 
Investigator or designee are accurate, complete, and verifiable with the source documents. The 
assigned Clinical Study Monitor(s) will monitor the study in accordance with the monitoring guidelines. 
A copy of their Monitoring Log will be obtained at the study close-out visits. 
 
Direct Access to Source Data/Documents 
 
The Investigator and the study centre must accept monitoring and auditing by the Sponsor or deputy 
as well as inspections from the IEC(s)/IRB(s) and/or relevant Regulatory Authorities. They must 
provide all study-related records, as well as source documents to these instances when they are 
requested to. The confidentiality of the patient’s identity shall be well protected and consistent with 
local and national regulations when the source documents are patient to direct access. 
 
Data Management 
 
Data management activities will be coordinated by Sponsor with the support of a CRO as necessary.  
All study-specific processes and definitions will be described in the Data Management Plan. Coding of 
AEs and Medical History terms will be performed using MedDRA; previous and concomitant 
medication will be coded using WHO codes. 
 
Ethical Conduct of Clinical Study 
 
The Investigator(s) and all parties involved in this study should conduct the study in adherence to the 
ethical principles based on the Declaration of Helsinki, GCP, ICH guidelines, and the applicable laws 
and regulations. 
ICH-GCP is an international ethical and scientific quality standard for designing, conducting, recording, 
and reporting study activities that involve the participation of human patients. Compliance with this 
standard provides public assurance that the rights, safety, and well-being of the patients are protected, 
consistent with the principles that have their origin in the Declaration of Helsinki, and that the study 
data are credible. 
The Investigator and all study staff will conduct the study in compliance with the IEC/IRB approved 
version of this protocol. The protocol, ICF, any information provided to the patient, recruitment 
advertisements, and any amendments to these items will have IEC/IRB approval prior to their use in 
the study. Voluntary informed consent will be given by every patient in order to be screened for the 
study and prior to the initiation of any study-related procedures. The consent process must meet all 
applicable local laws. The rights, safety, and well-being of the patients are the most important 
considerations and prevail over the interests of science and society. All personnel involved in the 
conduct of this study must be qualified by education, training, and experience to perform their 
assigned responsibilities. 
 
Authorities 
 
The protocol, name, and study centre of the Investigators, the votes of the IEC(s)/IRB(s), as well as 
other locally required documents will be submitted to SwissMedic, according to local requirements for 
review and approval before the beginning of the study. SwissMedic will be informed about the end of 
the study.  
 
Patient Confidentiality 
 
Individual patient medical information obtained as a result of this study is considered confidential and 
disclosure to third parties is prohibited. Such information may only be given to a third party after 

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approval of the patient, to the patient’s general practitioner or to other appropriate medical personnel 
responsible for the patient’s well-being. 
The Sponsor, its board members, and its personnel shall not disclose any confidential information on 
patients obtained during the performance of their duties in the study without justifiable reasons. 
All individuals and organizations involved in conducting the study and/or processing the study data 
must pay very careful attention to protect the patients’ privacy with appropriate measures, for example, 
by prohibiting the use of any private information that may identify a patient (e.g. name or address). 
These details shall be processed in accordance with the applicable local and regional laws. 
 
Patient Information/Written Informed Consent 
 
According to ICH GCP (CPMP/ICH135/95) the patient must give consent to participate in the study, 
only after having been fully informed by the Investigator of the nature, significance, and implications of 
the study, as well as to the associated risks involved. Such meetings must be carried out on an 
individual basis, and adapted to the educational background and previous knowledge of the patient. 
Participation to this meeting will be documented in the patient’s clinical chart. In the present protocol, 
patient will be informed by the rheumatologist (CHUV) about the scope and goals of the study based 
on the patient information sheet. Patient will have at least 24 hours to consider his participation to the 
protocol before signing the informed consent. Any study-related procedure will only take place after 
signed patient informed consent has been collected. 
The patient will be instructed by the Investigator that the consent for study participation can 
be withdrawn at any time, without having to justify a reason, and that no disadvantageous 
consequences will follow regarding further medical treatment. The Investigator shall ask for the reason 
of premature termination without violating the patient’s rights (ICH GCP Definition 4.3.4). 
Furthermore, the patient must be informed about insurance coverage and the corresponding patient 
obligations (see Patient Information). The ICF must be personally dated and signed by both the 
Investigator/Delegate and the patient. The patient receives 1 copy of the original patient information 
and Informed Consent Form signed and dated by both Investigator/Delegate and the patient. 
The original of the ICF will be retained by the Investigator in the Investigator’s File, who will confirm 
the patient’s consent in the CRF. The patient will only be included in the study after written consent is 
given. 
Furthermore, the Investigator is recommended to inform the patient’s general practitioner of his/her 
participation in the study, provided that the patient has a general practitioner and the patient agrees to 
disclose this information. For this purpose, a copy of the patient information sheet and the patient’s 
signed informed consent will be sent to the GP if the patient agrees with this and has ticked the 
appropriate tickbox on the Patient Information Consent Form. 
 
Arrangement for Use of Information and Publication of Clinical Study Data 
 
The present study will be registered on http://clinicaltrials.gov/ and its results will be published. 
All information regarding the investigational product under study in the outlined protocol and Sponsor’s 
operations, such as patent applications, formulas, manufacturing processes, basic scientific data, or 
formulation information, supplied by the Sponsor and not previously published, are considered 
confidential by the Sponsor and shall remain the sole property of the Sponsor. The Investigator agrees 
to use this information only to perform this study and will not use it for other purposes including 
publications and presentations without the Sponsor’s written consent. 
It is understood by the Investigator that the information developed during the conduct of this study is 
considered confidential and will be used by the Sponsor for the development of the specified 
investigational medication. This information may be disclosed as deemed necessary by the Sponsor to 
other Investigators, other pharmaceutical companies, and to governmental agencies. To allow for the 
use of the information derived from this study and to ensure complete and thorough analysis, the 
Investigator is obligated to provide the Sponsor with complete test results and all data developed in 
this study, and to provide direct access to source data/documents for study-related monitoring, audits, 

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IEC/IRB review, and regulatory inspection. 
Any publication or public presentation of the results of this study must be according to the Sponsor’s 
standards. The first publication is coordinated by the Sponsor. The Investigator agrees that before 
he/she publishes any results of this study, he/she shall send the draft manuscripts and copies of the 
information to be presented to the Sponsor at least 30 working days before submission to a publisher 
or presentation. The Sponsor reserves the right to review these materials before submission for 
publication or presentation. This is not intended to restrict or hinder publication or presentation but 
instead to allow the Sponsor to protect proprietary information and to provide comments based on 
information that may not yet be available to the Investigator(s). 
 
Documents and Records Related to the Clinical Study 
 
The Investigator must retain CRFs and source documents of all enrolled patients (i.e. all patients who 
gave consent to be screened for the study), study medication disposition, and other documents 
required by regulation, in his/her possession or in an accessible area for at least 10 years after the 
completion of this study. The Sponsor will notify the Investigator when the records no longer need to 
be kept. 
The Investigator should take measures to prevent accidental or premature destruction of these 
documents. 
Under no circumstance shall the Investigator relocate or dispose any study documents before having 
obtained the Sponsor’s written approval. 
If it becomes necessary for the Sponsor or the appropriate Regulatory Authority to review any 
documentation relating to this study, the Investigator must permit access to such reports. 
Any difficulty in archiving and storage of clinical study documents must be discussed with the study 
monitor prior to the initiation of the study. 
The data and information collected during this study will be reported in Clinical Study Report(s) by the 
Sponsor.  
 
Sampling collection 
 
Biological samples collected at site for routine lab analysis (Heamatology and Biochemistry) will be 
discarded after study analysis, according to local rules. For samples that are to be sent to a 
centralized foreign laboratory, i.e. for ELISA analysis, the Clinical Trial Agreement will be adapted 
according to local rules. These collected samples will be stored for up to 10 years (counting from when 
the last subject performed the last study visit) and then discarded, unless local rules, regulations or 
guidelines require different timeframes or different procedures, which will then be in line with the 
subject consent. 
In case of patient consent withdrawal to the use of personnel data, biological samples will not be 
analyzed and will be destroyed.  
Samples collected will only be used for study purposes as per protocol. 
 
Protocol Amendment and/or Revision 
 
Any changes to the study, which arise after approval of the protocol, must be documented as protocol 
amendments and/or revisions. Depending on the nature of the amendment and/or revision, either 
IEC/IRB approval or notification is required. The changes will become effective only after the approval 
of the Sponsor, Swissmedic, and the IEC/IRB (if applicable). 
 
Qualification of the Investigators 
 
The Investigator(s) should be qualified by education, language, training, and experience to assume 
responsibility for the proper conduct of the study. He/she should meet all qualifications specified by the 

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applicable regulatory requirements and should provide evidence of such qualifications through an up-
to-date curriculum vitae (Principal as well as all other Investigators) and/or other relevant 
documentation requested. 
The Investigator should be thoroughly familiar with the appropriate use of the investigational 
product(s), as described in the protocol, the current Investigator’s Brochure, the product information, 
and other information sources provided by the Sponsor. 
The Investigator should be aware of, and should comply with, ICH-GCP and the applicable regulatory 
requirements. 
The Investigator should maintain a list of appropriately qualified persons to whom the Investigator has 
delegated significant study related duties. 
 
Financial Disclosure 
 
The disclosed financial interest of the Investigator must be collected prior to enrolment of the first 
patient into the study, following study centre completion, and 1 year following study completion. The 
Investigator should promptly update this information if any relevant changes occur during this period. 
Disclosable financial interests will be recorded on the Investigator Financial Disclosure Form. 
Any Investigator(s) added as investigational staff must complete the Investigator Financial Disclosure 
Form at the beginning of his/her participation to the study. For any Investigator(s) leaving the site prior 
to study completion, an Investigator Financial Disclosure Form should be obtained at the end of 
his/her participation. 
 
Insurance of Patients and Others 
 
The Sponsor has covered this study by means of insurance for the patient according to national 
requirements. The name and address of the relevant insurance company, the certificate of insurance, 
the policy number, and the sum insured are provided in the Investigator’s File. 
 
Investigator Indemnity 
 
The Sponsor shall be liable towards the patients in accordance with the provisions of the Clinical 
Study Law. Notwithstanding the foregoing; the Sponsor does not, however, agree to indemnify, 
defend, or hold the Investigator harmless against liability, damage, loss, cost or expense (including 
reasonable attorney’s fees and expenses), including liabilities arising out of or in connection with 
claims of any nature by third parties, including, without limitation, in respect of bodily injury or death, 
arising out of or in connection with the negligence, wrongful acts or omissions or willful misconduct of 
the Investigator, the Institution, or its affiliates. 
Including but not limited to: 
 
The making of unauthorised representations and warranties concerning the study medication 
or the study; 
 
The failure to obtain appropriate informed consent; 
 
Non-compliance with applicable rules or regulations; 
 
Failure to conduct the study in accordance with this protocol. 
A condition of this indemnity obligation is that, whenever the Investigator has information from which it 
may be reasonably concluded that an incident of bodily injury, sickness, disease, or death has 
occurred, the Investigator must immediately notice the Sponsor of all pertinent data surrounding any 
such incident, and, in the event a claim is made or a suit is brought, the Investigator will assist the 
Sponsor and cooperate in gathering information with respect to the time, place, and circumstances, 
and in obtaining the names and addresses of the injured parties and available witnesses. 
The Investigator shall not, except at his/her own cost, voluntarily make any payment or incur any 
expense in connection with any such claim or suit without the prior written consent of the Sponsor. 

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12 QUALITY ASSURANCE 
 
The Sponsor is implementing and maintaining QA and QC systems with written SOPs to ensure that 
studies are conducted and data are generated, documented (record), and reported in compliance with 
the protocol, GCP, and applicable regulatory requirement(s). 
The Sponsor or designee may arrange to inspect or audit the study centre. The auditor is independent 
from the clinical monitoring and project management team at the Sponsor’s site. The audit may 
include on-site review of regulatory documents, CRFs and source documents. The auditors will have 
direct access to these documents. 
Medical imaging is the main research tool used in the present study. These tools are subject to strict 
quality control laws such as regular controls performed by the producer and regular internal controls. 
 

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Appendix 1 
 
 
Radiolabelled Imaging Product 99mTc-rhAnnexin V-128 
 
The Technetium solution to be used for the labeling of rh-Annexin V-128 kit is the solution which can 
be obtained by commercially available Tc Generators compliant with the Ph.Eur. Monograph “Sodium 
Pertechnetate (99mTc) Injection (Fission)” and Tc 99m Injection USP.      
During the product development, the following procedures and conditions have been tested and 
confirmed as adequate: 
a) Radioactive concentration of the Pertechnetate solution added for labelling should be 370 
MBq/mL (the reconstitution volume is 2 mL ± 0.2 mL). 
b) Labelling at room temperature under slight rotation by introducing the vial in a shielded roller 
for 90 min: shorter incubation times may result in inadequate labelling. 
c) Stability of the Radiolabelled compound up to 6h at room temperature (RCP ≥ 90 %). 
d) Suitability of the Radio TLC method to determine the radiochemical yield and purity by using 
three different eluents: Acetone 100% (99mTcO4
-, Rf=1.0); Anticoagulant Citrate Dextrose 
solution (ACD) (99mTc-rhAnnexin V-128, Rf=0.0); PBS (99mTc-Glucoheptonate, Rf=1.0 and 
99mTcO2,Rf=0.0). 
 
 
Labelling takes place through an exchange reaction [40, 41] with 99m-Technetium-Glucoheptonate.  
 
 
Scheme of the exchange reaction between 99mTc-Glucoheptonate (99mTc-GH) and rhAnnexin V-128. 
 
The instructions for the preparation of the 99mTc-rhAnnexin V-128 are in accordance with the following 
aseptic procedure: 
1) Remove an rhAnnexin V128 Kit reaction vial from refrigerated storage and allow it to reach 
room temperature (from 5 to 10 minutes). 
2) Waterproof gloves should be worn during the preparation procedure. Flip off cap from the 
rhAnnexin V-128 Kit vial and swab the top of the vial closure with an appropriate antiseptic to 
disinfect the surface, and then allow the stopper to dry. 
3) Place the vial in a suitable radiation shield appropriately labelled with date, time of 
preparation, volume and activity. 
4)  Aseptically add 2 mL ± 0.2 mL of Sodium Pertechnetate Tc-99m solution containing 740 MBq 
± 74 MBq (20 mCi ± 2 mCi)  to the vial in the lead shield (Do not shake).   
5) Remove the vial from the lead shield and place it in an appropriately shielded roller. Leave the 
vial under slow rotation for 90 min.   

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6) Remove the vial from the shielded roller, inspect visually for the absence of particulate matter 
and discoloration and place it again in a lead shield. 
7) Aseptically withdraw material using a sterile shielded syringe. The so-obtained solution is 
stable for 6 hours after completion of radiolabelling reaction. For the purpose of this study it is 
recommended to use it within 4 hours after preparation. 
8) Radiochemical purity should be checked prior to patient administration according to the Radio 
TLC Method. 
 
Cautionary Notes: 
 
Tc-99m pertechnetate eluate should be obtained from a generator which has been 
eluted within the last 24 h 
 
Tc-99m pertechnetate eluate which is more than 6 hour old from the time of elution 
should NOT be used [40-42]. 

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Analytical and Biological Controls 
 
Specifications for the Kit for the preparation of 99mTc-rhAnnexin V-128  
 
Test 
Method 
Acceptance Criteria 
Colour of the freeze dried cake 
Visual Ph. Eur. 
White 
Appearance of the reconstituted solution 
Visual Ph. Eur. 
Clear, colourless  
Time of reconstitution 
Visual Ph. Eur. 
< 30 sec 
Leak test 
Visual Ph. Eur. 
Conforms 
Particulate matter (sub-visible particles) 
Light Obscuration Particle 
count test (Ph.Eur. 2.9.19 
method 1) 
≥ 10 µm: ≤  6000/vial 
≥ 25 µm: ≤  600/vial 
pH 
pH meter 
5.0 – 5.8  
Uniformity of content 
Internal SOP (by weighing) 
Theoretical content (65.17 mg/vial) 
± 10%  
Residual moisture 
Karl Fisher (Ph. Eur. 2.5.12).  
 5.0% 
Total Tin 
ICP-OES 
0.0047 – 0.0058 mg/vial 
Sn++ / Sn total 
UV/Vis Spectrophotometry 
> 50% 
Sodium -D-Glucoheptonate dihydrate   
HPLC/MS-MS-detector 
3.0 mg/vial ± 10% 
Gentisic acid sodium hydrate 
RP-HPLC - UV 
0.020 mg/vial ± 10% 
Identity D(+)-Trehalose dihydrate 
HPLC/ MS-MS-detector 
Conforms to reference 
Identity Hydroxypropyl-β-Cyclodextrin 
HPLC - Evaporative Light 
Scattering Detector (ELSD) 
Conforms to reference 
Sodium Metabisulfite 
Titrimetric determination with 
titration pipette (MColortestTM) 
10-30 ppm/vial 
Identity Lactic acid 
HPLC - UV 
Conforms to reference 
Identity rh-Annexin V-128 protein 
Western Blot  
Conforms to reference 
rh-Annexin V-128 protein concentration 
Bradford Assay 
0.400 mg/vial ± 10% 
Chemical Purity (% rh-Annexin V-128 
monomer) 
SEC-HPLC – UV 
≥ 90.0% 
RP-HPLC – UV 
Chemical Purity (% rh-Annexin V-128 
dimer) 
SEC-HPLC – UV 
≤ 10.0% 
RP-HPLC – UV 
Radiochemical Purity (% 99mTc-rh-
Annexin V-128)# 
ITLC 
≥ 90.0% 
Radiochemical Purity (% 99mTcO4 + 
99mTcO2)# 
≤ 8.0% 
Radiochemical Purity (% 99mTc- 
glucoheptonate)# 
≤ 10.0% 
Radiochemical Purity  (% 99mTc-rh-
Annexin V-128)# 
SEC-HPLC 
≥ 90.0% 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 50 of 
67 
Biopotency (%)# 
RBC binding assay 
90 - 110 % 
Bioaffinity 
RBC Displacement Assay 
ratio IC50 0.5-2 to reference  
Sterility 
Ph. Eur. 2.6.1 
Sterile 
Bacterial Endotoxin Test (LAL) 
Ph. Eur., 2.6.14, USP <85> 
<175 EU/vial* 
*The specification for Bacterial Endotoxins for Radiopharmaceuticals to be administered by i.v., according to Ph. Eur. and USP, 
is 175 IU/maximum administered volume (Vmax). In the case of this Drug Product 175 IU/Vmax corresponds to 175 IU/vial or 
175 EU/vial. 
# Test performed right after the completion of labelling reaction (T=0) and 6 hours after (T=6h). 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 51 of 
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Specifications of the Radiolabelled Imaging Product (99mTc-rhAnnexin V-128) (test to be 
performed at the clinical site) 
 
Test 
Method 
Acceptance Criteria 
Radiochemical Purity                              
(% 99mTc-rhAnnexin V-128) 
ITLC 
≥ 90.0% 
Radiochemical Purity                              
(% 99mTcO4 + 99mTcO2) 
≤ 8.0% 
 
 Analytical and Biological methods for Quality Control 
 
Test 
Method 
Appearance  
Appearance is tested following the Ph. Eur. 2.2.1. method. The 
method consists in a visual check of the vial size, colour, crimp type, 
freeze dried cake appearance and clarity and degree of opalescence 
of the reconstituted vials. The time of reconstitution is also checked. 
Leak 
The test is performed by means of vacuum- pressure treatment and 
methylene blue dye solution. No change in the aspect of the vial has 
to be observed. 
Sub-visible particles test 
The insoluble particulate matter test follows the Ph.Eur. 2.9.19 
method 1 (Light Obscuration Particle Count Test). This method is 
performed using the instrument HYAC-Royco mod. 9703  Liquid 
Particle Counter and it is based on the principle of light blockage 
which allows an automatic determination of the size and number of 
particles. The particles with size ≥ 10 µm have to be ≤ 6000/vial and 
those with size ≥ 25 µm must be ≤ 600/vial. 
pH 
The pH control is performed by measuring the [H+] with a pH 
microelectrode (sensitivity = 0.1 unit), according to the Ph. Eur. 2.2.3 
method. The pH test is performed on a lyophilized kit after 
reconstitution with Saline solution for injection. The pH value must 
be within the following range: 5.0 to 5.8. 
Uniformity of content 
The uniformity of content is checked on 3 vials. The aluminum crimp 
cap is removed and each vial is weighed. The content is then 
completely removed, the vial and the stopper are properly rinsed 
and dried. The weight of each vial + stopper is measured again and 
the content calculated as follows: [Weight of the intact (filled) 
vial+stopper] – [Weight of the empty vial+stopper]. The content must 
be within 90%-110% of the nominal weight. 
Residual moisture 
The percentage of residual moisture that is an expression of the 
water content of the lyophilized vials is performed according to Ph. 
Eur. 2.5.12. (by Karl Fisher method). The water content must be not 
more than 5%. 
Total Tin 
The Tin present in the sample is analyzed by Inductively Coupled 
Plasma – Optical Emission Spectroscopy (ICP-OES), technique 
based on the atomic emission spectroscopic characteristics typical 
of every chemical element. The concentration of the samples (mg/L) 
is determined at the wavelength corresponding to the Tin emission 
line (189.927 nm) and calculated by interpolation on the standard 
curve (r2  0.995). Total Tin content must be in the range:  0.0047 to 
0.0058 mg/vial. 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 52 of 
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Sn++ / Sn total 
This 
quantitative 
analysis 
is 
performed 
by 
UV/VIS 
spectrophotometry.  The reading is performed at the wavelength of 
700 nm. The method exploits the reducing action of Sn2+ on the 
phosphomolybdic acid with consequent formation of “Molybdene 
blue”. The intensity of the blue colour developed is directly 
proportional to the Sn2+ concentration. The samples concentration 
(mg/mL) is calculated by interpolation on the standard curve (r2  
0.990).   Stannous Tin / Total Tin ratio must be higher than 50%. 
Sodium -D-
Glucoheptonatedihydrate 
The quantification of the sodium D-Glucoheptonate dihydrate 
used as transchelating agent is performed by HPLC assay using a 
MS-MS detector. The amount of sodium D-Glucoheptonate 
dihydrate is calculated by interpolation on the standard curve (r2  
0.995) preliminary prepared using 5 different concentration of D-
Glucoheptonic acid sodium salt. The amount must be 3 mg/vial ± 
10%.  
Gentisic acid sodium salt 
hydrate 
The quantification of the Gentisic acid sodium hydrate used as 
radiation stability enhancer is performed by RP-HPLC assay using 
an Ultra Violet (= 220 nm and 254 nm) detector. The amount of 
Gentisic acid sodium hydrate, retention time 4.5 ± 0.5 min, is 
calculated by comparing three chromatograms of the sample with 
the average value obtained from the system suitability test (six 
injections of Gentisic acid sodium salt hydrate standard solution: 
0.020 mg/mL). The amount must be 0.020 mg/vial  ± 10%.  
Identity D(+)-Trehalose 
dihydrate 
The identification of the D(+)-Trehalose dihydrate used as 
lyoprotectant/cake forming agent is performed by HPLC assay using 
a MS-MS detector. Three HPLC runs of the D(+)-Trehalose 
dihydrate standard solution are performed. Three chromatographic 
runs on the sample to be analysed are also performed. The 
chromatograms of the sample are compared to the chromatograms 
of the reference standard. Identification is considered valid if the 
averages of the retention times of the sample runs and of the 
standard runs do not differ by more than 0.5 min. 
Identity Hydroxypropyl-β-
Cyclodextrin 
The identification of the Hydroxypropyl-β-Cyclodextrin used as 
solubilizing agent is performed by HPLC using an Evaporative Light 
Scattering Detector (ELSD).  
Three HPLC runs of the Hydroxypropyl-β-Cyclodextrin (HPβCD) (5 
mg/mL) standard solution are performed. Three chromatographic 
runs on the sample to be analysed are also performed. The 
chromatograms of the sample are compared to the chromatograms 
of the reference standard. Identification is considered valid if the 
signal corresponding to the HPβCD (RT about 25 min) is present 
and peaks interfering with HPβCD signal are absent or do not 
compromise the target molecule identification.. 
Sodium Metabisulfite 
The quantification of Sodium Metabisulfite is performed using a 
titrimetric determination method with titration pipette. In sulfuric 
solution by titration with potassium iodate solution against starch as 
the indicator, iodide ions are oxidized to iodine, which in turn 
oxidizes sulphite ions to sulfate ions. At the titration end-point, 
excess iodine forms a blue complex with the indicator. The sulfite 
concentration is determined from the consumption of titration 
solution (iodometric determination). The amount of sodium 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 53 of 
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metabisultife is calculated by interpolation on the standard curve 
(correlation coefficient or r2  0.990) preliminary prepared using 3 
different concentrations of sodium metabisulfite (including matrix). 
The amount must be within a range of 10-30 ppm/vial. 
Identity Lactic acid 
The identification of the Lactic acid used as buffering agent is 
performed by RP-HPLC using a UV (= 210 nm) detector. Three 
HPLC runs of the Lactic acid standard solutions are performed. 
Three chromatographic runs on the sample to be analysed are also 
performed. The chromatograms of the sample are compared to the 
chromatograms of the reference. Identification is considered valid if 
the averages of the retention times of the sample runs and of the 
standard runs do not differ by more than 1 min. 
Identity rhAnnexin V-128 
The identification of the rhAnnexin V-128 protein is performed by 
“Western Blot” using a specific anti-rhAnnexin V-128 antibody 
developed in rabbit. The sample and a molecular weight standard 
are run electrophoretically on a Tris-Glycine gel under denaturing 
conditions, where proteins migrate based on their molecular weight. 
The proteins are then transferred into a PVDF membrane and 
incubated with a primary antibody specific for Annexin V128 followed 
by a secondary antibody (anti-rabbit) labelled with peroxidase. The 
substrate 4-chloro-1-naphthol (4CN) is added making visible the 
band corresponding to Annexin V128. The identity is conform when 
only 2 bands at 36kDa and 72kDa are visible. 
Bradford assay 
rhAnnexin V-128 protein 
concentration 
The quantification of the protein is performed by UV/VIS 
spectrophotometry (=595 nm). The method exploits the ability of 
Coomassie Brilliant Blue G-250 to bind proportionally to protein: 
determinations are made by comparison to the colour response of 
protein assay standards. Results are interpolated against the 
standard curve.  The correlation coefficient (or r2) of the standard 
curve must be > 0.990 to accept the test. The amount of rhAnnexin 
V-128 must be 0.400 mg/vial ± 10%. 
Chemical Purity by SEC-
HPLC and RP_HPLC (% 
rhAnnexin V-128 
monomer) 
The determination of the % of the rhAnnexin V-128 monomer and 
dimer/high molecular weight species is performed using a Size 
Exclusion column by analytical HPLC and Reverse Phase 
(RP_HPLC). Detection of the peaks is made by UV detector (λ=220 
nm and 280 nm both for SEC-HPLC and RP-HPLC). The Chemical 
Purity is calculated by integration of the rhAnnexin V-128 monomer 
peak (tR= 13.0 ± 0.5 min for SEC-HPLC and tR= 26.0 ± 0.5 min for 
RP-HPLC) and rhAnnexin V-128 natural dimer/high molecular 
weight species peak (tR= 11.5 ± 0.5 min for SEC-HPLC and tR= 27.5 
± 0.5 min for RP-HPLC). The percentage of rhAnnexin V-128 
monomer must be ≥ 90.0% and consequently the percentage of 
dimer/high molecular weight species must be ≤ 10%. 
Chemical Purity (% 
rhAnnexin V-128 
dimer/high molecular 
weight species) 
Radiochemical Purity 
(ITLC) 
The Radiochemical Purity (RCP) test is performed in compliance 
with the Ph. Eur. by ITLC. The three different eluents are used as 
follow: Acetone 100% (Tc-99m, Rf=1.0); ACD (99mTc-AxV128, 
Rf=0.0); PBS (99mTc-Glucoheptonate, Rf=1.0) and 99mTcO2, Rf=0.0). 
The RCP is calculated by integration of 99mTc-rhAnnexin V-128 peak 
that must be ≥ 90.0%; sum of 99mTc-Glucoheptonate + 99mTc-free + 
99mTcO2 must be ≤ 10% (where sum of 99mTc-free + 99mTcO2 must be 
≤ 8.0% and 99mTc-glucoheptonate must be ≤ 10.0%). 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
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Radiochemical Purity 
(SEC-HPLC) 
The RCP test is performed by analytical SEC-HPLC using Ultraviolet 
and radiometric detectors in series. The RCP is calculated by 
integration of 99mTc-rhAnnexin V-128 peak (tR= 13.5 ± 0.5 min) that 
must be ≥ 90.0%.  
Biopotency (%) 
The 
% 
of 
rhAnnexinV-128 
capable 
to 
bind 
to 
PS 
(PhosphatidylSerine) is calculated by the Biopotency assay: a fixed 
amount of labelled rhAnnexin V-128 and a fixed amount of 
preserved RBC (expressing PS on their surface) are incubated 
either in the presence of calcium (positive binding) or of chelating 
agent EDTA (negative binding). The degree of binding, after RCP 
adjustment, is calculated: {[(Negative Binding counts - Positive 
Binding Count) / Negative Binding counts] x 100}/(% rhAnnexin V-
128 RCP in ITLC) = Binding % corrected. The % of binding must be 
within the range  90 - 110%.  
Bioaffinity 
The 
affinity 
of 
rhAnnexin 
V-128 
in 
binding 
the 
PS 
(PhosphatidylSerine) in the presence of Calcium is determined by 
the displacement of FITC (Fluorescein Isothiocyanate)-AnnexinV. 
The IC50 ratio to reference value must be between 0.5 and 2. 
Sterility 
The method is compendial and complies with the current Ph. Eur. 
Monograph: 2.6.1 “Sterility”. 
Bacterial Endotoxin Test 
(LAL) 
The method employs the “LAL GEL CLOT” test. The method is 
compendial and adherent to the current Ph. Eur. Monograph: 2.6.14 
“Bacterial Endotoxins”. 
 
 
Specifications justification 
 
Sub-visible particles test: The specification is ≤ 6000 counts/vial for particles ≥ 10μm and ≤ 
600 counts/vial for particles ≥ 25μm. These levels ensure that there is not an excess of 
insoluble particulates in the reconstituted vial previous injection. 
 
pH: The specification for the pH measurement is 5.0 to 5.8. This range was determined to be 
the suitable one for the labeling with Tc-99m.  
 
Residual Moisture: The specification is fixed as NMT 5%. The stability of the 
pharmaceuticals in lyophilized form is demonstrated to be strictly correlated to the water 
content after freeze-dry cycle. Data in the literature confirm that for the proteins a value ≤ 5% 
is appropriate. 
 
Total Tin: The specification is 0.0047 – 0.0058 mg/vial. This corresponds to 0.009 – 0.011 
mg/vial in term of SnCl2 x 2H2O. The stability of the excipient Tin Chloride Dihydrate is 
reflected in the specification corresponding to the  10% standard range stipulated for the 
content of excipients in drug products. 
 
Sn++/Sn Total: The specification is not less than 50%. During the development phase it was 
demonstrated that, when fresh, even an amount equal to 3.2 µg is sufficient to reach a good 
Radiochemical purity (> 85.0%). 
 
Sodium -D-Glucoheptonate dihydrate amount: The specification is 3 mg/vial ± 10%. 
During the development phase increasing amounts of this transchelating agent were tested, 
going from 0.027 mg/vial (which was the amount present in the previous formulation) up to 6 
mg/vials (about 200-fold more concentrated compared to the previous formulation). The 
concentration of sodium -D-glucoheptonate dihydrate that showed the best performance in 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
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terms of labelling efficiency (and therefore radiochemical purity) is the 3 mg/vials. It is 
important to note that this concentration is inferior to the one present in other approved drugs 
(for example Draximage kit). A variation of ± 10% guarantees a good labeling yield. 
 
Gentisic acid sodium salt hydrate: The specification is 0.020 mg/vial ± 10%. This amount is 
sufficient to stabilize the formulation for at least 6 months (as shown by preliminary stability 
studies). A variation of ± 10% guarantees a good stability. 
 
Identity D(+)-Trehalose dihydrate: The specification is “conforms to reference in HPLC”. The 
quantification of this excipient is not essential. 
 
 
 
Identity Hydroxypropyl-β-Cyclodextrin: The specification is “conforms to reference in 
HPLC”. The quantification of this excipient is not essential. 
 
Sodium Metabisulfite: The specification is 10 – 30 ppm/vial (20 ppm/vial ± 50%). This 
amount is sufficient to maintain the active pharmaceutical ingredient (rhAnnexin V-128) in the 
monomeric form, blocking formation of the Disulphuric Bridge between two rhAnnexin V-128 
molecules (dimer). The 10 ppm/vial is the minimum amount to guarantee the desired reduced 
status of the protein; the 30 ppm/vial higher limit was chosen in order to guarantee the 
antioxidant effect over time. 
 
Identity Lactic Acid: The specification is “conforms to reference in RP-HPLC”. The 
quantification of this salt is not essential: the pH of the reconstituted lyophilized product in 
saline (5.0 to 5.8) indicates that the formulation is perfectly buffered. 
 
Identity rhAnnexin V-128: The specification is “conforms to reference” by Western Blot. The 
protein rhAnnexin V128 needs to be recognized by the specific antibodies and run at the right 
molecular weights in its two forms: 36kDa for the monomer and 72kDa for the dimer. 
 
rhAnnexin V-128 content: The specification is 0.400 mg/vial ± 10%. This range guarantees a 
good radiochemical purity, yield and specific activity. 
 
Chemical Purity: The specification is ≥ 90.0%. The main detectable impurity in the product is 
the rhAnnexin V-128 dimer formed through a sulphur bridge (S-S) between the cysteins of two 
rhAnnexin V-128 molecules. The cysteine residue cannot be blocked, since it is essential for 
the chelation of the 99mTc. However, the formation of sulphur bridge between the two cysteines 
is limited (≤ 10%) by using inert gas to remove oxygen, acidic pH of the solution (that 
decreases the reactivity of the cysteine), sodium metabisulfite and sodium gentisate as 
antioxidant agent.  
Non covalent  high molecular weight forms of Annexin can also be detected, by SEC-HPLC, in 
the Drug Product, in a very limited percentage. The sum of Annexin dimer and high molecular 
weight species (if any) is always  10%. 
 
Radiochemical Purity (ITLC): The specification is ≥ 90.0%. The radiochemical impurities are 
99mTc-Sodium Glucoheptonate, 99mTcO4
- (99mTc free pertechnetate) and 99mTcO2 . The main 
impurity is represented by 99mTc-Sodium Glucoheptonate that is known to be rapidly excreted 
following administration by the kidneys [45, 46]This impurity cannot be avoided because its 
formation is essential for a successful labelling. The sum of the other two by-products 
(99mTcO4
- + 99mTcO2) is always ≤ 8.0 and 99mTc-glucoheptonate is always ≤ 10.0. 
 
Radiochemical Purity (SEC-HPLC): The specification is ≥ 90.0%. See Radiochemical Purity 
(HPLC) justification of specification.  
 
Biopotency: The specification is 90 - 110%. A value of red blood cells binding ≥ 90% ensures 
that the protein has retained its biological activity, namely binding specifically to anionic 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 56 of 
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phosphatdylserine exposed on the cellular membrane of cells in the presence of the optimal 
calcium concentration. 
 
Bioaffinity: the specification is 0.5 to 2 expressed as IC50 ratio to reference value. It is 
performed on the API material as well as on the Drug Product to ensure that the protein has 
retained its biological activity throughout the process. 
 
Sterility: The specification is “Sterile”. The acceptance criteria set are in line with the 
provisions of Section "2.6.1 Sterility" of the current Ph. Eur. 
 
Bacterial Endotoxin: The specification is 175 IU/Vmax corresponding to 175 IU/vial. It is in 
compliance with Ph. Eur. (01/2008: 20614).  
 
Stability and Shelf Life of the Kit for radiopharmaceutical preparation of 99mTc-
rhAnnexin V-128 
 
The target for the stability of the Drug Product (Kit for radiopharmaceutical preparation of 99mTc-
rhAnnexin V-128) is 18 months at 5°C ± 3°C.  
 
The stability evaluation has been performed on lab-scale and engineering batches of the Drug Product 
and is now ongoing on the batch manufactured in GMP conditions . (CT001 14002). Drug Product 
stability will be assessed up to 18 months (every 3 months for the first year and every 6 months for the 
second year, up to 18 months) at the intended storage temperature (5°C ± 3°C). Furthermore, stability 
assessment will be also performed at the accelerated temperature condition (25°C ± 2°C), up to 9 
months. 
The stability assessment of the first GMP batch CT001 14002 will cover the stability of future GMP 
batches that will be produced for clinical trial use.  
  
 
Stability of the Finished Product (99mTc-rhAnnexin V-128 radiolabelled Imaging Agent) 
 
The stability of the Finished Product is 6 h after labeling at room temperature. At this time the 
Radiochemical Purity is still ≥ 90%. For the purpose of this study it is recommended to inject the 
product within 4 h  after completion of the radiolabelling reaction. 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 57 of 
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Appendix 2 
Dosimetry and Pharmacokinetics: 
Manual for Procurement, Storage and Handling of Blood and Urine Samples 
 
Blood samples (10 mL) will be collected just before administration of the therapeutic dose and then at 
the following time intervals:  5, 10, 15, 30, 60 minutes, 2 hrs, 4 hrs and 24 hours post the first rhAnnexin 
V-128 administration for the first 3 patients of the sub-study. Depending upon the results in those 3 
patients, the timeframe for dosimetry measurements and PK will be confirmed or modified with a time-
point at 3 hrs (instead of 2 hrs) and 6 hrs (instead of 4 hrs) for the following 7 enrolled patients in the 
sub-study The following whole blood or serum aliquots have to be prepared. 
1) 2 x 1 mL of whole blood (for radioactivity measurements) 
2) 2 x 1 mL of serum (for radioactivity measurements) 
3) 2 x 0.6 mL at least of serum (for ELISA assay) 
 
Therefore, out of the 10 mL, 2 x 1 mL of whole blood will be collected in tubes with anticoagulant and 
counted in a gamma-counter at the CHUV/NUC laboratory. 
The remaining 8 mL will be collected in serum tubes (preferably serum tubes with gel separator) and 
centrifuged for 5 min at 1500 rpm at room temperature. The serum will be divided in 2 aliquots of 1 mL 
each and in 2 aliquots of at least 0.6 mL each. The 1 mL serum aliquots will be counted in the gamma-
counter at the CHUV/NUC laboratory. 
The 0.6 mL serum samples will be frozen at -80°C (please note that these samples should be put at 
-80°C within 1 hour from blood withdrawal). After complete decay of radioactivity, one out of two 
samples per time-point will be shipped to the centralized laboratory for ELISA assay. 
Avoid freeze-thawing of the serum samples. 
 
Urine samples will be collected as follows. One sample will be collected within 24 hrs prior to 99mTc-
rhAnnexin V-128 administration, preferable just prior to the administration of study drug (0 h sample) to 
achieve bladder emptying. Quantitative urine collections will be obtained (and volume recorded) 
possibly in the time intervals 0-1 h, 1 h – 4 hrs, 4 hrs – 16 hrs, and 16 hrs – 24 hrs post the first 
administration. Dual 2 mL aliquots of urine from each period will be counted in a gamma counter at the 
CHUV/NUC laboratory. The mean between the two 99mTc radioactivity measurements and the 
measured volume of urine will be used to calculate the amount of 99mTc excreted in that period and the 
cumulative percent injected dose (radioactivity).  
Urine samples (10 mL aliquot from each urine sample) will be also analysed as a function of time by an 
SEC-HPLC technique at the CHUV/NUC laboratory, in order to gain information on the chemical status 
of 99mTc-rhAnnexin V-128 and on the presence of 99mTc-rhAnnexin V-128-related species. For this 
purpose, 10 mL aliquot from each urine sample will be transferred to the CHUV-NUC laboratory where 
the SEC-HPLC analysis will be performed as soon as possible to avoid stability issues. 
 
The collection of blood and urine will be recorded in the time-schedule template shown below. 
 
 
 
 
Dosimetry and Pharmacokinetics: Time schedule for biological samples 
(after first 99mTc-rhAnnexin V-128 administration) 
 
 
Patient ID: ________________________________________________ 
weight:  __________kg;    height:_____________cm;     

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 58 of 
67 
Date of injection_______________ time: ______________ 
Administered activity (background corrected) _____________GBq 
 
 
BLOOD SAMPLES -  1 ml/sample 
URINE COLLECTION - COMPLETE 
n. 
Time 
date 
n. 
Time interval 
date 
1 
Before 
administration
Day 1 
1 
Before treatment 
Day 1 
2 
5 min 
Day 1 
2 
Up to 1 h  
Day 1  
3 
10 min 
Day 1 
3 
From 1h  4 hrs  
Day 1 
4 
15 min  
Day 1 
4 
 4 hrs 16 hrs 
Day 1 
5 
30 min 
Day 1 
5 
16 hrs  24 hrs 
Day 1-2 
6 
60 min 
Day 1 
 
 
 
7 
2 hrs 
Day 1 
 
 
 
8 
4 hrs 
Day 1 
 
 
 
9 
24 hrs 
Day 2 
 
 
 
 
 
URINE COLLECTION: Please ask the patient to void the urinary bladder BEFORE the acquisition of 
each scintigraphic image, especially within the first 24 hrs post injection, when the activity elimination 
rate is high.  
 
 
 
 
 
Dosimetry and Pharmacokinetics: Time schedule for biological samples in case 
of modified time-points after results of the first 3 patients. 
(after first 99mTc-rhAnnexin V-128 administration) 
 
Patient ID: ________________________________________________ 
weight:  __________kg;    height:_____________cm;     
Date of injection_______________ time: ______________ 
Administered activity (background corrected) _____________GBq 
 
 
 
BLOOD SAMPLES -  1 ml/sample 
URINE COLLECTION - COMPLETE 
n. 
Time 
date 
n. 
Time interval 
date 
1 
Before 
administration
Day 1 
1 
Before treatment 
Day 1 
2 
5 min 
Day 1 
2 
Up to 1 h  
Day 1  

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 59 of 
67 
3 
10 min 
Day 1 
3 
From 1h  4 hrs  
Day 1 
4 
15 min  
Day 1 
4 
 4 hrs 16 hrs 
Day 1 
5 
30 min 
Day 1 
5 
16 hrs  24 hrs 
Day 1-2 
6 
60 min 
Day 1 
 
 
 
7 
3 hrs 
Day 1 
 
 
 
8 
6 hrs 
Day 1 
 
 
 
9 
24 hrs 
Day 2 
 
 
 
 
URINE COLLECTION: Please ask the patient to void the urinary bladder BEFORE the acquisition of 
each scintigraphic image, especially within the first 24 hrs post injection, when the activity elimination 
rate is high.  

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 60 of 
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Appendix 3 
Total quantity of collected blood  
 
Patients who will not participate in the PK and dosimetric sub-study: 
 
Analysis 
Screening 
Day 30 
Day 42 
Day 56 
Day 90 
Haematology 
and 
biochemistry 
15 ml 
15 ml 
15 ml 
 
15 ml 
Immunogenicity 
analysis 
10 ml 
10 ml 
 
10 ml 
10 ml 
TOTAL 
100 ml 
 
Patients who will participate in the PK and dosimetric sub-study: 
 
Analysis 
Screening 
Day 1 
Day 2 
Day 30 
Day 42 
Day 56 
Day 90 
Heamatology 
and 
biochemistry 
15 ml 
 
15 ml 
15 ml 
15 ml 
 
15 ml 
PK and 
dosimetry sub-
study 
 
80 ml (10 
ml * 8 time 
points 
between 0 
and 6h) 
10 ml 
 
 
 
 
Immunogenicity 
analysis 
10 ml 
 
 
10 ml 
 
10 ml 
10 ml 
TOTAL 
205 ml 
 

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Appendix 4 
 
 
References 
 
1. 
Majno, G. and I. Joris, Apoptosis, oncosis, and necrosis. An overview of cell death. Am J Pathol, 1995. 
146(1): 3-15. 
2. 
Saraste, A. and K. Pulkki, Morphologic and biochemical hallmarks of apoptosis. Cardiovasc Res, 2000. 
45(3): 528-37. 
3. 
Saikumar, P., et al., Apoptosis: definition, mechanisms, and relevance to disease. Am J Med, 1999. 
107(5): 489-506. 
4. 
Kam, P.C. and N.I. Ferch, Apoptosis: mechanisms and clinical implications. Anaesthesia, 2000. 55(11): 
1081-93. 
5. 
Eguchi, K., Apoptosis in autoimmune diseases. Intern Med, 2001. 40(4): 275-84. 
6. 
Post, A.M., et al., Imaging cell death with radiolabeled annexin V in an experimental model of 
rheumatoid arthritis. J Nucl Med, 2002. 43(10): 1359-65. 
7. 
Yamanishi Y., F.G.S., Apoptosis in rheumatoid arthritis in Apoptosis and autoimmunity J.W. Sons, 
Editor. 2003, Kalden J.R. and Herrmann 169-196. 
8. 
Lawrence, R.C., et al., Estimates of the prevalence of arthritis and selected musculoskeletal disorders in 
the United States. Arthritis Rheum, 1998. 41(5): 778-99. 
9. 
Britsemmer, K., et al., Validation of the 2010 ACR/EULAR classification criteria for rheumatoid 
arthritis: slight improvement over the 1987 ACR criteria. Ann Rheum Dis, 2011. 70(8): 1468-70. 
10. 
De Rycke, L., et al., Rheumatoid factor and anticitrullinated protein antibodies in rheumatoid arthritis: 
diagnostic value, associations with radiological progression rate, and extra-articular manifestations. 
Ann Rheum Dis, 2004. 63(12):1587-93. 
11. 
Guillemin, F., et al., Reproducibility and sensitivity to change of 5 methods for scoring hand 
radiographic damage in patients with rheumatoid arthritis. J Rheumatol, 2005. 32(5): 778-86. 
12. 
Ejbjerg, B.J., et al., The smallest detectable difference and sensitivity to change of magnetic resonance 
imaging and radiographic scoring of structural joint damage in rheumatoid arthritis finger, wrist, and 
toe joints: a comparison of the OMERACT rheumatoid arthritis magnetic resonance imaging score 
applied to different joint combinations and the Sharp/van der Heijde radiographic score. Arthritis 
Rheum, 2005. 52(8): 2300-6. 
13. 
Bruynesteyn, K., et al., Radiography as primary outcome in rheumatoid arthritis: acceptable sample 
sizes for trials with 3 months' follow up. Ann Rheum Dis, 2004. 63(11):1413-8. 
14. 
Beckers, C., et al., Assessment of disease activity in rheumatoid arthritis with (18)F-FDG PET. J Nucl 
Med, 2004. 45(6): 956-64. 
15. 
Beckers, C., et al., (18)F-FDG PET imaging of rheumatoid knee synovitis correlates with dynamic 
magnetic resonance and sonographic assessments as well as with the serum level of metalloproteinase-3. 
Eur J Nucl Med Mol Imaging, 2006. 33(3): 275-80. 
16. 
Goekoop-Ruiterman, Y.P., et al., Clinical and radiographic outcomes of four different treatment 
strategies in patients with early rheumatoid arthritis (the BeSt study): a randomized, controlled trial. 
Arthritis Rheum, 2005. 52(11): 3381-90. 
17. 
Sieper, J., et al., The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to 
assess spondyloarthritis. Ann Rheum Dis, 2009. 68 Suppl 2: 1-44. 
18. 
Zochling, J., et al., Current evidence for the management of ankylosing spondylitis: a systematic 
literature review for the ASAS/EULAR management recommendations in ankylosing spondylitis. Ann 
Rheum Dis, 2006. 65(4): 423-32. 
19. 
Lahorte, C.M., et al., Apoptosis-detecting radioligands: current state of the art and future perspectives. 
Eur J Nucl Med Mol Imaging, 2004. 31(6): 887-919. 
20. 
Tait, J.F., C. Smith, and F.G. Blankenberg, Structural requirements for in vivo detection of cell death 
with 99mTc-annexin V. J Nucl Med, 2005. 46(5): 807-15. 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 62 of 
67 
21. 
Steinmetz N, T.R., Hendel RC, et al, Simultaneous dual isotope 201TI/99mTc-Annexin (apomateTM) 
SPECT in detection of acute myocardial infarction: initial results of a phase II multicenter trial J Nucl 
Med 2002. 43(5): 4P. 
22. 
Taillefer R, P.D., Duong DH, et al, 99mTc-Annexin V scintigraphy in detection of acute myocardial 
infarction (MI): repeat imaging after the onset of acute symptoms in order to evaluate the persistence of 
abnormal radiotracer uptake J Nucl Med 2002. 43(5):5P. 
23. 
Thimister PWL, P.M., Janssen D, Heidendal GAK, Disappearance of apoptosis in the sub acute phase of 
acute myocardial infarction (abstract). Eur J Nucl Med Mol Imaging 2002. 29(suppl I): S49. 
24. 
Haas RLM, V.-O.R., De Jong D, Zerp SF, Van den Heuvel IJ, Hoefnagel CA, Bartelink H, Verheij 
Radiation induced apoptosis in follicular lymphoma subjects assessed by 99mTc-Annexin V scintigraphy 
Eur J Nucl Med Mol Imaging 2003. 30(suppl. 2):S197. 
25. 
van de Wiele, C., et al., Quantitative tumor apoptosis imaging using technetium-99m-HYNIC annexin V 
single photon emission computed tomography. J Clin Oncol, 2003. 21(18): 3483-7. 
26. 
Vermeersch, H., et al., 99mTc-HYNIC Annexin-V imaging of primary head and neck carcinoma. Nucl 
Med Commun, 2004. 25(3): 259-63. 
27. 
Van den Heuvel IJ, P.B., Valdés-Olmos R, Haas R, Labelling and imaging aspects of 99mTc-rh-Annexin 
V in tumour-apoptosis detection. Eur J Nucl Med Mol Imaging 2003. 30(Suppl. 2): S167. 
28. 
Kemerink, G.J., et al., Safety, biodistribution, and dosimetry of 99mTc-HYNIC-annexin V, a novel human 
recombinant annexin V for human application. J Nucl Med, 2003. 44(6): 947-52. 
29. 
Tait, J.F., et al., Improved detection of cell death in vivo with annexin V radiolabeled by site-specific 
methods. J Nucl Med, 2006. 47(9): 1546-53. 
30. 
Emami, B., et al., Tolerance of normal tissue to therapeutic irradiation. Int J Radiat Oncol Biol Phys, 
1991. 21(1): 109-22. 
31. 
DeGrado, T.R., et al., Synthesis and evaluation of (18)F-labeled choline analogs as oncologic PET 
tracers. J Nucl Med, 2001. 42(12): 1805-14. 
32. 
Services, U.S.D.o.H.a.H., et al., Guidance for Industry - Developing Medical Imaging Drug and 
Biological Products - Part 1: Conducting Safety Assessments. 2004. 
33. 
Cloutier, R.J., et al., Dose to the fetus from radionuclides in the bladder. Health Phys, 1973. 25(2):147-
61. 
34. 
Protection, I.C.o.R., Age-dependent Doses to Members of the Public from Intake of Radionuclides - Part 
1, ed. I. Publication. 56. 1990: Pergamon Press. 
35. 
Protection, I.C.o.R., Limits for Intakes of Radionuclides by Workers. Ann. ICRP. Vol. 30 (Part 1). 1979. 
36. 
Chen Z. P., W.S.P., Tang J., Li X. M., Liu C. Y., Xu X. J., Cao G. X., Simplified method for determining 
radiochemical purity of 99mTc-TRODAT-1. Journal of Radioanalytical and Nuclear Chemistry.. 277(3). 
2008. 
37. 
Stabin, M.G., R.B. Sparks, and E. Crowe, OLINDA/EXM: the second-generation personal computer 
software for internal dose assessment in nuclear medicine. J Nucl Med, 2005. 46(6): 1023-7. 
38. 
Ahlgren, S., K. Andersson, and V. Tolmachev, Kit formulation for 99mTc-labeling of recombinant anti-
HER2 Affibody molecules with a C-terminally engineered cysteine. Nucl Med Biol, 2010. 37(5): 39-46. 
39. 
Siegel, J.A., et al., MIRD pamphlet no. 16: Techniques for quantitative radiopharmaceutical 
biodistribution data acquisition and analysis for use in human radiation dose estimates. J Nucl Med, 
1999. 40(2): 37S-61S. 
40. 
Millar, A.M., Effect of source and age of sodium pertechnetate Tc 99m on radiochemical purity of 
technetium Tc 99m exametazime. Am J Hosp Pharm, 1993. 50(1): 103-6. 
41. 
Hung, J.C., et al., Generator eluate effects on the labeling efficiency of 99mTc-sestamibi. Nucl Med Biol, 
1995. 22(7): 949-51. 
42. 
Hung, J.C. and L.M. Thorson, Effects of generator eluate age on the radiochemical purity of fractionated 
99Tcm-MAG3. Nucl Med Commun, 1995. 16(3): 157-60. 
43. 
Rottey S., Slegers G., Van Belle S., Goethals I., Van de Wiele C.,Sequential 99mTc-
Hydrazinonicotinamide-Annexin V Imaging for Predicting Response to Chemotherapy, J. Nucl. Med. 
2006; 47: 1813-1818. 
44. 
Hung, J.C. and L.M. Thorson, Effects of generator eluate age on the radiochemical purity of fractionated 
99Tcm-MAG3. Nucl Med Commun, 1995. 16(3): p. 157-60. 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 63 of 
67 
45. 
de Kieviet, W., Technetium radiopharmaceuticals: chemical characterization and tissue distribution of 
Tc-glucoheptonate using Tc-99m and carrier Tc-99. Journal of nuclear medicine : official publication, 
Society of Nuclear Medicine, 1981. 22(8): p. 703-9. 
46. 
Qiu, K., et al., 99mTc-labeled HAb18 McAb Fab fragment for radioimmunoimaging in nude mice 
bearing human hepatocellular carcinoma. World journal of gastroenterology : WJG, 1998. 4(2): p. 117-
120. 
 
 
 
 

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SERIOUS CRITERIA: 
 
 
DEATH   
 
 
LIFE-THREATENING 
 
 
INVOLVED OR PROLONGED HOSPITALIZATION  
 
CONGENITAL ANOMALY 
 
PERSISTENT OR SIGNIFICANT DISABILITY OR INCAPACITY 
 
MEDICALLY SIGNIFICANT   SUHFLVH: ________________________________
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99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 65 of 
67 
 
5. Non Serious event of special interest 
 
 
 
 
 
 No 
 Yes – Specify bellow 
Use only in exceptional circumstances to indicate when a non-serious event of special interest (as defined by the protocol) is being 
reported: 
 
 
 
 
 
6. Serious adverse Event Outcome 
 
 
SERIOUS CRITERIA: 
Date  
 
 
FATAL    
   
 
 
RESOLVED 
   
 
 
RESOLVED WITH SEQUELAE 
   
Sequelae : ____________________________ 
 
IMPROVED 
 
 
 
PERSISTING 
 
 
 
WORSENED 
 
 
 
UNKNOW 
 
 
 
7. Study drug(s) 
 
 
All study treatments specified in the protocol 
Name 
Dose 
Batch Number 
Frequency 
Route 
Start date 
End date 
Ongoing 
 
 
 
 
 
   
   
 
 
 
 
 
 
   
   
 
 
 
 
 
 
   
   
 
 
 
 
 
 
   
   
 
 
 
 
 
 
   
   
 
Delay of occurrence after last dose intake:  ________ (time unit) 
 
8. Action taken with study drug(s) 
 
Name 
No 
change 
Temporarily interrupted 
Ongoing 
Dose adjusted 
(detail) 
Unknow 
Date stopped 
Date restarted 
Date stopped 
 
 
   
   
   
 
 
 
 
   
   
   
 
 
 
 
   
   
   
 
 
 
 
   
   
   
 
 
 
 
   
   
   
 
 
In case of re-administration, did the reaction recur? 
 Yes 
 No 
 
 
 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 66 of 
67 
 
9. Concomitant treatment 
 
Name 
Daily dose 
Route 
Start date 
End date 
Ongoing 
Indication 
 
 
 
   
   
 
 
 
 
 
   
   
 
 
 
 
 
   
   
 
 
 
 
 
   
   
 
 
 
 
 
   
   
 
 
 
10. Corrective treatment (drug, procedure, etc.) 
 
 
Name 
Total daily dose 
Start date 
End date 
Ongoing 
 
 
      
 
 
 
      
 
 
 
      
 
 
 
      
 
 
 
      
 
 
11. Relevant Laboratory / Diagnostic Tests 
 
 
Rq: Include laboratory values preceding the event 
Details of additional tests can be completed on the Additional Laboratory / Diagnostic Tests form.  
Additional form provided? 
 No 
 Yes (Number of extra-pages: ___) 
Name of the test 
Results (units) 
Normal values / Reference 
ranges 
Sample collection date 
Result 
pending 
 
 
 
   
 
 
 
 
   
 
 
 
 
   
 
 
 
 
   
 
 
 
 
   
 
 
 
 
   
 
 
 
 
   
 
 
 
 

99mTc-rhAnnexin V-128 in patients with rheumatoid arthritis or ankylosing spondylitis 
 
Protocol Amendment n°4, 16 December 2014                                                                                       Page 67 of 
67 
 
12. Possible causes of the event 
 
 
Check off all that apply 
Specify 
Pre-existing / underlying disease 
 
 
Study treatment 
 
 
Other treatment 
 
 
Protocol-related procedure 
 
 
Other (e.g. accident, new or intercurrent illness) 
 
 
 
13. Investigator 
 
 
SAE Form 
Full name (in uppercase letters) 
Function 
Date 
Signature 
Filled out by: 
 
 
   
 
Validated by: 
 
 
   
 
 
 
 
14. AAA PV department 
 
 
SAE Form 
Full name (in uppercase letters) 
Function 
Date 
Signature 
Reception by: 
 
 
   
 
QC by: 
 
 
   
 
 
 
 
15. AAA Comments