A Randomized Trial in 2 Parts: Double-Blind, Placebo-Controlled, Crossover Part 1 and Open-label Part 2, Evaluating the Efficacy and Safety of Dasiglucagon for the Treatment of Children With Congenital Hyperinsulinism
Phase: PHASE2
Conditions: Congenital Hyperinsulinism
Sponsor: Zealand Pharma

PROTOCOL TITLE:  A Randomized, Double-Blind, Parallel-Group Trial Evaluating the 
Efficacy and Safety of Dasiglucagon for the Treatment of Children with 
Congenital Hyperinsulinism 
PROTOCOL DATE:  Original Protocol Version 1.0, 14-Dec-2017 
NCT Number: 
NCT04172441 
Document version  
Date 
Comments 
Version 14.0 – Germany only 
04-Jun-2021 
Local protocol in Germany combining 
protocol 12.0 and 13.0. 
Version 13.0 – All countries 
except Germany 
04-Jun-2021 
Updates to the secondary endpoints. 
Statistical section was updated with the 
updated endpoints. The safety section was 
clarified further.  
Version 12.0 –  Germany 
only 
05-Nov-2020 
Update requested by Germany competent 
authority to outline that only Dexcom G6 
continuous glucose monitoring device was to 
be used in Germany. 
Version 11.0 – Germany only 
27-Aug-2020 
Local protocol in Germany combining 
protocol 9.0 and 10.0 with additional to 
updating all device-specific sections related to 
Dexcom G4 to Dexcom G6. 
Version 10.0 –  All countries 
except Germany 
08-Jul-2020 
Dexcom G4 was changed to Dexcom G6 as 
the G4 was being phased out. 
Statistical section was updated focusing on 
the key secondary analysis description; the 
endpoint was rewritten to match the 
description in the endpoint section. 
Pharmacokinetics/drug exposure section was 
updated: Visit 5 corrected to Day 5. 
Version 9.0 – All countries 
except  Germany 
29-Apr-2020 
Local protocol in Germany combining 
protocol versions 6.1 and 8.0. 
Version 6.1 –  Germany only 
05-Mar-2020 
Device adapted protocol to fulfill the 
requirements from Germany competent 
authority in their query letters to protocol 
version 6.0. Protocol version includes 
protocol  version 6.0 and mandated text on 
analysis of device related safety events. 
Version 8.0 – Germany only 
11-Oct-2019 
Local  protocol in Germany combining 
protocol versions 6.0 and 7.0. 
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Document version  
Date 
Comments 
Version 7.0 – All countries 
except Germany 
19-Sep-2019 
First patient enrolled under this version.  
Version 6.0 – Germany only 
05-Jul-2019 
Device adapted protocol to fulfill the 
requirements of the German competent 
authority. New section added to address the 
devices used in the trial and additional device 
related safety reporting added. 
Version 5.0 – Global 
03-Jun-2019 
 
Version 4.0 – Global 
15-Apr-2019 
 
Version 3.0 – France, 
Germany, Israel, United 
Kingdom 
25-Jul-2018 
 
Version 2.0 – Global 
20-Jun-2018 
 
Version 1.0 – Global 
14-Dec-2017 
 
 
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PROTOCOL 
PRODUCT 
NAME/NUMBER: 
Dasiglucagon 
PROTOCOL NUMBER: 
ZP4207-17103 
IND NUMBER: 
135869 
EUDRACT NUMBER: 
2017-004545-24 
DEVELOPMENT PHASE: 
Phase 2/3 
PROTOCOL TITLE: 
A Randomized Trial in 2 Parts: Double-Blind, 
Placebo-Controlled, Crossover Part 1 and Open-label Part 2, 
Evaluating the Efficacy and Safety of Dasiglucagon for the 
Treatment of Children with Congenital Hyperinsulinism 
PROTOCOL DATE: 
Original Protocol Version 1.0, 14-Dec-2017 
Final Version 14.0, 04-Jun-2021 (Germany) 
SPONSORED BY: 
Zealand Pharma A/S 
Sydmarken 11 
2860 Soeborg (Copenhagen) 
Denmark 
Telephone: +45 88 77 36 00 
CONTRACT RESEARCH 
ORGANIZATION: 
Premier Research  
One Park Drive 
Suite 150 
Durham, NC  27709  USA 
This trial will be performed in compliance with Good Clinical Practices (GCP) and applicable 
regulatory requirements, including the archiving of essential documents. Information contained 
in this protocol is confidential in nature, and may not be used, divulged, published, or otherwise 
disclosed to others, except to the extent necessary to obtain approval of the institutional review 
board or independent ethics committee, or as required by law. Persons to whom this information 
is disclosed should be informed that this information is confidential and may not be further 
disclosed without the express permission of Zealand Pharma A/S. 
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1.
REVISION HISTORY
PROTOCOL TITLE: 
A Randomized Trial in 2 Parts: Double-Blind, 
Placebo-Controlled, Crossover Part 1 and Open-label Part 2, 
Evaluating the Efficacy and Safety of Dasiglucagon for the 
Treatment of Children with Congenital Hyperinsulinism 
PROTOCOL DATE: 
Original Protocol Version 1.0, 14-Dec-2017 
This updated protocol version 14.0 is applicable for Germany 
only, and includes: 
AMENDMENT No. 1 
Final Version 2.0, 20-Jun-2018 (All Countries) 
AMENDMENT No. 2 
Final Version 3.0, 25-Jul-2018 (France, Germany, Israel, 
United Kingdom) 
AMENDMENT No. 3 
Final Version 4.0, 15-Apr-2019 (All Countries) 
AMENDMENT No. 4 
Final Version 5.0, 03-Jun-2019 (All Countries) 
AMENDMENT No. 5 
Final Version 6.0, 05-Jul-2019 (Germany) 
AMENDMENT No. 5.1 
Final Version 6.1, 05-Mar-2020 (Germany) 
AMENDMENT No. 6 
Final Version 7.0, 19-Sep-2019 (All countries except 
Germany) 
AMENDMENT No. 7 
Final Version 8.0, 11-Oct-2019 (Germany) 
AMENDMENT No. 8 
Final Version 9.0, 29-Apr-2020 (Germany) 
AMENDMENT No. 9 
Final Version 10.0, 08-Jul-2020 (All countries except 
Germany) 
AMENDMENT No. 10 
Final Version 11.0, 27-Aug-2020 (Germany) 
AMENDMENT No. 11 
Final Version 12.0, 05-Nov-2020 (Germany) 
AMENDMENT No. 12 
Final Version 13.0, 04-Jun-2021 (All countries except 
Germany) 
AMENDMENT No. 13 
Final Version 14.0, 04-Jun-2021 (Germany) 
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2. APPROVAL SIGNATURES 
PROTOCOL 
NUMBER: 
ZP4207-17103 
PROTOCOL TITLE: 
A Randomized Trial in 2 Parts: Double-Blind, Placebo-Controlled, 
Crossover Part 1 and Open-label Part 2, Evaluating the Efficacy and 
Safety of Dasiglucagon for the Treatment of Children with Congenital 
Hyperinsulinism 
I, the undersigned, have read this protocol and confirm that to the best of my knowledge it 
accurately describes the planned conduct of the trial. 
 
 
 
 
 
 
Clinical Trial Manager 
Zealand Pharma A/S 
 
Date 
 
 
 
 
 
 
Medical Director 
Zealand Pharma A/S 
 
Date 
 
 
 
 
 
 
Senior Manager Biostatistics 
Premier Research 
 
Date 
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3. SYNOPSIS 
PRODUCT 
NAME/NUMBER 
Dasiglucagon 
PROTOCOL 
NUMBER 
ZP4207-17103 
EUDRACT 
NUMBER 
2017-004545-24 
DEVELOPMENT 
PHASE 
Phase 2/3  
PROTOCOL TITLE 
A Randomized Trial in 2 Parts: Double-Blind, Placebo-Controlled, Crossover Part 1 and 
Open-label Part 2, Evaluating the Efficacy and Safety of Dasiglucagon for the 
Treatment of Children with Congenital Hyperinsulinism 
INDICATION 
Congenital hyperinsulinism (CHI) 
OBJECTIVES 
Primary: To evaluate the efficacy of dasiglucagon in reducing glucose requirements in 
children with persistent CHI requiring continuous IV glucose administration to 
prevent/manage hypoglycemia. 
Secondary: To evaluate the safety and tolerability of dasiglucagon administered as a 
subcutaneous (SC) infusion in patients with CHI. 
TRIAL DESIGN 
This is a combined phase 2 and 3, randomized, multinational trial to evaluate the 
efficacy and safety of individually titrated dasiglucagon in children ≥7 days and <1 year 
of age who have been diagnosed with CHI, comprising 2 parts, a crossover (2 periods, 
48 hours each), double-blind, placebo-controlled Part 1, and an open-label, single-arm 
Part 2 of 21 days. 
After screening, eligible patients will complete a minimum 24-hour run-in period to 
confirm the IV glucose randomization requirement (≥10 mg/kg/min). All 
non-nutritional carbohydrates and carbohydrate fortification of feeds are prohibited 
during this 24-hour run-in period. After the run-in period, patients will be randomly 
assigned in a double-blind fashion to receive dasiglucagon or placebo for 48 hours, after 
which they will be crossed over to the other trial treatment for an additional 48 hours. At 
the time of crossover, the trial drug will be initiated from the starting dose of 10 µg/hr, 
and IV glucose infusion rate (GIR) will be set to the rate obtained at the end of the run-
in period and titrated accordingly.  
There will be no washout between the 2 periods in Part 1 to limit the length of time in 
which patients are reliant on IV GIR as their only means of preventing/treating 
hypoglycemia. This is deemed acceptable because: 
• 
The half-life (t½) of dasiglucagon is short (~30 minutes for the 0.6 mg dose and 
potentially shorter for lower doses, ~22 minutes) relative to the 48-hour duration of 
each crossover period. Moreover, for the primary endpoint, only the last 12 hours of 
the 48-hour period will be used for endpoint assessment.  
• 
Assuming a positive effect of dasiglucagon, the absence of washout is more 
conservative with respect to key secondary endpoints since a potential carry over 
effect of dasiglucagon in Period 2 is attributed to placebo.  
During Part 1, the trial drug and IV GIR should be adjusted according to the 
protocol-specified algorithm. Non-nutritional carbohydrates and/or carbohydrate 
fortification of feeds during Part 1 is only allowed when the maximum tolerable volume 
and concentration of IV glucose for the patient is reached, and should be limited to the 
minimum needed to ensure the patient’s safety. All feedings (administered as parenteral 
nutrition, by nasogastric [NG] tube, gastrostomy, or normal route), will be recorded 
during this period. Safety assessments will be performed daily after initiation of the trial 
drug (active or placebo).  
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After Part 1, patients will continue in open-label Part 2 to receive dasiglucagon for 
21 days. Additional CHI treatments can be introduced during Part 2 if needed, if 
up-titration of dasiglucagon is not possible because of undesirable side effects or if the 
maximum dose level (70 µg/hr) has been reached. Gradual transfer from IV glucose to 
oral and gastric carbohydrates should be initiated in Part 2, enabling weaning of IV 
glucose and hospital discharge. Patients will continue to be hospitalized until IV GIR is 
weaned off; however, as soon as local site criteria for discharge are met, patients can be 
discharged to continue the treatment period at home. Visits are planned at Day 11 and 
Day 18 in Part 2. These visits can be converted to telephone visits if appropriate, at the 
investigator’s discretion. On Day 25, the End of Treatment Visit will take place, and 
based on the investigator’s confirmation of continued positive benefit-risk balance, 
patients will be offered the opportunity to participate in the long-term extension trial 
(Trial ZP4207-17106) to continue dasiglucagon treatment. Patients who do not enter the 
long-term extension trial will have a Follow-up Visit 28 days after their last dose of trial 
drug. 
PLANNED 
NUMBER OF 
PATIENTS 
A total of 12 patients is planned to be randomized 1:1 to receive either placebo first and 
then dasiglucagon or vice versa. 
TRIAL ENTRY 
CRITERIA 
Eligible patients will be ≥7 days and <12 months of age at screening with a body weight 
of ≥2.0 kg (4.4 lbs.) and a diagnosis of CHI established based on the following:  
• 
Hyperinsulinemia (plasma insulin above the limit of detection of the assay 
documented during an event of hypoglycemia), and/or  
• 
Hypofattyacidemia (plasma free fatty acid <1.7 mmol/L), and/or  
• 
Hypoketonemia (beta-hydroxy-butyrate <1.8 mmol/L), and/or  
• 
Glycemic response (increase in plasma glucose [PG] of >30 mg/dL after 1 mg IV 
or intramuscular [IM] glucagon administration) 
Eligible patients will be dependent on continuous IV glucose to prevent hypoglycemia. 
INVESTIGATIONAL 
PRODUCTS 
Dasiglucagon injection 4 mg/mL in a 3 mL vial containing 1 mL for injection. 
Matching placebo for dasiglucagon injection in a 3 mL vial containing 1 mL for 
injection.  
REFERENCE 
PRODUCT 
None 
TREATMENT 
REGIMENS 
As long as the patient is receiving IV glucose, PG will be measured and reviewed 
hourly using a hand-held PG meter. The IV GIR will be titrated to achieve glycemia of 
at least 70 mg/dL (3.9 mmol/L) (minimum GIR will be established as the rate up-titrated 
after the patient drops at least once below 70 mg/dL, or 3.9 mmol/L). When the patient 
is no longer on IV GIR, the PG will be checked according to local practice, but at least 
3 times daily. The PG will be measured using the same trial-supplied hand-held PG 
meter during the entire trial.  
Additionally, blinded continuous glucose monitoring (CGM) will be started 24 hours 
prior to randomization using either the Dexcom G4 or G6 (all countries except 
Germany), or Dexcom G6 system (Germany). CGM monitoring will continue until the 
end of Part 2. 
Dosing of trial drug 
Dosing of dasiglucagon will approximate continuous infusion by delivering small doses 
at frequent intervals via a trial-supplied infusion pump. The adjustment of trial drug 
dosing is closely linked to the PG level achieved, which in turn will determine the 
adjustments to the IV GIR. 
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Part 1 (Crossover, double-blind, randomized, placebo controlled) 
The starting dose of trial drug is 10 µg/hr at t=0. Every 2 hours (t=2, 4, 6h, etc.), the 
dose will be increased by an additional 10 µg/hr until either: 
• 
The patient is totally weaned off IV glucose, or 
• 
PG during the last 2 hours was constantly above 120 mg/dL (6.7 mmol/L), or 
• 
IV GIR has not decreased despite 2 sequential dose increases (in this situation the 
dose of trial drug product should be maintained until the IV GIR can be further 
decreased or until crossover or the end of the treatment period), or 
• 
The maximum dose of 70 µg/hr is reached, or 
• 
Adverse events (AEs) emerge that are considered to be related to the trial drug 
(e.g., nausea/change in feeding patterns or increased vomiting) and that are limiting 
further dose escalation 
The 2-hour dose-adjustment interval will allow drug plasma levels to approach steady 
state before the dose is further increased. 
The cumulative dose will not exceed 1.26 mg over the first 24 hours and 1.68 mg for the 
subsequent 24-hour periods.  
At the time of crossover from the first 48-hour period to the second 48-hour period, the 
trial drug will again be titrated from the starting dose of 10 µg/hr, and IV GIR will be 
set to the rate obtained at the end of the run-in period and titrated accordingly. 
 
Part 2 (Open-label) 
After Part 1, all patients will continue in open-label Part 2 to receive dasiglucagon for 
an additional 21 days. Since treatment allocation during Part 1 remains blinded, all 
patients are required to initiate dasiglucagon dosing at 10 µg/hr in Part 2, while IV GIR 
in Part 2 should be started at the rate obtained at the end of the run-in period. During 
Part 2, the dasiglucagon dose, the amount and route of administration of carbohydrates 
(IV GIR, parenteral nutrition, gastric carbohydrate infusions, and carbohydrates from 
oral feeds) can be adjusted at the discretion of the investigator. Plasma glucose should 
be monitored at least hourly to adjust the IV GIR as appropriate and to avoid 
hypoglycemia. Additional concomitant medications, including somatostatin analogs 
and/or sirolimus/mechanistic target of rapamycin (mTOR) inhibitors, may be introduced 
at the investigator’s discretion if the maximum dose level of dasiglucagon (70 µg/hr) 
has been reached or if further up-titration is not possible due to undesirable side effects. 
Adjustment of total carbohydrates administered (IV glucose, parenteral nutrition, gastric 
carbohydrate infusions, and carbohydrates from oral feeds) should continue throughout 
this period according to local practice to maintain PG levels in the range of 70 mg/dL to 
120 mg/dL (3.9-6.7 mmol/L). The aim will be to obtain stable glucose levels with 
minimum rescue/hypoglycemia-prevention carbohydrates administered by invasive 
routes and to encourage/optimize oral feeds, and achieve weaning off IV glucose. 
Regardless of their discharge status, all patients will be offered the opportunity to 
participate in the long-term safety extension trial (ZP4207-17106), providing the 
investigator attests to the positive benefit-risk balance of continued dasiglucagon 
treatment. 
PLANNED TRIAL 
SITES 
Five to 7 sites in the United States, Europe, and Israel 
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ENDPOINTS 
Primary endpoint 
Part 1 (Day 1 to 4) 
• 
Mean IV GIR in the last 12 hours of each treatment period during Part 1 
(dasiglucagon or placebo administration) 
Key secondary endpoint 
Part 1 (Day 1 to 4, for each 48-hour treatment period) 
• 
Total amount (g) of carbohydrates administered (regardless of the route) per day. 
STATISTICAL 
METHODS 
Continuous endpoints will be summarized with number (n), mean, standard deviation 
(SD), median, minimum, and maximum. In addition, change from baseline values will 
be calculated at each time point and summarized descriptively; the exception to this is 
the time of PG within prespecified ranges, which will not have a baseline value. For 
categorical endpoints, descriptive summaries will include counts and percentages. 
All data will be presented in the data listings. 
Analysis Populations 
Four analysis populations have been defined for this trial: 
Safety analysis set: defined as all patients administered any randomized treatment.  
Full analysis set (FAS): defined as all patients in the Safety Set who have a valid 
baseline efficacy assessment. Patients will be analyzed according to randomized 
treatment (Part 1) or overall patients (otherwise). 
Per protocol (PP) set: defined as all patients in the FAS without any major protocol 
deviations. Patients will be excluded from the PP set if they do not receive both 
treatments and/or do not have efficacy data available to evaluate the primary endpoint 
for both treatments. 
Pharmacokinetic Set (PK): defined as all patients in the Safety Set who have at least 1 
measurement with quantifiable plasma concentration of dasiglucagon. 
Efficacy Analyses  
The primary analyses of the primary and the key secondary endpoint will be based on 
the FAS. Supportive analyses of the primary endpoint will be based on the PP. 
Primary Endpoint 
Part 1, Day 1 to 4 
The mean IV GIR in the last 12 hours of each treatment period will be calculated as a 
weighted mean across the 12 hours, taking the actual time periods between the 
measurements into account (corresponding to calculating the area under the curve 
(AUC) and dividing it by the length of the time period, i.e., weighted mean IV GIR). 
The IV GIR endpoint is expressed as glucose in mg/kg/min, i.e., data reported from 
different concentrations of the glucose used for infusion will be transformed to this 
standardized unit prior to analysis. 
The primary analysis is defined by the estimand based on the treatment policy (de-facto) 
strategy, where the actual GIR measurement reported irrespective of adherence to 
treatment or use of subsequent therapy is used. The reduction in weighted mean IV GIR, 
as determined as the difference in weighted mean IV GIR between placebo and 
dasiglucagon, will be estimated. 
The weighted mean IV GIR will be analyzed using a mixed-model regression approach, 
with treatment and period as fixed effects and patient as a random effect. The 2-sided 
95% confidence interval (CI) for the treatment difference will be calculated from the 
mixed regression model. 
Handling of missing data and sensitivity analyses are defined in the body of the 
protocol. 
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Key Secondary Endpoints  
Part 1, Day 1 to 4 
The key secondary endpoint of total amount of gastric carbohydrates administered will 
be analyzed by using a mixed-model regression approach, with treatment and period as 
fixed effects and patient as a random effect.  
Safety Analyses 
Adverse events will be coded using the latest version of the Medical Dictionary for 
Regulatory Activities (MedDRA). Adverse events that begin after the first dose of trial 
drug will be defined as treatment emergent. The overall incidence of AEs will be 
displayed by system organ class, preferred term, and treatment. The incidence of AEs 
will also be presented by severity and by relationship to the trial drug. Vital signs, 
clinical laboratory measures (including hematology, biochemistry, and incidence of 
anti-drug antibodies [ADAs]), 12-lead electrocardiograms (ECGs), echocardiography, 
physical examinations, and local tolerability data will be summarized by treatment, 
where applicable. Out-of-range safety endpoints may be categorized as low or high, 
where applicable. 
Safety results will be summarized by treatment received within treatment period and 
part and by trial visit, if applicable.  
A formal statistical analysis plan (SAP) will be prepared to provide further details on 
the methods for statistical analysis. 
No interim analysis is planned. 
SAMPLE SIZE 
DETERMINATION 
A total of 12 patients will be randomized in this crossover trial on the basis of the 
following considerations: 
The GIR results from 40 infants treated with IV glucagon for 24 hours published in the 
JIMD Research Report “The Effect of Continuous Intravenous Glucagon on Glucose 
Requirements in Infants with Congenital Hyperinsulinism” (Hawkes et al 2019). 
“Overall there was a statistically significant reduction in the median (IQR) GIR during 
the 24h following initiation of continuous glucagon infusion compared to 24 h before 
initiation (18.5 (12.9, 22.8) to 11 (6.6, 17.5) mg/kg/min…” 
This trial is powered to detect an effect in GIR for dasiglucagon after 48 hours 
compared to placebo of at least this effect size. Based on the longer infusion and 
titration of dasiglucagon in this trial, this is considered a conservative approach, 
allowing for some uncertainty when translating the published data into a clinical trial 
setting. Using unpublished individual patient data from the above-referenced study, the 
difference in GIR between the 2 treatment groups is assumed to follow a normal 
distribution. Assuming the true mean difference is 7.5 mg/kg/min with a standard 
deviation of differences of 7.36, the trial will have 89% power using a one-sample t-test 
with 12 patients randomized to receive either placebo first and then dasiglucagon or 
vice versa. 
TRIAL AND 
TREATMENT 
DURATION 
The sequence and maximum duration of the trial periods will be as follows: 
1. Screening Period: up to 28 days, including a minimum 24-hour run-in period 
2. Part 1 (2x48-hour period: double-blind, randomized, placebo-controlled): 96 hours 
3. Part 2 (Open-label Active Treatment Period): 21 days 
4. Follow-up Period: Patients who do not enter the extension trial will have a 
Follow-up Visit 28 days after their last dose of trial drug 
The maximum trial duration for each patient is 81 days. 
The maximum treatment duration for each patient is 25 days. 
 
 
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4. TABLE OF CONTENTS 
1. 
REVISION HISTORY .............................................................................................................2 
2. 
APPROVAL SIGNATURES ...................................................................................................3 
3. 
SYNOPSIS ...............................................................................................................................4 
4. 
TABLE OF CONTENTS .........................................................................................................9 
4.1. 
LIST OF TABLES ......................................................................................................13 
4.2. 
LIST OF FIGURES ....................................................................................................13 
5. 
LIST OF ABBREVIATIONS .................................................................................................14 
6. 
INTRODUCTION ..................................................................................................................16 
6.1. 
Background and Rationale ..........................................................................................16 
6.2. 
Current Treatment and Unmet Medical Need .............................................................16 
6.3. 
Dasiglucagon for the Treatment of Congenital Hyperinsulinism ...............................17 
6.3.1. 
Dasiglucagon .....................................................................................................17 
6.3.2. 
Nonclinical Experience......................................................................................18 
6.3.3. 
Clinical Experience............................................................................................18 
6.3.4. 
Literature Data ...................................................................................................20 
6.3.5. 
Anticipated Medical Benefit of Dasiglucagon in the Treatment of CHI ...........21 
6.3.6. 
Anticipated Risks of Dasiglucagon in the Treatment of CHI ............................21 
6.3.7. 
Summary of Potential Benefits and Risks .........................................................22 
7. 
OBJECTIVES AND ENDPOINTS ........................................................................................23 
7.1. 
Objectives....................................................................................................................23 
7.1.1. 
Primary Objective ..............................................................................................23 
7.1.2. 
Secondary Objectives ........................................................................................23 
7.2. 
Endpoints ....................................................................................................................23 
7.2.1. 
Primary Endpoint ...............................................................................................23 
7.2.2. 
Key Secondary Efficacy Endpoint ....................................................................23 
7.2.3. 
Secondary Efficacy Endpoints...........................................................................23 
7.2.4. 
Safety Endpoints ................................................................................................24 
8. 
TRIAL DESIGN .....................................................................................................................25 
8.1. 
Overall Trial Design and Plan .....................................................................................25 
8.2. 
Discussion of Trial Design ..........................................................................................26 
8.3. 
Trial Sites ....................................................................................................................26 
8.4. 
Point of Contact ..........................................................................................................27 
9. 
PATIENT POPULATION ......................................................................................................27 
9.1. 
Selection of Trial Population ......................................................................................27 
9.2. 
Trial Entry Criteria ......................................................................................................27 
9.2.1. 
Inclusion Criteria ...............................................................................................27 
9.2.2. 
Exclusion Criteria ..............................................................................................27 
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9.2.3. 
Randomization Exclusion Criteria ....................................................................28 
9.3. 
Premature Patient Withdrawal ....................................................................................28 
9.4. 
Treatment Discontinuation ..........................................................................................29 
9.5. 
Rescue Criteria ............................................................................................................29 
9.6. 
Patient Replacement Criteria ......................................................................................29 
10. TREATMENTS ......................................................................................................................30 
10.1. Identification of Investigational Product .....................................................................30 
10.1.1. 
Packaging and Labeling ....................................................................................30 
10.2. Treatments Administered ............................................................................................30 
10.3. Trial Supplies ..............................................................................................................32 
10.4. Dispensing and Storage ...............................................................................................33 
10.5. Method of Assigning Patients to Treatment Groups ...................................................33 
10.6. Blinding and Unblinding Treatment Assignment .......................................................34 
10.7. Selection of Doses in the Trial ....................................................................................34 
10.8. Selection of Timing of Dose for Each Patient ............................................................35 
10.9. Dose Adjustment Criteria............................................................................................35 
10.10. Treatment Compliance ................................................................................................35 
10.11. Permitted and Prohibited Therapies ............................................................................35 
10.11.1. Permitted Therapies ...........................................................................................35 
10.11.2. Prohibited Therapies ..........................................................................................35 
10.12. Discharge of Patients for Home Treatment .................................................................36 
10.13. Treatment After End of Trial ......................................................................................37 
11. TRIAL PROCEDURES ..........................................................................................................37 
11.1. Trial Duration ..............................................................................................................37 
11.2. Assessments ................................................................................................................37 
11.2.1. 
Efficacy ..............................................................................................................37 
11.2.1.1. 
Plasma Glucose Monitoring .....................................................................37 
11.2.1.2. 
Continuous Glucose Monitoring ..............................................................38 
11.2.1.3. 
Diary .........................................................................................................38 
11.2.2. 
Pharmacokinetics/Drug Exposure .....................................................................38 
11.2.3. 
Safety .................................................................................................................39 
11.2.3.1. 
Laboratory Safety Assessments ...............................................................39 
11.2.3.2. 
Clinical Examinations ..............................................................................40 
11.2.3.3. 
Reporting of Hypoglycemia Events .........................................................41 
11.2.3.4. 
Technical Complaints ..............................................................................42 
11.2.3.5. 
Adverse Events ........................................................................................43 
12. ADVERSE EVENTS ..............................................................................................................43 
12.1. Definitions ...................................................................................................................43 
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12.1.1. 
Adverse Events ..................................................................................................43 
12.1.2. 
Severity ..............................................................................................................43 
12.1.3. 
Causality ............................................................................................................44 
12.1.4. 
Outcome ............................................................................................................44 
12.1.5. 
Serious Adverse Events .....................................................................................44 
12.1.6. 
Other Important Events .....................................................................................45 
12.1.7. 
Nonserious Adverse Events ...............................................................................45 
12.1.8. 
Adverse Events of Special Interest ....................................................................45 
12.1.9. 
Suspected Unexpected Serious Adverse Reactions ...........................................45 
12.1.10. Adverse Events Associated with Devices .........................................................45 
12.1.10.1. Adverse Device Effect .............................................................................45 
12.1.10.2. Serious Adverse Device Effect ................................................................45 
12.1.10.3. Unanticipated Serious Adverse Device Effect .........................................46 
12.1.10.4. Device Deficiency ....................................................................................46 
12.2. Collection, Recording, and Reporting of Adverse Events ..........................................46 
12.2.1. 
Serious Adverse Event Reporting Process in Germany ....................................47 
12.2.2. 
Contact Information ...........................................................................................47 
12.3. Follow-up of Adverse Events .....................................................................................47 
12.4. Precautions ..................................................................................................................48 
12.5. Safety Committee ........................................................................................................49 
12.6. Independent Data Monitoring Committee ..................................................................49 
13. STATISTICS ..........................................................................................................................50 
13.1. Statistical Hypotheses .................................................................................................50 
13.2. Sample Size Determination .........................................................................................50 
13.3. Analysis Populations ...................................................................................................51 
13.4. Statistical Analyses .....................................................................................................51 
13.4.1. 
Trial Patients and Demographics .......................................................................52 
13.4.1.1. 
Disposition and Withdrawals ...................................................................52 
13.4.1.2. 
Protocol Deviations ..................................................................................52 
13.4.1.3. 
Demographics and Other Baseline Characteristics ..................................52 
13.4.2. 
Duration of Exposure and Compliance .............................................................52 
13.4.3. 
Efficacy Analyses ..............................................................................................52 
13.4.3.1. 
Primary Analysis ......................................................................................52 
13.4.3.2. 
Key Secondary Analyses .........................................................................53 
13.4.3.3. 
Secondary and Other Efficacy Analyses ..................................................53 
13.4.4. 
Safety and Tolerability Analyses .......................................................................54 
13.4.4.1. 
Adverse Events ........................................................................................54 
13.4.4.2. 
Clinical Laboratory Evaluations ..............................................................54 
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13.4.4.3. 
Vital Signs ................................................................................................55 
13.4.4.4. 
Twelve-lead Electrocardiograms .............................................................55 
13.4.4.5. 
Echocardiograms ......................................................................................55 
13.4.4.6. 
Physical Examination Findings ................................................................55 
13.4.4.7. 
Local Tolerability .....................................................................................55 
13.4.5. 
Interim Analysis ................................................................................................55 
14. TRIAL CONDUCT ................................................................................................................56 
14.1. Sponsor and Investigator Responsibilities ..................................................................56 
14.1.1. 
Sponsor Responsibilities ...................................................................................56 
14.1.2. 
Investigator Responsibilities .............................................................................56 
14.2. Site Initiation ...............................................................................................................57 
14.3. Screen Failures ............................................................................................................57 
14.4. Trial Documents ..........................................................................................................57 
14.4.1. 
Investigator’s Regulatory Documents ...............................................................57 
14.4.2. 
Case Report Forms ............................................................................................57 
14.4.3. 
Source Documents .............................................................................................58 
14.5. Data Quality Control ...................................................................................................58 
14.5.1. 
Monitoring Procedures ......................................................................................58 
14.5.2. 
Data Management ..............................................................................................59 
14.5.3. 
Quality Assurance/Audit ...................................................................................59 
14.6. Trial Termination ........................................................................................................59 
14.6.1. 
Regular Trial Termination .................................................................................59 
14.6.2. 
Premature Trial Termination .............................................................................60 
14.7. Trial Site Closure ........................................................................................................60 
14.7.1. 
Record Retention ...............................................................................................60 
14.7.2. 
Sample Retention ...............................................................................................61 
14.8. Changes to the Protocol ..............................................................................................61 
14.9. Use of Information and Publication ............................................................................61 
15. FINAL CLINICAL TRIAL REPORT ....................................................................................62 
16. ETHICAL AND LEGAL CONSIDERATIONS ....................................................................62 
16.1. Declaration of Helsinki and Good Clinical Practice ...................................................62 
16.2. Patient Information and Informed Consent .................................................................62 
16.3. Approval by Institutional Review Board and Independent Ethics Committee ...........63 
16.4. Finance and Insurance .................................................................................................63 
17. REFERENCES .......................................................................................................................64 
18. ATTACHMENTS ...................................................................................................................66 
18.1. Schedule of Events ......................................................................................................66 
18.2. Investigator’s Agreement ............................................................................................69 
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19. APPENDICES ........................................................................................................................70 
A.
Address List ................................................................................................................71 
B.
Regulations and Good Clinical Practice Guidelines ...................................................72 
Regulations ........................................................................................................72 
Good Clinical Practice Guidelines ....................................................................72 
20. ADDENDUM .........................................................................................................................73 
20.1. Administrative Information.........................................................................................73 
20.2. Device Information .....................................................................................................73 
20.2.1. 
Planned Devices ................................................................................................73 
20.2.1.1. 
Pump System Accu-Chek Spirit Combo ..................................................73 
20.2.1.2. 
Self-Monitoring Plasma Glucose StatStrip Xpress2 ................................75 
20.2.1.3. 
Dexcom G6 Continuous Glucose Monitoring System .............................76 
20.2.1.4. 
Other Medical Devices .............................................................................78 
20.2.2. 
Risk Evaluation for Off-label Use of Devices ...................................................79 
20.2.2.1. 
Anticipated Clinical Benefit of Planned Devices.....................................79 
20.2.2.2. 
Risks Associated with the Planned Devices and their Control ................79 
20.2.2.3. 
Possible Interactions with Concomitant Medical Treatment ...................80 
20.2.2.4. 
Risk/Benefit Assessment ..........................................................................80 
20.3. Device-related Safety Section .....................................................................................81 
20.3.1. 
Anticipated Adverse Device Effects..................................................................81 
20.3.2. 
Pump System Accu-ChekSpirit Combo ............................................................82 
20.3.3. 
Self-monitored Plasma Glucose StatStrip Xpress2 ...........................................82 
20.3.4. 
Continuous Glucose Monitoring Dexcom G6 ...................................................82 
20.4. Protocol Clarifications ................................................................................................83 
20.4.1. 
Informed Consent ..............................................................................................83 
20.4.2. 
Vulnerable Population .......................................................................................83 
20.4.3. 
Addition to Statistical Section ...........................................................................83 
20.4.4. 
Protocol Deviations ...........................................................................................83 
4.1. 
LIST OF TABLES 
Table 1 
Algorithm to Maintain Plasma Glucose ............................................................31 
Table 2 
Schedule of Events ............................................................................................66 
4.2. 
LIST OF FIGURES 
Figure 1 
Design of Trial ZP4207-17103 ..........................................................................25 
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5. LIST OF ABBREVIATIONS 
 
ADA 
anti-drug antibody 
ADE 
adverse device effect 
A&E 
accident and emergency 
AE 
adverse event 
AESI 
adverse event of special interest 
ANOVA 
analysis of variance 
AOCglucose 
area over the glucose curve 
AUC 
area under the curve 
AUC0-inf 
area under the plasma concentration-time curve from time zero to infinity 
BfArM 
Bundesinstitut für Arzneimittel und Medizinprodukte 
CGM 
continuous glucose monitoring 
CHI 
congenital hyperinsulinism 
CI 
confidence interval 
Cmax 
maximum observed concentration 
CRA 
clinical research associate 
CRF 
case report form 
CRO 
contract research organization 
CTR 
clinical trial report 
DMC 
independent data monitoring committee 
ECG 
electrocardiogram 
eCRF 
electronic case report form 
EDC 
electronic data capture  
ER 
emergency room 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GI 
gastrointestinal 
GIR 
glucose infusion rate 
GLMM 
generalized linear mixed model  
H 
hypothesis 
ICF 
informed consent form 
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ICH 
International Council for Harmonisation of Technical Requirements for 
Pharmaceuticals for Human Use 
IEC 
independent ethics committee 
IM 
intramuscular(ly) 
IRB 
institutional review board 
ISF 
investigator site file 
IV 
intravenous(ly) 
MedDRA 
Medical Dictionary for Regulatory Activities 
mTOR 
mechanistic target of rapamycin 
NG 
nasogastric 
NME 
necrolytic migratory erythema 
PD 
pharmacodynamic(s) 
PG 
plasma glucose 
PK 
pharmacokinetic(s) 
PT 
preferred term 
RSI 
Reference Safety Information 
SADE 
serious adverse device effect 
SAE 
serious adverse event 
SAP 
statistical analysis plan 
SC 
subcutaneous(ly) 
SMPG 
self-monitored plasma glucose 
SoC 
standard of care 
SpO2 
peripheral capillary oxygen saturation 
SUSAR 
suspected unexpected serious adverse reaction 
t½ 
half-life 
TMM 
trial materials manual 
USADE 
unanticipated serious adverse device effect 
Zealand 
Zealand Pharma A/S 
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6. INTRODUCTION 
6.1. 
Background and Rationale 
Congenital hyperinsulinism (CHI) is a rare and challenging disorder in which β-cells in the 
pancreas secrete insulin irrespective of plasma glucose (PG) concentration, resulting in persistent 
and often severe hypoglycemia.1 Congenital hyperinsulinism affects up to 1 in 50,000 newborns. 
It is typically diagnosed on the basis of signs and symptoms of hypoglycemia during the neonatal 
period or in infancy; however, the diagnosis may be made later in childhood. Mutations in 
several different β-cell genes have been described to cause CHI. Hypoglycemia that results from 
CHI is of particular concern because it is an important cause of brain injury in neonates, infants, 
and children with this disease, which leads to long-term neurological impairments.1,2 Up to 
approximately 50% of children with CHI experience neurodevelopmental abnormalities caused 
by severe hypoglycemia that results from inadequate treatment and/or delays in diagnosis.1,3 
Severe brain damage is the consequence of severe hypoglycemia, which presents as coma and/or 
long-lasting epileptic seizures in neonates. Major intellectual disability is, therefore, most 
frequent in patients with neonatal initial onset, whereas hypoglycemia is usually less severe and 
brain damage less frequent in children with CHI diagnosed later in childhood.1 Since symptoms 
and severity of hypoglycemia can vary and pose a diagnostic challenge in neonates, infants, and 
children with CHI, prompt recognition and treatment of hypoglycemia is critical to reduce the 
risk of long-term neurological consequences. 
6.2. 
Current Treatment and Unmet Medical Need 
Medical treatment for CHI is focused on chronic therapies to avoid hypoglycemia, as well as on 
rescue therapy during acute episodes of severe hypoglycemia. Available medical therapies 
(mainly diazoxide, octreotide, or glucagon alone or in combination with glucose infusion) are 
often inadequate and accompanied by inability to control PG, as reflected in a large proportion of 
patients requiring sub-total pancreatectomy.4,5,6 With the exception of surgery for focal CHI, 
which is curative in the vast majority of patients, sub-total pancreatectomy for diffuse CHI has 
substantial inadequacies. A recent retrospective chart review7 showed that 60% of patients who 
underwent near-total pancreatectomy had persistent hypoglycemia after surgery. Moreover, 
96% had developed insulin-dependent diabetes within 11 years after surgery. 
First-line medical treatment of CHI is diazoxide, which is the only EU- and US-approved drug 
for treatment of hyperinsulinemic hypoglycemia. Diazoxide acts to open KATP channels of the 
pancreatic β-cells, thereby inhibiting insulin secretion. Unfortunately, many patients with CHI 
are resistant to diazoxide because of mutations in the genes encoding the KATP channel of the 
pancreatic β-cells.6 For those who respond to diazoxide treatment, the more common side effects 
comprise hypertrichosis, fluid retention, and gastrointestinal (GI) symptoms; however, side 
effects are usually not severe. In diazoxide nonresponders, second-line (and off-label) treatment 
is a somatostatin analog (octreotide or lanreotide [long acting]), which (among other effects) 
inhibits secretion of insulin and glucagon from the pancreas and suppresses GLP-1 secretion. 
Factors that limit their use comprise tachyphylaxis, as well as possible side effects, including 
necrotizing enterocolitis, gallstones, and hepatitis.6 
The glycogenolytic effect of glucagon and its ability to increase PG levels has been confirmed in 
children with CHI or neonatal hypoglycemia.8,9 Administration of marketed glucagon 
(intravenous [IV] or subcutaneous [SC] injection) is often used in the diagnostic phase of CHI to 
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stabilize patients before surgery or initiation of other medical treatments.10 In a retrospective 
review of 55 neonates with resistant hypoglycemia, native glucagon IV infusion achieved a 
median rise in plasma glucose of 45 mg/dL (2.5 mmol/L) after an hour of administration, 
regardless of the underlying cause for the persistent neonatal hypoglycemia.9 Furthermore, 
glucagon is administered as single SC doses to treat severe hypoglycemic episodes. While IV 
administration of glucagon to patients with CHI is used short-term in the hospital setting, 
e.g., before pancreatectomy,2,10,11 long-term glucagon treatment is challenging since currently 
available glucagon products are unstable and form fibrils within hours after reconstitution.12 
Catheter obstruction and occlusion because of glucagon instability were observed daily to 2 to 
3 times weekly in a retrospective review of 9 patients with CHI receiving continuous SC infusion 
of glucagon for weeks or months.11 In another series of patients, 60% of the patients treated with 
short-term SC glucagon experienced catheter occlusion.6 Instability of currently available 
glucagon products and the associated risk of dosing errors contributing to hypoglycemic events 
is a major barrier for using glucagon for long-term treatment of patients with CHI.  
When successfully administered, long-term home treatment with subcutaneously infused 
glucagon over extended periods (years) has been beneficial, with a potentially good safety profile 
as compared to diazoxide and octreotide.6,11,13 
6.3. 
Dasiglucagon for the Treatment of Congenital Hyperinsulinism 
6.3.1. 
Dasiglucagon 
Dasiglucagon is a peptide analog of human glucagon in development for the treatment and 
prevention of hypoglycemia in patients with diabetes mellitus and CHI via SC or intramuscular 
(IM) administration. Dasiglucagon is a stable analog of glucagon that has been specifically 
designed to overcome the issues with fibril formation and instability in solution observed with 
marketed glucagon products. Compared to native human glucagon, dasiglucagon also comprises 
29 amino acids. As a result of chemical modifications (7 amino acid substitutions compared to 
human glucagon), the pronounced tendency of glucagon to form fibrils and aggregate has been 
effectively prevented in dasiglucagon. In addition, the chemical stability in aqueous media at 
physiological pH has been improved.  
To support the use of dasiglucagon in the pump for this trial, compatibility/in-use studies have 
been performed with dasiglucagon 4 mg/mL in Roche Accu-Chek® Combo pump using the 
Accu-Chek® Spirit 3.15 mL cartridge system and the Accu-Chek® FlexLink infusion set. The 
studies support an in-use time for up to 6 days at 37ºC. 
Dasiglucagon has been granted orphan drug designation by the European Commission on 
20 June 2017 for the ‘treatment of congenital hyperinsulinism.’ Furthermore, the FDA granted 
an orphan drug designation for the ‘treatment of hypoglycemia in patients with congenital 
hyperinsulinism (CHI)’ on 10 August 2017. 
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6.3.2. 
Nonclinical Experience 
The completed nonclinical pharmacology program has determined that dasiglucagon is a specific 
glucagon receptor agonist with comparable in vitro potency to glucagon, promoting a rapid onset 
of PG increase in both normoglycemic and insulin-induced hypoglycemic animals, similar to that 
of glucagon. 
Results of the toxicity studies with dasiglucagon are comparable to what has been reported for 
glucagon. Those from chronic toxicity studies with dasiglucagon in rats and dogs are in line with 
the results of short-term toxicity studies, indicating that long-term treatment with dasiglucagon is 
safe and that the pharmacodynamic (PD) effects noted do not adversely affect organ function 
following chronic use. 
6.3.3. 
Clinical Experience 
Dasiglucagon is being developed to manage patients with CHI 1) as an initial short-term therapy 
to stabilize PG levels and reduce glucose infusion needs, and 2) as a long-term treatment to help 
maintain euglycemia. Dasiglucagon has not previously been studied in patients with CHI. 
Clinical experience with dasiglucagon comes from the following studies in healthy subjects and 
type 1 diabetics. 
The safety, tolerability, pharmacokinetic (PK), and PD characteristics of dasiglucagon were 
investigated in 2 phase 1 trials, 3 phase 2 trials, and 2 phase 3 trials.  
ZP4207-14013 was a phase 1 randomized, double-blind, 2-part, single-dose trial designed to 
evaluate the pharmacokinetics, PD, safety, and tolerability of dasiglucagon compared to 
GlucaGen®. Part 1 consisted of SC and IM administration of single ascending doses of 
dasiglucagon in 64 adult healthy volunteers. Part 2 consisted of 20 adult patients with type 1 
diabetes using a crossover design with IM administration of 0.7 mg dasiglucagon. 
GlucaGen 1.0 mg was used as a comparator in both parts of the trial. 
ZP4207-15007 was a phase 1 randomized, placebo-controlled, double-blind, multiple-dose trial 
designed to evaluate the PK, PD, safety, and tolerability of repeated doses of dasiglucagon SC in 
24 healthy adult volunteers. The trial included 3 dose cohorts of 8 healthy volunteers each. In 
each cohort, patients were randomly assigned in a 3:1 ratio to receive 5 repeated daily doses of 
0.1, 0.3, and 1.0 mg dasiglucagon (n=6) or placebo (n=2). 
After the 2 phase 1 trials were completed, the composition of the dasiglucagon formulation was 
optimized with respect to its excipients (buffer, tonicity adjusting agent, and stabilizer). The PK 
and PD properties, safety, and tolerability of the optimized formulation were evaluated in the 
phase 2 trials. 
ZP4207-15126 was a phase 2 randomized, double-blind, single-dose trial designed to evaluate 
the PK, PD, safety, and tolerability of a single SC dose of dasiglucagon in the optimized 
formulation (0.1, 0.3, 0.6, and 1.0 mg) or GlucaGen (0.5 and 1.0 mg) in 58 adult patients with 
type 1 diabetes. 
ZP4207-16051 was a phase 2 open-label, randomized, crossover trial designed to evaluate the 
feasibility of using dasiglucagon 1 mg/mL SC in conjunction with insulin in a pump setting 
using an iLet algorithm as part of an automated dual hormone pump delivery system in 
12 patients with type 1 diabetes. The primary objective was to evaluate the safety and tolerability 
of dasiglucagon compared to marketed glucagon (Lilly Glucagon™). The trial also aimed to 
demonstrate the functionality and accuracy of the iPhone-based bionic pancreas in a controlled, 
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clinical setting. Patients were randomly assigned to two 1-day treatment arms: dasiglucagon or 
Lilly Glucagon in the iPhone-based bionic pancreas. 
ZP4207-16098 was a phase 2 randomized, crossover, double-blind trial designed to evaluate the 
safety, tolerability, PK, and PD of dasiglucagon in 23 patients with type 1 diabetes using a 
4 mg/mL formulation of dasiglucagon (0.03 mg, 0.08 mg, 0.2 mg, and 0.6 mg) compared to an 
active comparator, Lilly Glucagon. 
ZP4207-16136 was a phase 3 randomized, double-blind parallel-group safety trial designed to 
evaluate the immunogenicity of dasiglucagon compared to GlucaGen in 111 adult patients with 
type 1 diabetes.  
ZP4207-16137 was a phase 3 randomized, double-blind, parallel-group trial designed to confirm 
the clinical efficacy and safety of a single dose of dasiglucagon (0.6 mg) for the rescue treatment 
of hypoglycemia compared to placebo and with reference to GlucaGen (1 mg) in 168 adult 
patients with type 1 diabetes.  
Overall, no safety concerns were observed for dasiglucagon at the doses investigated in these 
clinical trials. The most frequently reported adverse event (AE) in each trial was nausea, which is 
a known side effect after administration of glucagon, and appeared at a similar frequency to 
marketed glucagon, which was used as active comparator in some of the trials. No local 
tolerability issues were reported. Injection site reactions were observed only sporadically after 
administration with dasiglucagon, placebo, or marketed glucagon in trials with SC or IM 
administration, and all events were mild and transient. No treatment-induced or 
treatment-boosted anti-drug antibodies (ADAs) were noted in any of the reported trials, except 
for trial ZP4207-16098, in which 1 patient tested positive for both anti-dasiglucagon and 
anti-glucagon antibodies. Due to the crossover nature of this trial, the induction of ADAs could 
not be associated with a specific treatment. 
Dose proportionality for dasiglucagon PK using the 1 mg/mL formulation was confirmed in the 
clinical trials, with doses ranging between 0.1 and 1.0 mg, characterized by a fast absorption 
with a peak plasma concentration obtained after 35 minutes. The median time to maximum 
concentration was later for dasiglucagon compared to marketed glucagon (GlucaGen) 
(35 vs 20 minutes). In the phase 2 trial ZP4207-15126, doses of 0.3 mg dasiglucagon and 0.5 mg 
GlucaGen and also 0.6 mg dasiglucagon and 1.0 mg GlucaGen were similar with regard to 
maximum observed concentration (Cmax). The total exposure in terms of area under the 
concentration-time curve (AUC) from time zero to infinity (AUC0-inf) was consistently higher for 
dasiglucagon compared to GlucaGen. This was likely due to a higher bioavailability of 
dasiglucagon since nonclinical data consistently show that the bioavailability of dasiglucagon is 
higher compared to marketed glucagon formulations. For the 4 mg/mL formulation, 
dose-proportionality of dasiglucagon doses between 0.03 and 0.6 mg was indicated for 
AUC0-240min and AUC0-inf in trial ZP4207-16098. Pharmacokinetic parameters were all similar for 
dasiglucagon administration under both euglycemic and hypoglycemic conditions. An 
approximately 30 to 40% greater exposure in terms of AUC0-inf and Cmax was observed with the 
4 mg/mL formulation as compared with the 1 mg/mL formulation. 
In the phase 2 trial ZP4207-15126, all patients achieved a PG level of at least 70 mg/dL 
(3.9 mmol/L) at all dose levels of dasiglucagon after insulin-induced hypoglycemia, as well as an 
increase in PG by at least 20 mg/dL (1.1 mmol/L) within 30 minutes postdose. The PD responses 
of 0.3 mg of dasiglucagon and 0.5 mg of marketed glucagon (GlucaGen) were similar in the first 
30 minutes postdose, as were the PD responses of 0.6 mg of dasiglucagon and 1.0 mg of 
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GlucaGen. The PD response over the entire observation time (0-360 minutes) was significantly 
greater after dosing with dasiglucagon than with GlucaGen for all prespecified dose 
comparisons. This was likely an effect of the higher total drug exposure (AUC0-inf) of 
dasiglucagon mentioned previously. 
In the phase 3 trial ZP4207-16137, the primary endpoint was time to plasma glucose recovery 
after insulin-induced hypoglycemia, which was defined as first increase in plasma glucose of 
≥20 mg/dL (1.1 mmol/L) from baseline. Superiority was shown for dasiglucagon relative to 
placebo, with a median time to plasma glucose recovery of 10 versus 40 minutes. The median 
time to recovery for GlucaGen was 12 minutes. All patients in the dasiglucagon and GlucaGen 
treatment arms recovered from insulin-induced hypoglycemia within 30 minutes. All patients but 
one receiving dasiglucagon and one receiving GlucaGen had recovered within 20 minutes 
(dasiglucagon: 99% and GlucaGen: 98%). At 15 minutes, 99% of patients receiving 
dasiglucagon and 95% of those receiving GlucaGen had recovered. At 10 minutes, 65% of 
patients receiving dasiglucagon and 49% of those receiving GlucaGen had recovered. 
No major differences in PD responses were observed between dasiglucagon doses under 
euglycemic or hypoglycemic conditions in phase 2 trial ZP4207-16098. Under euglycemic 
conditions, all patients achieved an increase in PG of at least 20 mg/dL (1.1 mmol/L) within 
30 minutes postdose with 0.08 mg dasiglucagon and above, while this target was reached only 
for 0.2 mg of marketed glucagon (Lilly Glucagon). Under hypoglycemic conditions, 
dasiglucagon met the target at doses of 0.2 mg and above. The PD response over the entire 
observation time of 240 minutes was significantly higher with dasiglucagon than with Lilly 
Glucagon at the same doses. In the bionic pancreas feasibility trial ZP4207-16051, results 
demonstrated comparable autonomous glycemic control with dasiglucagon compared to 
Lilly Glucagon. This was despite the stressed conditions of the trial in terms of fasted patients 
being on up to twice their basal insulin rate to stimulate glucagon use during the 8-hour test, and 
inclusion of a structured exercise period. With dasiglucagon, patients obtained a glucose value 
within target (70-180 mg/dL [3.9-10.0 mmol/L]) 70.9% of the time vs 65.6% with Lilly 
Glucagon. 
6.3.4. 
Literature Data 
In a retrospective review of 223 cases of diffuse or focal CHI, glucagon was reported to be used 
in 55% of patients with diffuse CHI and in 31% of patients with focal CHI.10 In an observational 
trial of 55 newborns who received glucagon because of hypoglycemia after birth, applied doses 
were mainly in the range of 0.5 to 1.0 mg/day, and results indicated an increase in PG from a 
mean of 36.3 md/dL to a mean of 93.0 mg/dL, observed within 4 hours after the start of glucagon 
infusion.9 The frequency of hypoglycemic episodes was significantly reduced, and no further 
episodes of severe hypoglycemia were observed. 
In another retrospective chart review of 40 children with CHI who received continuous IV 
glucagon for prevention of hypoglycemia,14 a median (inter quartile range) glucagon dose of 
205 (178, 235) mcg/kg/day over a median duration of 5 (3, 9) days enabled a glucose infusion 
rate (GIR) reduction from 18.5 (12.9, 22.8) to 11 (6.6, 17.5) mg/kg/min per 24 h (p < 0.001), and 
reduced hypoglycemia frequency from 1.9 (1.3, 2.9) to 0.7 (0.3, 1.2) episodes per day. 
The long-term use of glucagon in patients with CHI is limited by the instability of marketed 
glucagon after reconstitution. A literature review on the long-term medical treatment of CHI 
revealed that only 1% of 619 patients identified received glucagon as part of their medical 
management.6 A retrospective review of 9 children with CHI who received continuous SC 
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infusion of glucagon for weeks or months showed that introduction of glucagon allowed the 
reduction or discontinuation of central glucose infusion in all patients.11 Six of 9 patients were 
discharged with continued glucagon therapy that their parents were able to continue without 
further symptomatic hypoglycemia, convulsions, or unconsciousness. In 3 children, glucagon 
therapy was continued for 1 to 4 years, which led to stable euglycemia.  
The data reported on marketed glucagon use in patients with CHI indicate that continuous SC 
infusion of a glucagon agonist could provide therapeutic benefit to patients by stabilizing PG 
levels and reducing the frequency of hypoglycemic episodes.5,6,9,10,11 
6.3.5. 
Anticipated Medical Benefit of Dasiglucagon in the Treatment of CHI 
With its physio-chemical stability in liquid formulation, dasiglucagon could provide significant 
added benefit in the treatment of CHI relative to currently marketed glucagon by enabling 
long-term reliable IV infusion. Long-term subcutaneous infusion of dasiglucagon through a 
pump may be an attractive alternative or addition to diazoxide and octreotide since it may reduce 
the dependency on intensive nutritional support, both IV and gastric (NG tube or gastrostomy), 
whilst maintaining euglycemia by harnessing physiological mechanisms for combating 
hypoglycemia. Furthermore, if long term euglycemia is achieved with medical therapy, 
pancreatectomy for the treatment of diffuse CHI could eventually be avoided. In one cohort of 
nonsurgically treated children, the mean clinical remission rate was 5 (1.5-12) years for diffuse 
CHI.5 This suggests that a significant proportion of infants with CHI could avoid surgery if 
medical treatment allowed for the effective long-term control of hyperinsulinism. 
The target population in this trial is children with CHI who are especially challenging to treat, 
and who need continuous IV glucose infusion to prevent or treat hypoglycemia, necessitating 
ongoing hospitalization. These children have limited options in terms of other treatments, and 
represent very high unmet medical need group within already ultra-rare CHI population. 
6.3.6. 
Anticipated Risks of Dasiglucagon in the Treatment of CHI 
So far, there is no previous clinical experience with dasiglucagon SC infusion for the treatment 
of CHI. The following anticipated risks are derived from other clinical trials with dasiglucagon 
conducted in other indications, from marketed glucagon labelling information, and from native 
glucagon’s physiological effects. 
In clinical trials with dasiglucagon conducted up to now, the most frequent treatment-related AEs 
were nausea and vomiting, followed by headache. 
Glucagon exerts positive inotropic and chronotropic effects and may, therefore, cause 
tachycardia and hypertension. Transient increases in heart rate and hypertension have been 
observed in clinical trials with dasiglucagon. Additionally, several episodes of hypotension and 
bradycardia have been noted in the clinical program, often in association with nausea and/or 
vomiting.  
Accidental overdose may occur due to inappropriate handling of the infusion pump or due to 
pump malfunction. Overdose may result in nausea, vomiting, inhibition of GI tract motility, 
short-term increase in heart rate or blood pressure, and/or hypokalemia. Symptomatic care for 
nausea and vomiting, as well as monitoring of heart rate, blood pressure, and hypokalemia is 
advised.  
Injection site reactions are seen with many injectable peptides. Injection site reactions have been 
reported across trials, with similar frequency in all treatment groups (dasiglucagon, marketed 
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glucagons, and placebo), irrespective of dose. The injection site reactions were generally mild 
and transient. 
Overall, the clinical trial data indicate that dasiglucagon has a low risk for induction of ADAs. 
Out of more than 350 doses of dasiglucagon administered to more than 200 patients, only 
1 low-titer transient ADA incident has been reported to date, in a patient following 
administration of 11 SC doses of dasiglucagon or Lilly Glucagon ranging from 0.03 to 0.6 mg, 
with low binding and low in vitro neutralizing capability. No apparent clinical effects on PK, PD, 
or AEs were noted. Due to the crossover trial design, the ADA induction could not be ascribed to 
a specific treatment. Based on the current clinical experience and the product characteristics, the 
risk of dasiglucagon inducing an ADA response is considered low. 
Administration of glucagon or dasiglucagon may be associated with a risk of allergic reactions 
similar to those observed for other therapeutic peptides or proteins.  
Data on the risks of chronic administration of dasiglucagon are not available. From sporadic 
reports of extended SC/IV infusion of marketed glucagon and in glucagonoma patients,15 
sustained exposure to high levels of glucagon may lead to development of the skin condition 
necrolytic migratory erythema (NME), a highly specific migrating, erythematous rash with 
predilection for perioral, perianal, and lower leg distribution.11 
For further information on risks, please refer to the current version of the investigator’s brochure 
(IB). 
6.3.7. 
Summary of Potential Benefits and Risks 
As with all treatment interventions, the anticipated benefits to trial patients should be balanced 
against the potential risks. The accumulated experience from nonclinical studies and clinical 
trials with dasiglucagon supports that dasiglucagon is a specific glucagon receptor agonist and is 
well tolerated. Glucagon and its analogs belong to a well-known drug class with known mode of 
action. The clinical investigators involved in the trial will all have had experience with use of 
glucagon in patients with CHI.  
The investigator will inform the patients/parent(s)/guardian of the potential risks of dasiglucagon 
treatment and other trial-related procedures before they enter the trial. The investigator must 
become familiar with all sections of the dasiglucagon IB before the start of the trial. 
In this trial population, the major and clinically relevant benefit is the expected reduction and 
eventually elimination of need for IV glucose, together with the reduction in gastric nutritional 
interventions while avoiding hypoglycemia. The reduced volume of nutritional interventions 
should limit the risk of volume overload. Furthermore, by removing the invasive methods of 
nutrition, the children should better retain or re-establish orality – the intake of nutrients by 
mouth.  
In summary, with its marked improvements in stability in solution and solubility in aqueous 
media compared to currently marketed glucagon products, dasiglucagon is expected to have 
significant clinical benefits in the treatment of CHI and to substantially reduce the disease burden 
in these patients. This includes discharge from the hospital by enabling convenient and reliable 
long-term treatment via a pump device in a home setting, together with the potential to delay and 
ultimately avoid pancreatectomy and its related exo/endocrine complications, particularly the 
development of insulin-dependent diabetes. 
Overall, the benefit to risk ratio for patients entering the ZP4207-17103 trial is considered 
acceptable. 
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7. OBJECTIVES AND ENDPOINTS 
7.1. 
Objectives 
7.1.1. 
Primary Objective 
To evaluate the efficacy of dasiglucagon in reducing glucose requirements in children with 
persistent CHI requiring continuous IV glucose administration to prevent/manage hypoglycemia. 
7.1.2. 
Secondary Objectives 
To evaluate the safety and tolerability of dasiglucagon administered as an SC infusion in patients 
with CHI. 
7.2. 
Endpoints 
7.2.1. 
Primary Endpoint 
Part 1 (Day 1 to 4) 
• 
Mean IV GIR in the last 12 hours of each treatment period during Part 1 (dasiglucagon or 
placebo administration) 
7.2.2. 
Key Secondary Efficacy Endpoint 
Part 1 (Day 1 to 4, for each 48-hour treatment period) 
1. Total amount (g) of carbohydrates administered (regardless of the route) per day. 
7.2.3. 
Secondary Efficacy Endpoints 
Part 1 (Day 1 to 4, for each 48-hour treatment period) 
• 
Mean IV GIR for each 48-hour treatment period during Part 1 (dasiglucagon or placebo 
administration) 
• 
Mean IV GIR below 10 mg/kg/min in the last 12 hours of each treatment period during Part 
1 (yes/no) (dasiglucagon or placebo administration)  
 
Part 2 (Day 5 to 25, assessed from the start of treatment in part 2) 
• 
Time to complete weaning off IV GIR.  
• 
Hypoglycemia event rate, defined as number of hypoglycemic events (PG <70 mg/dL or 
3.9 mmol/L), as detected by SMPG.  
• 
Clinically significant hypoglycemia event rate, defined as number of events <54 mg/dL 
(3.0 mmol/L), as detected by SMPG.  
• 
Time to actual hospital discharge. 
• 
Time to pancreatic surgery (sub-total or total pancreatectomy). 
• 
Total amount (g) of carbohydrates administered (regardless of the route) per day, together 
with amounts (g) of carbohydrates administered per day: 
- 
via IV glucose infusion, or bolus (not as part of total parental nutrition), 
- 
as part of total parenteral nutrition (if applicable), 
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- 
via oral route, and 
- 
via NG tube or gastrostomy. 
• 
CGM percent time in range 70-180 mg/dL (3.9-10.0 mmol/L). 
• 
CGM percent time in hypoglycemia (<70 mg/dL or 3.9 mmol/L). 
• 
CGM percent time in clinically significant hypoglycemia (<54 mg/dL or 3.0 mmol/L). 
• 
Rate of hypoglycemia episodes, defined as number of episodes <70 mg/dL (3.9 mmol/L) for 
15 min or more, as measured by CGM. 
• 
Rate of clinically significant hypoglycemia episodes, defined as number of episodes 
<54 mg/dL (3.0 mmol/L) for 15 min or more, as measured by CGM. 
• 
Extent of hypoglycemia (area over the glucose curve [AOCglucose] below 70 mg/dL 
[3.9 mmol/L]) as measured by CGM.  
• 
Extent of clinically significant hypoglycemia (AOCglucose below 54 mg/dL [3.0 mmol/L]) as 
measured by CGM. 
• 
CGM percent time in hyperglycemia (>180 mg/dL or 10.0 mmol/L). 
7.2.4. 
Safety Endpoints 
By Part 1 or 2 of the trial: 
• 
Adverse events 
• 
Changes in clinical evaluations: 
- 
Vital signs 
- 
Physical examination 
- 
12-lead ECG 
- 
Echocardiogram  
• 
Changes in clinical laboratory assessments:  
- 
Hematology 
- 
Biochemistry 
- 
ADA 
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8. TRIAL DESIGN 
8.1. 
Overall Trial Design and Plan 
This is a combined phase 2 and 3, randomized, multinational trial to evaluate the efficacy and 
safety of individually titrated dasiglucagon in children ≥7 days and <1 year of age who have 
been diagnosed with CHI, comprising 2 parts, a crossover (2 periods, 48 hours each), 
double-blind, placebo-controlled Part 1, and an open-label, single-arm Part 2 of 21 days 
(Figure 1).  
Abbreviations: Min = minimum 
Figure 1 
Design of Trial ZP4207-17103 
After screening, eligible patients will complete a minimum 24-hour run-in period to confirm the 
IV glucose randomization requirement (≥10 mg/kg/min). All non-nutritional carbohydrates and 
carbohydrate fortification of feeds are prohibited during this 24-hour run-in period. After the 
run-in period, patients will be randomly assigned in a double-blind fashion to receive 
dasiglucagon or placebo for 48 hours, after which they will be crossed over to the other trial 
treatment for an additional 48 hours. At the time of crossover, the trial drug will be initiated from 
the starting dose of 10 µg/hr, and IV GIR will be set to the rate obtained at the end of the run-in 
period and titrated accordingly.  
There will be no washout between the 2 periods in Part 1 to limit the length of time in which 
patients are reliant on IV GIR as their only means of preventing/treating hypoglycemia. This is 
deemed acceptable because: 
• 
The half-life (t½) of dasiglucagon is short (~30 minutes, for the 0.6 mg dose, and potentially 
shorter for lower doses, ~22 minutes) relative to the 48-hour duration of each crossover 
0 
Dasiglucagon 
-
Placebo 
Period 
Screening, Run-in or Follow-up 
Screening 
Run-in 
1: 1 randomization 
6 patients 
6 patients 
-28 
-1 
0 
Part 1 
Blinded 
2-period, crossover 
2 x48 hr 
Dasiglucagon j 
Placebo 
Placebo 
Dasiglucagon 
2 
4 
Part2 
3 weeks open label 
Dasiglucagon 
Dasiglucagon 
Days from first treatment 
25 
Follow-up 
4 weeks follow-up 
(only for patients not continuing 
in the extension trial) 
Standard of Care or to 
Long-term extension 
53 
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period. Moreover, for the primary endpoint, only the last 12 hours of the 48-hour period will 
be used for endpoint assessment.  
• 
Assuming a positive effect of dasiglucagon, the absence of washout is conservative with 
respect to key secondary endpoints since a potential carry over effect of dasiglucagon in 
Period 2 is attributed to placebo.  
During Part 1, the trial drug and IV GIR should be adjusted according to the protocol-specified 
algorithm (see Section 10.2). Non-nutritional carbohydrates and/or carbohydrate fortification of 
feeds during Part 1 is only allowed if the maximum tolerable volume and concentration of IV 
glucose for the patient is reached, and should be limited to the minimum needed to ensure the 
patient’s safety (Section 9.5). All feedings (administered as parenteral nutrition, by NG tube, 
gastrostomy, or normal route), will be recorded during this period. Safety assessments will be 
performed daily after initiation of the trial drug (active or placebo).  
After Part 1, patients will continue in open-label Part 2 to receive dasiglucagon for 21 days. 
Additional CHI treatments can be introduced during Part 2 if needed, if up-titration of 
dasiglucagon is not possible due to undesirable side effects or if the maximum dose level 
(70 µg/hr) has been reached. Gradual transfer from IV glucose to oral and gastric carbohydrates 
should be initiated in Part 2, enabling weaning of IV glucose and hospital discharge. Patients will 
continue to be hospitalized until IV GIR is weaned off; however, as soon as local site criteria for 
discharge are met, patients can be discharged to continue the treatment period at home. Visits are 
planned on Day 11 and Day 18 in Part 2. These visits can be converted to telephone visits if 
appropriate, at the investigator’s discretion. On Day 25, the End of Treatment Visit will take 
place, and based on the investigator’s confirmation of continued positive benefit-risk balance, 
patients will be offered the opportunity to enter the long-term extension trial (Trial ZP4207-
17106) to continue dasiglucagon treatment. Patients who do not enter the long-term extension 
trial will have a Follow-up Visit 28 days after their last dose of trial drug. 
8.2. 
Discussion of Trial Design 
The initial 2x48-hour treatment period (Part 1) is double-blind and placebo controlled to avoid 
bias in the assessment of the effect of dasiglucagon on GIR. A crossover design has been chosen 
to limit the influence of inherent variability of the population, which allows for recruitment of 
fewer patients compared to a parallel-group design, reflecting the ultra-rare status of the disease. 
All patients will receive dasiglucagon in open-label Part 2. According to International Council 
for Harmonisation (ICH) guidelines, for the conduct of clinical trials in rare diseases, where the 
anticipated likelihood of considerable benefit is high, such design has some potential efficiencies 
because all patients will be exposed to test drug, which is of particular importance in rare 
diseases.16 
8.3. 
Trial Sites 
The trial will take place at 5 to 7 sites in the US and Europe that are experienced in the treatment 
of CHI. A total of 12 patients with CHI is planned to be randomized and exposed to the trial 
product. Patients who withdraw prematurely will not be replaced.  
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8.4. 
Point of Contact 
A point of contact will be identified to provide information to each patient’s parent(s)/guardian 
about where to obtain information on the trial, the patient’s rights, and whom to contact in case 
of trial-related injury. This information will be provided in the patient information and informed 
consent form (ICF). 
9. PATIENT POPULATION 
9.1. 
Selection of Trial Population 
A screening log of potential trial candidates must be maintained at each trial site. 
9.2. 
Trial Entry Criteria 
9.2.1. 
Inclusion Criteria 
A patient will be eligible for trial participation if he or she meets all of the following criteria: 
1. CHI diagnosis established based on the following: 
a. Hyperinsulinemia: plasma insulin above the limit of detection of the assay documented 
during an event of hypoglycemia, and/or 
b. Hypofattyacidemia: plasma free fatty acid <1.7 mmol/L, and/or  
c. Hypoketonemia: Beta-hydroxybutyrate <1.8 mmol/L, and/or  
d. Glycemic response: an increase in PG of >30 mg/dL (1.7 mmol/L) after 1 mg IV or 
IM glucagon administration 
2. Male or female, age ≥7 days and <12 months at screening  
3. Body weight of ≥2.0 kg (4.4 lbs.) 
4. Continuous IV glucose requirement to prevent hypoglycemia  
5. One or both parents* or guardians of the patient must provide signed informed consent before 
any trial related activity is performed. (*according to local regulations) 
9.2.2. 
Exclusion Criteria 
A patient will be excluded from the trial if he or she meets any of the following criteria: 
1. Is suspected of having a transient form of CHI (e.g., transient hyperinsulinism due to 
maternal diabetes or perinatal stress) 
2. Was born preterm below 34 weeks of gestational age 
3. Presence of hypertension or hypotension, including circulatory instability requiring 
supportive medication or presence of pheochromocytoma 
4. Known or suspected presence of severe brain damage 
5. Evidence of metabolic, endocrine, or syndromic causes of hypoglycemia not due to 
hyperinsulinism 
6. Use of systemic corticosteroids, e.g., hydrocortisone >20 mg/m2 body surface area or 
equivalent within 5 days before screening 
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7. Prior use of lanreotide, sirolimus (mechanistic target of rapamycin [mTOR inhibitors]), 
anti-inflammatory biological agents, or other immune-modulating agents. Prior use of 
octreotide is allowed after a minimum of 48-hour washout before randomization. 
8. Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >2.5 X the upper limit 
of normal (ULN), or estimated glomerular filtration rate (eGFR) <30 mL/min/1.73m2 
adjusted by a pediatric formula (e.g., Schwartz formula) 
9. Any clinically significant abnormality identified on echocardiogram that in the opinion of the 
investigator would affect the subject’s ability to participate in the trial 
10. Known history of laboratory test results obtained before screening that show presence of 
HIV, hepatitis B surface antigen, hepatitis C antibody, or hepatitis A immunoglobulin M 
11. Any recognized clotting or bleeding disorder 
12. Previous administration of dasiglucagon (previously referred to as ZP4207) 
13. Known or suspected allergy to the trial drug or related products 
14. Previous participation (randomization) in the clinical program (Trials ZP4207-17103 
or -17109) 
15. Has participated in an interventional clinical trial (investigational or marketed product) 
within 30 days of screening, or plans to participate in another clinical trial, except for 
18F-Dopa PET CT/MRI investigation (where performed as a part of a research trial), which 
is allowed for diagnosis of focal CHI. 
16. The use of prescription or non-prescription medications known to cause QT prolongation.  
9.2.3. 
Randomization Exclusion Criteria 
A screened patient will not be randomized if: 
1. Mean IV glucose requirement is <10 mg/kg/min to maintain glycemia above 70 mg/dL 
(3.9 mmol/L) during the previous 24 hours prior to randomization 
2. Use of glucagon within 24 hours before randomization. 
3. Use of additional enteral glucose within 24 hours before randomization. Patients should be 
transitioned to IV glucose infusions only at least 24 hours before randomization. 
4. Is not sufficiently clinically stable on IV GIR only (± diazoxide, as applicable), in the 
opinion of the investigator, to undergo the placebo-controlled randomized Part 1 of the trial 
(2x48 hours). 
The Randomization Visit may be rescheduled once if Randomization Exclusion Criterion 2 is 
met. 
9.3. 
Premature Patient Withdrawal 
Randomization day exclusion criteria are described in Section 9.2.3. 
Patients’ parent(s)/guardian will be advised that they are free to withdraw their child from 
participation in this trial at any time, for any reason, and without prejudice. Every reasonable 
attempt should be made by the investigator to keep patients in the trial to obtain data for the 
primary endpoint in Part 1 and for safety follow-up even if trial treatment has been discontinued. 
However, patients must be withdrawn from the trial if their parent(s)/guardian withdraw consent 
to participate.  
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Investigators must attempt to contact patients’ parent(s)/guardian who fail to attend scheduled 
visits by telephone or other means to exclude the possibility of an AE being the cause of 
withdrawal. Attempts to contact the patient must be documented. At least 3 phone calls and 
3 written attempts to contact the patient will be made prior to considering them lost to follow-up. 
Should an AE be the cause of withdrawal, it must be documented, reported, and followed up as 
described in Section 12.3. 
If a patient/parent(s)/guardian withdraws consent, the reason for withdrawal and the date of 
withdrawal will be recorded on the appropriate page of the electronic case report form (eCRF). 
Whenever possible and reasonable, the evaluations that were to be conducted at the completion 
of the trial should be performed at the time of premature withdrawal. 
9.4. 
Treatment Discontinuation 
To prevent missing data, patients should, to the extent possible, be kept in the trial; therefore, 
treatment discontinuation is often the preferred option in case of, e.g., substantial noncompliance 
with trial procedures or initiation of prohibited treatment that interferes with the efficacy and 
safety evaluation. If it is an investigator’s decision to discontinue the patient’s treatment, the 
investigator should, whenever possible, discuss the potential discontinuation of the treatment 
with the medical monitor. If the patient is discontinued from trial treatment by the investigator or 
by parent/guardian’s decision, the reason for treatment discontinuation and the date of treatment 
discontinuation will be recorded on the appropriate page of the eCRF. The patient should be 
asked to continue in the trial by following the planned visit schedule and to have trial 
assessments performed according to the Schedule of Events. This is especially important during 
Part 1 of the trial where the primary endpoint is evaluated. As a minimum, the patient will be 
asked to attend the Follow-up Visit 28 days (± 3 days) after discontinuation of trial treatment. 
9.5. 
Rescue Criteria 
During Part 1, the IV glucose concentration and rate of infusion can be increased to avoid 
hypoglycemia. When the maximum (or maximum tolerable) dose of trial drug has been reached 
and the necessary amount of GIR to prevent hypoglycemia is likely to cause (in the 
investigator’s opinion) a moderate or severe AE (e.g., volume overload), oral/gastric 
non-nutritional carbohydrates can be introduced to ensure the patient’s safety whilst maintaining 
the maximum tolerable concentration and infusion rate of IV glucose.  
During Part 2, patients are allowed to initiate and titrate oral/gastric non-nutritional 
carbohydrates, and initiate any CHI treatment. 
9.6. 
Patient Replacement Criteria 
Patients who withdraw from the trial prematurely will not be replaced. If a substantial number of 
patients withdraw prematurely, the sponsor will evaluate the need for developing replacement 
criteria. 
Enrolled patients (defined as randomized) who are subsequently withdrawn from the trial may 
not re-enter. The patient number for a withdrawn patient will not be reassigned to another 
patient. 
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10. TREATMENTS 
10.1. Identification of Investigational Product 
Dasiglucagon Injection, 4 mg/mL will be supplied by the sponsor in a 3 mL vial containing 1 mL 
of drug product. 
Matching placebo for dasiglucagon injection will be supplied by the sponsor in a 3 mL vial 
containing 1 mL of drug product.  
Dasiglucagon and matching placebo will be provided in the form of solution for injection for 
subcutaneous administration through an infusion pump. 
The trial drug product, as applicable, must be transferred from the vial to the Accu-Chek Spirit 
Cartridge. The amount of drug product dosed via the pump will vary among patients. 
Cartridges and infusion sets should be filled and replaced as indicated in the instructions for use. 
10.1.1. Packaging and Labeling 
Trial drug products will be packaged and labeled by the sponsor.  
Part 1 dispensing unit configuration: 3 vials containing dasiglucagon, 4 mg/mL or placebo for 
dasiglucagon, packed in an outer carton. The vials and carton will be packaged and labeled in 
local language without revealing the treatment. 
Part 2 dispensing unit configuration: 3 vials containing dasiglucagon, 4 mg/mL, packed in an 
outer carton. The vials and carton will be packaged and labeled in local language, revealing the 
treatment. 
The storage conditions for trial drug products will be described on the trial drug product label. 
The labels will supply no information about patients. Each dispensing unit (3 vials) will have a 
unique Dispensing Unit Number for drug allocation, drug accountability, and traceability 
purposes.  
Labelling will be performed according to Annex 13 of the Good Manufacturing Practice 
guidelines of the European Commission, ICH Good Clinical Practice (GCP) guidelines, local 
laws, and regulations. 
10.2. Treatments Administered 
As long as the patient is receiving IV glucose, the PG will be measured and reviewed hourly 
using a hand-held PG meter. The IV GIR will be titrated to achieve glycemia of at least 
70 mg/dL (3.9 mmol/L) (a minimum GIR will be established as the rate up-titrated after the 
patient drops at least once below 70 mg/dL [3.9 mmol/L]). When the patient is no longer on 
IV GIR, the PG will be checked according to local practice, but at least 3 times daily. The PG 
will be measured using the same trial-supplied hand-held PG meter during the entire trial.  
Additionally, blinded CGM will be started 24 hours prior to randomization and continued until 
the end of Part 2.  
Dosing of dasiglucagon will approximate continuous infusion by delivering small doses at 
frequent intervals via the infusion pump. The adjustment of trial drug dosing is closely linked to 
the PG level achieved, which in turn will govern the IV GIR. In Part 1 the algorithm in Table 1 
should be used. 
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The pump administers 0.000025 mL/dose ~ 0.1 µg/dose (4 mg/mL formulation): 
• 
10 µg/hr ~ 0.5 µg every 3 min 
• 
20 µg/hr ~ 1 µg every 3 min 
• 
30 µg/hr ~ 1.5 µg every 3 min 
• 
40 µg/hr ~ 2µg every 3 min 
• 
50 µg/hr ~ 2.5µg every 3 min 
• 
60 µg/hr ~ 3µg every 3 min 
• 
70 µg/hr ~ 3.5µg every 3 min 
Table 1 
Algorithm to Maintain Plasma Glucose 
Plasma Glucose 
(mg/dL) 
Plasma Glucose 
(mmol/L) 
Action 
<50 
<2.8 
Give 200 mg/kg of dextrose as a bolus and increase IV GIR by 
2 mg/kg/min 
50-59 
2.8-3.3 
Increase IV GIR by 2 mg/kg/min 
60-69 
3.3-3.9 
Increase IV GIR by 1 mg/kg/min 
70-80 
3.9-4.4 
No change 
81-90 
4.4-5.0 
Reduce IV GIR by 0.5 mg/kg/min 
91-100 
5.0-5.5 
Reduce IV GIR by 1 mg/kg/min 
101-120 
5.5-6.7 
Reduce IV GIR by 1.5 mg/kg/min 
>120 
>6.7 
Reduce IV GIR by 2 mg/kg/min 
Abbreviations: GIR = glucose infusion rate; IV = intravenous 
The IV GIR will be reviewed, evaluated, and adjusted (if indicated) every hour according to the 
above PG-driven algorithm to maintain a PG of >70 mg/dL (>3.9 mmol/L). Rechecks of PG are 
allowed.  
Part 1 (Crossover, double-blind, randomized, placebo-controlled) 
The starting dose of trial drug is 10 µg/hr at t=0. Every 2 hours (t=2, 4, 6, etc.), the dose will be 
increased by an additional 10 µg/hr until either: 
• 
The patient is totally weaned off IV glucose, or 
• 
Plasma glucose during the last 2 hours was constantly above 120 mg/dL (6.7 mmol/L), or 
• 
IV GIR has not decreased despite 2 sequential dose increments of trial drug (in this 
situation, the dose of trial drug should be maintained until the IV GIR can be further 
decreased or until crossover or the end of Part 1), or 
• 
The maximum dose of 70 µg/hr is reached, or 
• 
AEs emerge that are considered to be related to dasiglucagon (e.g., nausea/change in feeding 
pattern or increased vomiting) that are limiting further dose escalation 
The 2-hour dose-adjustment interval will allow drug plasma levels to approach steady-state 
before the dose is further increased. The cumulative dose will not exceed 1.26 mg over the first 
24 hours and 1.68 mg for each of the subsequent 24-hour periods.  
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At the time of crossover from the first 48-hour period to the second 48-hour period, the trial drug 
will again be titrated from the starting dose of 10 µg/hr, and IV GIR will be set to the rate 
obtained at the end of the run-in period and titrated accordingly.  
Part 2 (Open label) 
After Part 1, patients will continue in open-label Part 2 to receive dasiglucagon for a further 
21 days. Since treatment allocation during Part 1 remains blinded, all patients are required to 
initiate dasiglucagon dosing at 10 µg/hr in Part 2, while IV GIR should be started at the rate 
obtained at the end of the run-in period. 
During Part 2, the dasiglucagon dose, the amount and route of administration of carbohydrates 
(IV GIR, parenteral nutrition, gastric carbohydrate infusions, and carbohydrates from oral feeds) 
can be adjusted at the discretion of the investigator. The PG should be monitored at least hourly 
to adjust the IV GIR as appropriate and to avoid hypoglycemia. Additional concomitant 
medications, including somatostatin analogs and/or sirolimus/mTOR inhibitors, may be 
introduced at the investigator’s discretion if the maximum dose level of dasiglucagon (70 µg/hr) 
has been reached or if further up-titration is not possible due to undesirable side effects. 
Adjustment of total carbohydrate administered (IV glucose, parenteral nutrition, carbohydrate 
infusions, and carbohydrates from oral feeds) should continue throughout this period according 
to local practice to maintain PG levels in the range of 70 mg/dL to 120 mg/dL (3.9-6.7 mmol/L). 
The aim will be to obtain stable glucose levels with minimum rescue/hypoglycemia-preventative 
carbohydrates administered by invasive routes, and to encourage/optimize oral feeds, and 
achieve weaning off IV glucose. Regardless of their discharge status, all patients will be offered 
the opportunity to participate in the long-term safety extension trial (ZP4207-17106), providing 
the investigator attests to the positive benefit-risk balance of continued dasiglucagon treatment. 
10.3. Trial Supplies 
The device and ancillaries listed in the following table will be supplied by the sponsor 
throughout the trial. Trained trial personnel will train parent(s)/guardian on the use of the devices. 
Instructions for the use of all these supplies will be provided in separate manuals. 
Item 
Name 
Manufacturer 
Pump 
Accu-Chek Spirit Combo 
Hoffman-La Roche AG, Basel, Switzerland 
Cartridge 
Accu-Chek Spirit 3.15 mL Cartridge system 
Hoffman-La Roche AG, Basel, Switzerland 
Infusion sets 
Accu-Chek FlexLink Infusion set (Accu-Check 
UltraFlex Infusion set in US) 
and 
Accu-Chek Rapid-D Link Infusion set 
Hoffman-La Roche AG, Basel, Switzerland 
Infusion set 
inserter 
Accu-Chek LinkAssist Insertion device (can be 
used with FlexLink & UltraFlex) 
Hoffman-La Roche AG, Basel, Switzerland 
SMPG  
StatStrip Xpress2 
Nova Biomedical, Waltham, MA, USA 
CGM 
Dexcom G4 (not to be used in Germany) 
Dexcom G6 
Dexcom Inc., San Diego, CA, USA 
 
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The infusion pump system is CE-marked for the management of diabetes mellitus in persons 
requiring insulin, as prescribed by a physician. In this trial, the pump system is used outside of 
the CE-marked intended use since the pump system will be delivering dasiglucagon to patients 
with CHI. The PG meter is used as intended according to the CE mark, except for the use by a 
lay person in a home care setting. The CGM devices are used as intended according to the CE 
mark, except for the age group and the disease. 
The pump, the SMPG, and the CGM will be labeled for use in an investigational trial. For more 
information on the devices please refer to Section 20. 
10.4. Dispensing and Storage 
The trial drug products supplied by the sponsor is to be dispensed exclusively to patients 
randomized in this clinical trial according to the instructions of this protocol and the pharmacy 
manual/trial materials manual (TMM). The investigator is responsible for dispensing the trial 
drug product according to the dosage scheme. Trial drug products will be allocated using an 
interactive automated web response system (IWRS), according to Section 10.5. 
Dasiglucagon and placebo for dasiglucagon injection must be stored at 2–8°C in a refrigerator. 
The investigator must ensure the availability of proper storage conditions. All trial drug products 
provided for this trial will be stored at the trial site in a secure area with restricted access.  
The temperature should be monitored by recording the actual, minimum, and maximum 
temperatures using a calibrated thermometer or thermocouple, or by continuous recording using 
a qualified temperature monitoring system. The temperature should be evaluated and 
documented at least on working days on a temperature log. This log must be included in the 
Investigator Site File (ISF) upon trial termination. 
The investigator must contact the clinical research associate (CRA) in case of temperature 
deviations outside the acceptable range.  
Please see the pharmacy manual/TMM for additional information on handling of the trial drug. 
The investigator must maintain adequate records showing the receipt, dispensing, return, or other 
disposition of the trial drug, including the date, quantity, batch or code number, and 
identification of patients (patient number) who received the trial drug. The investigator will not 
supply the trial drug to any person except subinvestigators, designated trial personnel, and 
patients in this trial. The trial drug may not be relabeled or reassigned for use by other patients. If 
any of the trial drug is not dispensed, is lost, stolen, spilled, unusable, or is received in a 
damaged container, this information must be documented and reported to the sponsor and the 
appropriate regulatory agencies as required. 
10.5. Method of Assigning Patients to Treatment Groups 
For Part 1, patients will be randomly assigned 1:1 in a double-blind fashion to 1 of 2 sequences: 
• 
Dasiglucagon 4 mg/mL for 48 hours, followed by placebo for dasiglucagon for 48 hours, or 
• 
Placebo for dasiglucagon for 48 hours, followed by dasiglucagon 4 mg/mL for 48 hours. 
Randomization will be performed using a block randomization scheme stratified by region 
(US/non-US). The randomization scheme will be generated prior to the initiation of the trial by 
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an independent statistician/programmer who will not be a member of the trial team; investigators 
will not be aware of the block size of the randomization scheme.  
Patients will be randomly assigned to a trial treatment sequence using an IWRS that has been 
validated for the intended use under the International Society of Pharmaceutical Engineers Good 
automated manufacturing practice guidelines, 21CFR Part 11 (FDA regulation for Electronic 
Records and Electronic Signatures), and the ICH Guidance E6 for Industry on Good Clinical 
Practice. 
After completing Part 1, patients will continue in Part 2 to receive active treatment for a 
maximum of 21 days.  
10.6. Blinding and Unblinding Treatment Assignment 
Trial personnel will endeavor to safeguard the integrity of the trial blind to minimize bias in the 
conduct of the trial. Treatment unblinding is discouraged if knowledge of the treatment 
assignment will not materially change the planned management of a medical emergency. 
Unblinding will be permitted in a medical emergency that requires immediate knowledge of the 
patient’s treatment assignment. 
For emergency unblinding, the investigator will use the measures provided through the IWRS. 
Unblinding should be discussed in advance with the medical monitor if possible. If the 
investigator is not able to discuss treatment unblinding in advance, then he or she must notify the 
medical monitor as soon as possible about the unblinding incident without revealing the patient’s 
treatment assignment.  
The investigator or designee must record the date and reason for unblinding on the appropriate 
eCRF page for that patient. 
10.7. Selection of Doses in the Trial 
Both the starting dose and the maximum allowed doses are based on experience with marketed 
glucagon products in this patient population.11 
At present, no pediatric PK data are available for dasiglucagon. However, an approximate 
estimation of expected drug concentration in a 3 kg patient has been made by extrapolation of a 
previously made PK model for pediatric patients with weights between 25 and 45 kg.17 
In this trial, dasiglucagon will be titrated to meet the needs of the individual patient on the basis 
of PD effects in regards to efficacy and tolerability, and it is expected that the majority of 
patients will be adequately treated with a dasiglucagon infusion rate of approximately 
20 to 40 μg/hr. The up-titration will stop when IV glucose is completely weaned, if undesirable 
side effects arise, or when no additional PD effects are observed as the dasiglucagon infusion 
rate is increased. 
Based on the current PK/PD model, the predicted plasma concentration is expected to result in a 
medium PD response at the lowest dose level and be approaching maximum effect at the highest 
dose level. The PD response of patients will be monitored closely in this trial, and the 
appropriateness of the applied titration algorithm will be evaluated. 
Although the PK of dasiglucagon has been shown to be dose-proportional in adults and in all 
toxicologically tested species over a wide range of doses, limited PK sampling at each dose level 
is planned based on the limited available blood volume in this population. 
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10.8. Selection of Timing of Dose for Each Patient 
Dosing details are provided in Section 10.2. 
10.9. Dose Adjustment Criteria 
Dose adjustment criteria are presented in Section 10.2. 
10.10. Treatment Compliance 
Compliance data will be collected. Infusion details will be recorded in the patient’s eCRF and 
drug accountability will be performed as detailed in the pharmacy manual/TMM. 
10.11. Permitted and Prohibited Therapies 
All concomitant medications used (including over-the-counter medications and herbal 
supplements) will be recorded in the source document and on the appropriate eCRF.  
Caution is advised when beta-blockers, indomethacin, anticholinergic drugs, and warfarin are 
prescribed due to reports of interaction with marketed glucagon products. 
10.11.1. Permitted Therapies 
Regarding diazoxide, patients entering the trial either: 
• 
Have tried diazoxide, but discontinued due to lack of efficacy. Minimum of 6 days’ washout 
is required prior to randomization. 
• 
Have tried diazoxide, but discontinued due to adverse events, or family choice, even if 
efficacy was established. Minimum of 6 days’ washout is required prior to randomization. 
• 
Have initiated diazoxide prior to screening, and continue on the treatment. Diazoxide dose 
should remain stable during Part 1 of the trial. Diazoxide should not be initiated during 
screening. 
• 
Have never tried diazoxide. Diazoxide should not be initiated during screening or Part 1 of 
the trial. 
Prior use of octreotide is allowed after a minimum 48-hour washout prior to randomization. 
Washout is required to eliminate the effect of octreotide during Part 1, where adjustment of GIR 
has to follow the protocol-defined PG-driven algorithm (Table 1) and the primary endpoint on 
mean GIR is assessed.  
Somatostatin analogs and/or diazoxide can be introduced during Part 2 if needed, at the 
investigator’s discretion, when the maximal limit of dasiglucagon (70 µg/hr) has been reached or 
if further up-titration is not possible due to undesirable side effects.  
Addition of other CHI-specific treatments (e.g., sirolimus/mTOR inhibitors) during Part 2 need 
to be discussed with the medical monitor. 
10.11.2. Prohibited Therapies 
The following therapies are prohibited:  
During the entire trial: 
• 
Systemic corticosteroids, e.g., hydrocortisone >20 mg/m2 body surface area or equivalent 
within 5 days before screening. 
• 
Anti-inflammatory biological agents or other immune-modulating agents.  
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• 
Other investigational agents. 
• 
Marketed glucagon products within the last 24 hours prior to randomization and throughout 
the trial unless necessary for rescue therapy in case of severe hypoglycemia, as per local 
standard of care. 
• 
Prescription or non-prescription medications known to cause QT prolongation.  
During Screening and Part 1:  
• 
Somatostatin analogs and sirolimus (mTOR inhibitors). No new CHI treatment is to be 
initiated during screening and Part 1. Octreotide is allowed in the screening period if 
discontinued at least 48 hours before randomization. 
During Part 2 and follow-up:  
• 
Initiation of somatostatin analogs, diazoxide and sirolimus (mTOR inhibitors) unless the 
maximum dose level of dasiglucagon (70 µg/hr) has been reached or further dasiglucagon 
up-titration is not possible due to undesirable side effects. 
10.12. Discharge of Patients for Home Treatment 
Patients can be discharged during Part 2 to complete the treatment at home as soon as IV GIR 
has been weaned off and local site criteria for discharge are met. Discharge for home treatment is 
contingent on the parent(s)/guardian being capable of taking care of the administration of 
investigative product via pump at home, can use SMPG and CGM device, and are able to attend 
planned assessment visits at the hospital. 
Before discharge of patients from hospital care, the investigator will ensure: 
• 
Appropriate training of patient’s parent(s)/guardian in the use of dasiglucagon in the Accu-
Chek Spirit Combo pump based on the training material provided. The first pump infusion 
set change should be performed at the hospital 
• 
Parent(s)/guardian are trained appropriately on the handling of CGM device 
• 
Parent(s)/guardian are trained appropriately on how to perform SMPG measurements and 
how to complete the diary. They will check their child’s SMPG at least 3 times daily 
(preferably before main meals) and in case of suspected hypoglycemia 
• 
Parent(s)/guardian are instructed not to change the dose of trial drug without prior 
consultation with the investigator  
• 
Parent(s)/guardian are instructed how to recognize and handle signs of hypoglycemia 
• 
Parent(s)/guardian are instructed to call the investigator/site staff in case of questions 
Patients who are discharged from hospital before Day 25 will be contacted by the investigator by 
telephone the day after discharge. The investigator will ask the parent(s)/guardian if they have 
any questions about the trial procedures and if their child has experienced any AEs. 
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10.13. Treatment After End of Trial 
On Day 25, the End of Treatment Visit will take place. Based on the investigator’s confirmation 
of continued positive benefit-risk balance, patients will be offered the opportunity to enter the 
long-term extension trial (Trial ZP4207-17106) to continue dasiglucagon treatment. Patients who 
do not enter the long-term extension trial will have a Follow-up Visit 28 days after their last dose 
of trial drug and return to standard of care as per investigator discretion. No further treatment 
with dasiglucagon will be offered.  
11. TRIAL PROCEDURES 
Patients’ parent(s)/guardian (according to local law) must provide written informed consent 
before any trial-related procedures are initiated, including the cessation of prohibited 
concomitant therapy. 
For the timing of assessments and procedures throughout the trial, refer to the Schedule of 
Events (Section 18.1). Throughout the trial, trial personnel should make every reasonable effort 
to follow the timing of assessments and procedures in Section 18.1 for each patient. If a patient 
misses a trial visit for any reason, it should be rescheduled as soon as possible. 
11.1. Trial Duration 
The sequence and maximum duration of the trial periods will be as follows: 
1. Screening Period: up to 28 days, including a minimum 24-hour run-in period 
2. Part 1 (2x48-hour period: double-blind, randomized, placebo-controlled): 96 hours 
3. Part 2 (Open-label Active Treatment Period): 21 days 
4. Follow-up Period: Patients who do not enter the extension trial will have a Follow-up 
Visit 28 days after their last dose of trial drug 
The maximum trial duration for each patient is 81 days. The maximum treatment duration for 
each patient is 25 days. 
11.2. Assessments 
11.2.1. Efficacy 
11.2.1.1. 
Plasma Glucose Monitoring 
As long as the patient is receiving IV glucose, the GIR will be reviewed hourly, based on an 
hourly PG check performed by the StatStrip Xpress2 meter. The IV GIR will be reviewed, 
evaluated, and adjusted (if indicated) according to the IV GIR algorithm based on PG levels 
specified in Table 1. If IV glucose has been stopped, PG will be checked according to local 
practice, but at least 3 times daily.  
Blood for PG check can be obtained either by finger or heel sticks or by an indwelling peripheral 
line. However, if using an indwelling peripheral line, the total blood volume drawn during a 
28-day period should be considered according to Section 11.2.3.1. 
At each visit, the investigator will ensure that SMPG data are downloaded from the patient’s 
device. The investigator will check for patient compliance in SMPG measurements. The 
procedure for download of SMPG data will be described in the pharmacy manual/TMM. 
Adjustments to the trial drug will be made as outlined in Section 10.2. 
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11.2.1.2. 
Continuous Glucose Monitoring 
Dexcom CGMs, configured and labeled for use in the trial, will be provided. In Germany, only 
the Dexcom G6 CGM will be used. Enrollment in Germany will start only after Dexcom G6 
CGM is available. 
For other countries: the Dexcom G4 may be used until all required approvals for use of the 
Dexcom G6 are obtained, but no later than to the end of 2020, when the Dexcom G4 will be 
taken off the market by the supplier. Patients enrolled thereafter will all be using the Dexcom G6 
CGM. Patients who started in the trial using the Dexcom G4 CGM should continue using this 
device throughout the trial and should not switch to the Dexcom G6 device. 
The CGM will be started at least 24 hours prior to randomization and will be used during Parts 1 
and 2 in a blinded mode to evaluate efficacy in terms of hypoglycemic episodes. Short pauses of 
1 to 3 days due to skin irritation or discomfort are allowed during Part 2 of the trial after 
consultation with the investigator. 
The CGM device should be calibrated and used according to the manufacturer’s instructions. 
At each visit, the investigator will ensure that CGM data are downloaded from the patient’s 
device. The procedure for download of CGM data will be described in the pharmacy 
manual/TMM.  
The contract research organization (CRO) or delegate will handle the device sourcing, 
configuration for use in this trial, procedures for blinded data extraction, device service, and 
handling of potential returns. 
11.2.1.3. 
Diary  
For patients who are discharged during the trial, the parent(s)/guardian will receive a paper diary 
to be completed at home. The investigator will instruct the patient’s parent(s)/guardian on how to 
complete the diary. The following information should be recorded in the diary:  
• 
Type and volume of fluid administered through NG tube/gastrostomy  
• 
Hypoglycemic events, including related SMPG measurements  
• 
Concomitant medications  
• 
AEs  
• 
Hospitalizations, visits to health care providers or emergency room (ER)/accident & 
emergency (A&E) department, and visits by paramedics  
• 
Data regarding suspicion of NME and neurological findings  
Diary entries should be reviewed at each visit and the review documented in the diary. Data from 
the diary entries should be transcribed to the eCRF on an ongoing basis. 
11.2.2. Pharmacokinetics/Drug Exposure 
Blood samples will be collected in Part 2 to measure dasiglucagon levels at steady-state 
(Schedule of Events; Section 18.1). The blood samples should be collected after a minimum of 
4 hours without changes to the dasiglucagon infusion rate. For patients with a body weight above 
4 kg, an additional PK sample should be collected at Day 5. However, the total amount of blood 
collected should always be considered according to Section 11.2.3.1. 
Details on sampling/collection, shipment, and analysis will be provided in the laboratory manual. 
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11.2.3. Safety 
Safety assessments will include the evaluation of AEs, clinical laboratory assessments 
(hematology, biochemistry, and ADAs), vital signs, physical examinations, ECGs, 
echocardiography, and local tolerability. 
11.2.3.1. 
Laboratory Safety Assessments 
Trial procedures require a maximum total of 8.8 to 9.2 mL of blood in a 28-day period. Where 
this exceeds the 2.5 mL/kg maximum18,19, safety laboratory tests (2 mL per sampling) will be 
prioritized over immunogenicity (1 mL) and drug exposure (0.4 mL) samples. 
All measurements described in this section are recognized standard methods. 
Hematology and Biochemistry 
Samples for hematology and biochemistry will be collected at the time points specified in the 
Schedule of Events (Section 18.1). 
Hematology: 
hemoglobin, hematocrit, red blood cell (RBC) count, RBC indices, mean 
corpuscular hemoglobin, mean corpuscular hemoglobin concentration, 
platelet count (or estimate), white blood cell count, including differential 
Biochemistry: 
albumin, total bilirubin, total protein, calcium, alkaline phosphatase, 
alanine aminotransferase, aspartate aminotransferase, blood urea 
nitrogen, creatinine, glucose, sodium, potassium, chloride, eGFR, 
ketones (measured with PG meter) 
Standard of care blood samples can be used as screening samples if they were collected within 
1 week of screening.  
Laboratory specimens will be analyzed at local laboratories. 
Immunogenicity 
Blood samples will be collected to test for antibodies against dasiglucagon at Visit 2 (Day 1, 
prior to dosing), Visit 7 (Day 25 ±3), and at the Follow-up Visit (Visit 8, Day 53 ±3) 
(Section 18.1) and processed and shipped according to instructions provided in the laboratory 
manual. The samples will be stored until the ADA screening and confirmatory assays have been 
approved by the FDA. Afterwards, the ADA samples will be analyzed in batches during the trial. 
The ADA samples will be analyzed at a specialty laboratory. 
The clinical ADA assays specific for dasiglucagon and glucagon have been validated in 
accordance with existing guidelines and recommendations.19,21,22,23 
Samples will be measured in anti-dasiglucagon antibody screening and confirmatory assays. Due 
to the limited sample volume, the ADA characterization of confirmed positive samples will be 
conducted according to the following priority: 
• 
Establishment of anti-dasiglucagon binding titer. 
• 
Cross-reactivity against endogenous glucagon  
The neutralizing potential in samples from ADA-positive patients will be evaluated on the basis 
of drug exposure/PD data (steady-state exposure and PG). 
The ADA samples will be analyzed in batches during the trial and any anti-dasiglucagon 
antibody-positive patients (treatment induced or treatment boosted, titer increase above 5-fold) 
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will be monitored at an additional follow-up visit, preferably 16 weeks after last ADA-positive 
sample. Patients who complete the trial before the ADA screening and confirmatory assays have 
been approved by the FDA and who do not continue treatment in the long-term extension trial 
will have this additional visit 16 weeks after the end of trial visit (Visit 8). Patients who are 
tested ADA positive after the additional Follow-up Period will be categorized as having 
persistent antibodies.  
It will not be possible to collect back-up ADA samples for long-term storage due to limited 
blood volume in these patients. However, any residual serum samples may be stored until 
approval of market authorization since further characterization of the antibody response may be 
requested. 
Specimen Handling Requirements 
The transmission of infectious agents may occur through contact with contaminated needles and 
blood or blood products. Consequently, appropriate blood and body fluid precautions should be 
employed by all trial personnel involved in the collection of blood and handling of specimens in 
both the clinic and laboratory settings. Refer to current recommendations of the appropriate 
authorities. 
In addition to appropriate handling of patient samples, specific regulations exist regarding the 
shipment of biologic/etiologic samples. Procedures and regulations for the packaging and 
shipping of infectious samples are outlined in the laboratory manual. The investigator is 
responsible for ensuring that all trial samples that are to be transported to another location are 
packed and shipped appropriately according to the applicable regulations.  
Evaluation of Laboratory Values 
The normal ranges of values for the laboratory assessments in this trial will be provided by the 
responsible laboratories and submitted to the sponsor before the beginning of the trial. They will 
be regarded as the reference ranges on which decisions will be made. 
If a laboratory value is out of the reference range, the investigator must evaluate if the value is 
clinically significant and record his or her assessment in the appropriate eCRF. 
All laboratory values that in the investigator’s opinion are clinically relevant during or after 
termination of the treatment have to be reported as AEs and followed, as described in 
Section 12.3. 
11.2.3.2. 
Clinical Examinations 
Vital Signs 
Vital signs, including blood pressure, heart rate, respiratory rate, and SpO2 will be measured 
while the child is sleeping or in a calm state at times specified in the Schedule of Events 
(Section 18.1). Vital signs can be performed using the bedside monitoring device as per standard 
of care. 
Twelve-lead Electrocardiogram 
A standard 12-lead ECG will be performed while the child is sleeping or in a calm state at times 
specified in the Schedule of Events (Section 18.1). If it is not practical or possible, then a 2-lead 
ECG may be used.24 If arrhythmia is detected on a 2-lead ECG, this should be followed by 
12-lead ECG. All ECG recordings will be identified with the patient number, date, and time of 
the recording and will be attached to his or her medical record. 
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The ECG parameters (heart rate, PQ, QRS, QT, and QTcF) and any abnormality will be recorded 
and described in the eCRF, including the investigator’s assessment of clinical significance 
(Abnormal, Clinically Significant; or Abnormal, Not Clinically Significant). At subsequent 
visits, any clinically significant deterioration of a pre-existing condition, as well as any new 
clinically significant findings, will be recorded as AEs. 
Echocardiogram 
An echocardiogram will be performed according to the time points specified in the Schedule of 
Events (Section 18.1). 
Physical Examination and Neurological Examination 
A complete physical examination of body systems according to standard of care and an 
age-appropriate neurological examination will be performed according to the Schedule of Events 
(Section 18.1). 
Local Tolerability 
Local tolerability data will be collected separately from AEs. Within the eCRF, data will be 
collected on the nature of any reaction (erythema, pain, swelling, etc.), the severity (mild, 
moderate, or severe), and any action taken (e.g., no action, interruption of infusion). The likely 
cause of the reaction will also be collected (e.g., insertion site, drug, adhesive dressing). 
Other skin findings will be collected along other AEs. If clinical suspicion of NME is made, data 
describing the lesion(s) will be collected as an AE of special interest (AESI) (see Section 12.1.8), 
together with a photograph or series of photographs of the lesion(s) uploaded to a central 
repository. 
Assessment of Fluid Balance for Patients Receiving IV Glucose 
Fluid balance assessments are to be performed and documented at least every 8 hours as long as 
the patient is hospitalized and receiving IV glucose. These assessments will include administered 
IV and oral fluids, fluid loss from stools and urine by weighing of diapers, and vital signs of fluid 
balance status. Furthermore, daily body weight will also be part of the individualized assessment 
based on the patients overall status, at investigator’s discretion. According to Section 9.5, the 
investigator should evaluate whether the IV glucose concentration should be increased to avoid 
volume overload or whether oral/gastric non-nutritional carbohydrates are to be introduced to 
ensure the patient’s safety whilst maintaining the maximum tolerable concentration and infusion 
rate of IV glucose. 
All details on IV GIR (including any bolus given) will be recorded in the eCRF. 
11.2.3.3. 
Reporting of Hypoglycemia Events 
All hypoglycemic episodes are to be reported via the dedicated hypoglycemia eCRF form. 
Hypoglycemic episodes that fulfill the definition of a serious adverse event (SAE) should also be 
recorded as an SAE. The following information should be collected: 
• 
Date, start time 
• 
PG value 
• 
Selected symptoms (e.g., unconsciousness, seizures) 
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• 
Intervention, type, and amount of food; route of administration (oral vs. NG 
tube/gastrostomy); and use of marketed glucagon as rescue therapy 
• 
Subsequent PG measurements 
• 
End time and PG value (time when PG exceeded a threshold of 70 mg/dL [3.9 mmol/L]) 
• 
Contact to trial doctor or emergency services, paramedic visit, ER admission, 
hospitalization, if applicable 
A single hypoglycemia episode is defined as up until 60 minutes from the start of the episode. If 
normoglycemia (>70 mg/dL) is not reached within this time, a new episode of hypoglycemia will 
be recorded. 
11.2.3.4. 
Technical Complaints 
Reporting of Technical Complaints 
Technical complaints should be reported to the sponsor on any of the following products if 
technical issues occur between the first and last use: 
• 
Dasiglucagon 4 mg/mL / placebo vial containing 1 mL 
• 
Accu-Chek Spirit pump 
• 
Accu-Chek Spirit 3.15 mL Cartridge system, Accu-Chek Flex-Link Infusion set 
(Accu-Check UltraFlex Infusion set in the US), and Accu-Check Rapid-D Link infusion set 
• 
Accu-Chek Link-Assist Insertion device 
• 
SMPG meter, StatStrip Xpress2 
• 
Dexcom G4/G6 systems (in Germany, only the Dexcom G6 CGM will be used) 
The investigator must report whether the technical complaint is associated with any AEs or 
SAEs. Any AE/SAE associated with a technical complaint must be reported in accordance with 
Section 12.2; the relationship between the technical complaint and the AE/SAE must be assessed 
by the investigator. 
Technical complaints must be reported on a dedicated technical complaint form.  
The investigator must complete the technical complaint form in the eCRF according to the 
following timelines, starting from the time the trial site becomes aware of the technical 
complaint: 
• 
Technical complaint assessed as related to an SAE within 24 hours 
• 
Technical complaint which could have led to serious medical occurrence if either suitable 
action had not been taken, if intervention had not been made, or if circumstances had been 
less fortunate within 24 hours 
• 
All other technical complaints within 5 calendar days 
Use Trial the paper technical complaint form when reporting a technical complaint for an item 
that is not yet allocated to a patient. The form should be sent by e-mail to e-mail address in the 
Appendix A.  
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Collection, Storage, and Shipment of Technical Complaint Items 
The investigator must collect and store the item(s) and notify the CRA (including photo 
documentation) within 5 calendar days of obtaining the item at the trial site. Upon request, the 
CRA must coordinate the shipment as per instruction from the sponsor. 
11.2.3.5. 
Adverse Events 
The definitions and management of and special considerations for AEs are provided in 
Section 12. 
12. ADVERSE EVENTS 
Timely, accurate, and complete reporting and analysis of safety information from clinical trials 
are crucial for the protection of patients, investigators, and the sponsor, and are mandated by 
regulatory agencies worldwide. 
12.1. Definitions 
12.1.1. Adverse Events 
An AE is any untoward medical occurrence in a clinical trial patient administered a medicinal 
(investigational or noninvestigational) product and which does not necessarily have a causal 
relationship with this treatment. An AE can therefore be any unfavorable and unintended sign 
(including an abnormal laboratory finding), symptom, or disease temporally associated with the 
use of a product, whether or not related to the product or medical device. 
AEs include: 
• 
A clinically significant worsening of a concomitant illness 
• 
A clinical laboratory AE: a clinical abnormality which is clinically significant, i.e., any 
abnormality that suggests a disease and/or organ toxicity and is of a severity that requires 
active management. Active management includes active treatment or further investigations, 
e.g., change of dose or more frequent follow-up due to the abnormality. 
The following should not be considered as AEs: 
• 
Pre-existing conditions, including those found as a result of screening procedures 
(pre-existing conditions should be reported as medical history or concomitant illness). 
• 
Preplanned procedure, unless the condition for which the procedure was planned has 
worsened from the first trial-related activity after the patient has signed the informed 
consent. 
12.1.2. Severity 
When assessing the severity of an AE, the following definitions are used: 
Mild: No or transient symptoms, no interference with the patient's daily activities 
Moderate: Marked symptoms, moderate interference with the patient's daily activities 
Severe: Considerable interference with the patient's daily activities, which the patient find 
unacceptable. A severe reaction does not necessarily deem the AE as serious (SAE), and an SAE 
is not always severe in nature. 
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12.1.3. Causality 
When assessing the cause of an AE, the following definitions are used: 
Probable: Good reason and sufficient documentation to assume a causal relationship 
Possible: A causal relationship is conceivable and cannot be dismissed 
Unlikely: The event is most likely related to etiology other than the product 
Not related: No relationship to product. 
Causality will take into consideration whether the cause of the AE was related to the trial drug, 
device, or procedures. 
12.1.4. Outcome 
When assessing the outcome of an AE, the following definitions are used: 
Recovered/resolved: The patient has fully recovered, or by medical or surgical treatment, the 
condition has returned to the level observed at the first trial-related activity after the patient 
signed the ICF 
Recovering/resolving: The condition is improving and the patient is expected to recover from 
the event. This term is only applicable as final outcome of an event if the patient has completed 
the trial or has died from another AE 
Recovered/resolved with sequelae: The patient has recovered from the condition, but with 
lasting effect due to a disease, injury, treatment, or procedure. If a sequela meets an SAE 
criterion, the AE must be reported as an SAE 
Not recovered/not resolved: The condition of the patient has not improved and the symptoms 
are unchanged, or the outcome is not known 
Fatal: This term is only applicable if the patient died from a condition related to the reported 
AE. Outcomes of other reported AEs in a patient before he/she died should be assessed as 
“recovered/resolved,” “recovering/resolving,” “recovered/resolved with sequelae,” or “not 
recovered/not resolved.” An AE with fatal outcome must be reported as an SAE 
Unknown: This term is only applicable if the patient is lost to follow-up. 
12.1.5. Serious Adverse Events 
An SAE is any untoward medical occurrence that at any dose results in any of the following: 
• 
results in death 
• 
is life-threatening 
• 
requires inpatient hospitalization or prolongation of existing hospitalization 
• 
results in persistent or significant disability or incapacity 
• 
is a congenital anomaly or birth defect 
• 
is otherwise medically important and may not result in death, be life threatening, or require 
hospitalization may be considered an SAE when (based on appropriate medical judgement) 
it may jeopardize the patient and may require medical or surgical intervention to prevent one 
of the outcomes listed in the definition of an SAE. Examples could be ER or home treatment 
of allergic bronchospasm or convulsion 
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12.1.6. Other Important Events 
The following events must always be reported in the electronic data capture (EDC) system on a 
dedicated form, regardless of whether it is related to an AE:  
• 
suspicion of transmission of infectious agents via the trial product 
• 
overdose of the trial product 
• 
medication error involving the trial product 
• 
inadvertent or accidental exposure to the trial product 
12.1.7. Nonserious Adverse Events 
A nonserious AE is any AE that does not fulfill the definition of an SAE. 
12.1.8. Adverse Events of Special Interest 
For this trial, the following events are to be regarded as AESIs, with data collected under a 
specific eCRF form:  
• 
Suspicion of NME 
• 
Risk of liver injury defined as ALT or AST >3 x UNL AND total bilirubin >2 x UNL, 
where no alternative etiology exists (Hy’s law). 
• 
Loss of consciousness, partial, and generalized seizures 
• 
Clinically significant changes in blood pressure or heart rate  
12.1.9. Suspected Unexpected Serious Adverse Reactions 
An AE is considered a suspected unexpected serious adverse reaction (SUSAR) if the nature or 
severity is not consistent with the applicable product Reference Safety Information (RSI). For 
dasiglucagon, the expectedness of an AE will be determined by whether or not it is listed in the 
RSI section of the investigator’s brochure. 
12.1.10. Adverse Events Associated with Devices 
Adverse events associated with devices must be reported to the ethics committee and competent 
authority according to local requirements. Such events include the following: 
12.1.10.1. Adverse Device Effect 
An adverse device effect (ADE) is an AE related to the use of an investigational medical device. 
This definition includes AEs resulting from insufficient or inadequate instructions for use, 
deployment, installation, operation, or any malfunction of the investigational medical device. 
This definition also includes any event resulting from use error or from intentional misuse of the 
investigational device.  
12.1.10.2. Serious Adverse Device Effect 
A serious ADE (SADE) is an ADE that has resulted in any of the consequence characteristics of 
an SAE, meaning that the SAE is related to one of the investigational devices.  
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12.1.10.3. Unanticipated Serious Adverse Device Effect 
An unanticipated SADE (USADE) is an SADE which by its nature, incidence, severity, or 
outcome has not been identified in the current version of the risk analysis report. 
12.1.10.4. Device Deficiency 
A device deficiency is the inadequacy of a medical device with respect to its identity, quality, 
durability, reliability, safety, or performance. It also includes malfunctions, use errors, and 
inadequate labelling. In this clinical trial, these are covered by the term technical complaint (see 
reporting requirements in Section 11.2.3.4). Reporting of technical complaints is synonymous 
with device deficiency. The device deficiencies will be monitored and managed by the sponsor 
throughout the trial.  
12.2. Collection, Recording, and Reporting of Adverse Events 
All AEs, whether serious or nonserious, will be reported from the time a signed and dated ICF is 
obtained until the end of the posttreatment follow-up period (which may include contacts for 
follow-up of safety) or inclusion in the ZP4207-17106 trial. Parent(s)/guardian will be asked 
about their child’s condition by open questioning, such as “How has your child been feeling 
since you were last asked?” at each contact with the trial site (visit or telephone). 
Parent(s)/guardian will also be encouraged to spontaneously report AEs occurring at any other 
time during the trial. In addition, patients will be observed for any signs or symptoms. 
All AEs, regardless of seriousness, severity, or presumed relationship to the trial drug, must be 
recorded and evaluated by the investigator. Whenever possible, diagnoses should be given when 
signs and symptoms are due to a common etiology. If no diagnosis can be made, the investigator 
should record each sign and symptom as individual AEs. Investigators must record their opinion 
concerning the relationship of the AE to the trial drug. All measures required for AE 
management must be recorded in the source document and reported according to sponsor 
instructions. 
Each AE must be reported on the AE eCRF within 5 days of the investigator becoming aware of 
the event.  
All AE information should at a minimum include the following: 
• 
Date and time of onset 
• 
Date and time of investigator's first information about the AE 
• 
Seriousness 
• 
Severity 
• 
Causal relationship with trial product 
• 
Measures taken due to AE 
• 
Interruption or discontinuation of treatment with trial product 
• 
Date and time of resolution and final outcome 
Each AE will be coded using the latest version of the Medical Dictionary for Regulatory 
Activities (MedDRA). 
All SAEs, including those spontaneously reported to the investigator within 30 days after the last 
dose of trial drug, must be reported within 24 hours after obtaining knowledge about the event by 
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completing the SAE form in the EDC system. A separate SAE form should be completed for 
each SAE. 
All SAEs will be reported in EDC; for each reported event a system-generated e-mail will be 
sent to the safety CRO (
), medical monitor, sponsor medical director, and trial 
manager. 
Specific information about AESIs will be collected via the SAE form (if qualifying for an SAE), 
as well as via the dedicated AESI eCRF page(s). Reporting requirements for serious and 
nonserious AEs as described previously also apply for serious and nonserious AESIs. 
Other important events (Section 12.1.6) will be reported via a dedicated eCRF page. Reporting 
timelines will be within 24 hours if related to an SAE, and 5 calendar days for all other events. 
It is the responsibility of 
 to report all SUSARs that occur in this trial to competent 
authorities, the institutional review board (IRB), or independent ethics committee (IEC) in 
accordance with the local requirements in force and ICH guideline for GCP. 
All SAEs, SADEs, and USADEs must be reported to the ethics committee and competent 
authority according to local requirements. 
12.2.1.  Serious Adverse Event Reporting Process in Germany 
The Bundesinstitut für Arzneimittel und Medizinprodukte (BfArM) is to be informed about 
events as defined per Medical Device Directive 93/42/EEC, and the Ordinance on Medical 
Device Vigilance Section 3, Sub-section 6. 
The Principal Investigator must report all SAEs and events with SADE potential to the Sponsor 
within 24 hours via the eCRF. Device- and/or procedure-related SAEs and events with SADE 
potential occurring in Germany will be reported individually by the Sponsor to the BfArM 
immediately by using the SAE Form available on the BfArM website. Device- or 
procedure-related SAEs and events with SADE potential occurring in all other countries in this 
trial will be reported by the Sponsor to the BfArM immediately using the European Medical 
Device Vigilance System (MEDDEV) 2.7/3 SAE Reporting Form. Serious adverse events 
deemed unrelated to the device and the procedure, occurring both in Germany and in all other 
countries, will be reported by the Sponsor to BfArM quarterly by using the MEDDEV 2.7/3 SAE 
Reporting Form next to the procedure laid out in the protocol. 
12.2.2. Contact Information 
Pharmacovigilance for this trial is outsourced to 
; refer to Appendix A for contact 
details. 
12.3. Follow-up of Adverse Events 
The investigator must record follow-up information on the eCRF for nonserious adverse event 
and on the SAE form for serious adverse events. Follow-up questions to investigators regarding 
serious adverse events are queried directly by 
 to the investigator.  
Follow-up information must be reported according to the following: 
• 
SAEs: All SAEs must be followed until the outcome of the events is “recovered/resolved,” 
“recovered/resolved with sequelae,” or “fatal,” and until all queries have been resolved. 
Cases of chronic conditions, cancer, or AEs that are ongoing at time of death (where death is 
due to another AE) may be closed with the outcome “recovering/resolving” or “not 
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recovered/not resolved.” Cases can be closed with the outcome of “recovering/resolving” 
when the patient has completed the follow-up period and is expected by the investigator to 
recover. 
The SAE follow-up information should only include new (e.g., corrections or additions) 
information and must be reported within 24 hours of the investigator's first knowledge of the 
information. This is also the case for previously nonserious AEs which subsequently become 
SAEs.  
• 
Nonserious AEs: Nonserious AEs must be followed until the outcome of the event is  
“recovered/resolved,” or “recovered/resolved with sequelae” or until the end of the follow-
up period stated in the protocol, whichever comes first, and until all queries related to these 
AEs have been resolved. Cases of chronic conditions, cancer, or AEs that are ongoing at 
time of death (where death is due to another AE) may be closed with the outcome of 
“recovering/resolving” or “not recovered/not resolved.” Cases can be closed with the 
outcome of “recovering/resolving” when a patient has completed the follow-up period and is 
expected by the investigator to recover or if the patient continues in the extension trial.  
If a potential hypersensitivity reaction is observed, additional blood samples, as clinically 
indicated, may be required to further characterize the potential hypersensitivity reaction. If an 
anaphylactic shock is suspected, samples may be taken for the measurement of tryptase. In this 
case, a blood sample should be taken 3 to 4 hours after the event and again approximately 
1 to 2 weeks later to determine tryptase baseline levels. In addition, assessments for elevated 
histamine levels may be considered. 
The investigator must ensure that the worst-case severity and seriousness of an event is kept 
throughout the trial, from the start of trial product administration (i.e. the most severe of the 
applied severity/seriousness categories should be ascribed to the event). Accordingly, for AEs 
with onset after trial product administration, changes in the severity or seriousness of an event 
should not lead to reporting of separate AEs. In contrast, for AEs with onset before trial product 
administration, any worsening of severity/seriousness after trial product administration should be 
recorded as a separate AE, with onset date of the event corresponding to the date of the 
severity/seriousness upgrade. Similarly, AEs with onset during the blinded treatment that worsen 
after the switch to the second blinded treatment or to the unblinded treatment, should be recorded 
as separate AEs. 
If an AE is resolved and re-appears later then it should be reported as a new AE. 
Queries or follow-up requests must be responded within 14 calendar days from the date of 
receipt of the request, unless otherwise specified in the follow-up request.  
12.4. Precautions 
Normal precautions taken for a clinical trial, including the provision of emergency equipment, 
will be taken during this trial. Qualified and well-trained physicians and medical staff will 
instruct patients’ parent(s)/guardian. During a patient’s participation in the trial, the investigator 
should ensure that adequate medical care is provided to patients for any AEs, including clinically 
significant laboratory values related to the trial. The investigator should inform the patient’s 
parent(s)/guardian when medical care is needed for intercurrent illnesses of which the 
investigator becomes aware. 
For further information on safety precautions for dasiglucagon, refer to the current version of the 
IB. 
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12.5. Safety Committee 
An internal Zealand Safety Committee is constituted to perform ongoing safety surveillance of 
clinical trials with dasiglucagon, including this trial. 
If safety signals or concerns are observed, whether based on reported SAEs, review of all AEs 
and laboratory parameters reported, or any other notification of significant findings, the Safety 
Committee will respond appropriately to protect the safety of the patients. The Safety Committee 
meets quarterly and on an ad hoc basis as needed. 
12.6. Independent Data Monitoring Committee 
An independent data monitoring committee (DMC) will be established for this trial and follow 
the procedures outlined in the DMC Charter. 
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13. STATISTICS 
13.1. Statistical Hypotheses 
This section details the null hypotheses for this trial. They are presented in the form Hij, where 
i = trial part (i = 1, 2) and j = hypothesis number (j = 1, 2, 3, 4, 5). 
The hypothesis relates to the primary endpoint of mean IV GIR in the last 12 hours of each 
treatment period during Part 1. Formally, the hypothesis is: 
H11:  Mean IV GIR dasiglucagon = Mean IV GIR placebo 
The hypotheses relating to the key secondary endpoints (based on the last 48 hours of each 
treatment period in Part 1) are: 
H12:  Total amount (g) of carbohydrates administered (regardless of the route) per day 
dasiglucagon = total amount (g) of carbohydrates administered (regardless of the route) 
per day placebo 
A fixed-sequence statistical strategy will test first the primary (Section 7.2.1) and then the key 
secondary endpoints of Part 1 (Section 7.2.2), all at the same significance level (α = 0.05, 2-sided 
test), moving to the next hypothesis only after rejecting the previous null hypothesis.  
The test hierarchy is: 
Part 1 
H11: Mean IV GIR in the last 12 hours of each treatment period during Part 1 (primary 
endpoint) 
H12: Total amount (g) of carbohydrates administered (regardless of the route) per day 
(key secondary endpoint) 
13.2. Sample Size Determination 
A total of 12 patients is planned to be randomized and exposed to trial product in this crossover 
trial on the basis of the following considerations. 
The GIR results from 40 infants treated with IV glucagon for 24 hours published in the JIMD 
Research Report “The Effect of Continuous Intravenous Glucagon on Glucose Requirements in 
Infants with Congenital Hyperinsulinism.”14 
“Overall there was a statistically significant reduction in the median (IQR) GIR during the 24h 
following initiation of continuous glucagon infusion compared to 24 h before initiation 
(18.5 (12.9, 22.8) to 11 (6.6, 17.5) mg/kg/min…” 
This trial is powered to detect an effect in GIR for dasiglucagon after 48 hours compared to 
placebo of at least this effect size. Based on the longer infusion and titration of dasiglucagon in 
this trial, this is considered a conservative approach, allowing for some uncertainty when 
translating the published data into a clinical trial setting. Using unpublished individual patient 
data from the above-referenced study, the difference in GIR between the 2 treatment groups is 
assumed to follow a normal distribution. Assuming the true mean difference is 7.5 mg/kg/min 
with a standard deviation of differences of 7.36, the trial will have 89% power using a 1-sample 
t-test with 12 patients randomized to receive either placebo first and then dasiglucagon or vice 
versa. 
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13.3. Analysis Populations 
Three analysis populations have been defined for this trial: 
• 
The Safety Set: defined as all patients administered any randomized treatment. 
• 
The Full Analysis Set (FAS): defined as all patients in the Safety Set who have a valid 
baseline efficacy assessment. Patients will be analyzed according to randomized treatment 
(Part 1) or overall patients (otherwise). 
• 
Per protocol (PP) set: defined as all patients in the FAS without any major protocol 
deviations. Patients will be excluded from the PP set if they do not receive both treatments 
and/or do not have efficacy data available to evaluate the primary endpoint for both 
treatments. 
• 
Pharmacokinetic Set (PK): defined as all patients in the Safety Set who have at least 1 
measurement with quantifiable plasma concentration of dasiglucagon. 
The primary analyses of the primary and key secondary endpoints will be based on the FAS. 
Supportive analyses of the primary and key secondary endpoints will be based on the PP. All 
safety analyses will be based upon the safety analysis set. 
Inclusion in the analysis populations will be determined prior to database lock. 
For the primary endpoint, baseline is defined as the IV GIR rate obtained at the end of the run-in 
period which corresponds to the last value obtained before randomization. During the 24-hour 
run-in period, all non-nutritional carbohydrates and carbohydrate fortification of feeds are 
prohibited as this might impact the GIR level and result in many updates during the run-in 
period. Therefore the IV GIR rate obtained at the end of the run-in period will give a better 
estimate of the stabilized value of GIR. For the second period of the crossover (Part 1), the IV 
GIR is also started at the IV GIR obtained at the end of the run-in period.For the purpose of all 
other efficacy analyses where applicable, baseline is defined as the last measurement prior to the 
start of trial drug administration on Day 1. 
13.4. Statistical Analyses 
This section presents a summary of the planned statistical analyses. A statistical analysis plan 
(SAP) that describes the details of the analyses to be conducted will be finalized prior to database 
lock.  
Unless otherwise indicated, testing of statistical significance will be 2 sided with a significance 
level of α = 0.05. 
Continuous endpoints will be summarized with number (n), mean, standard deviation (SD), 
median, minimum, and maximum. In addition, change from baseline values will be calculated at 
each time point and summarized descriptively; the exception to this is the time of PG within 
prespecified ranges, which will not have a baseline value. For categorical endpoints, descriptive 
summaries will include counts and percentages. 
All data will be presented in the data listings. 
Immunogenicity data will be analyzed descriptively. No statistical tests are planned. Baseline 
ADA-positive patients will be calculated as a percentage of the total number of patients whose 
baseline samples were tested for ADA. Overall ADA incidence, the combined results of 
treatment-induced and treatment-boosted ADA-positive patients will be calculated as a 
percentage of the total number of evaluable patients, excluding baseline positive patients without 
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any samples available after drug administration. Titers will be reported as median and 
interquartile range. 
Graphical presentations of selected endpoints will be prepared and will be outlined in the SAP. 
13.4.1. Trial Patients and Demographics 
13.4.1.1. 
Disposition and Withdrawals 
The numbers of patients randomized, completing, and withdrawing, along with reasons for 
withdrawal, will be tabulated overall and by treatment sequence. The number of patients in each 
analysis population will be reported. 
13.4.1.2. 
Protocol Deviations 
Protocol deviations will be provided in a listing and summarized if appropriate. 
13.4.1.3. 
Demographics and Other Baseline Characteristics 
Demographic and baseline characteristics (including age, sex, race, ethnicity, weight, and length) 
at screening will be summarized using descriptive statistics. No formal statistical analyses will be 
performed. 
Prior and concomitant medications and procedures will be summarized by treatment sequence 
(prior medications and procedures) or treatment and part (concomitant medications and 
procedures), by the number and percentage of patients taking each medication, classified using 
World Health Organization Drug Dictionary Anatomical Therapeutic Chemical classes and 
preferred term (PT). 
13.4.2. Duration of Exposure and Compliance 
Trial drug administration (i.e., amount administered) will be summarized in terms of each 
patient’s mean, mode, and final dose, and in terms of duration of exposure. Descriptive statistics 
for these quantities, including the mean, median, SD, minimum, maximum, and quartiles, will be 
provided by treatment and part. 
13.4.3. Efficacy Analyses 
13.4.3.1. 
Primary Analysis 
The mean IV GIR in the last 12 hours of each treatment period during Part 1 will be analyzed for 
the FAS and PP populations. The hypothesis: 
H11:  Reduction in weighted mean IV GIR dasiglucagon = Reduction in weighted mean 
IV GIR placebo 
will be based the last 12 hours of each treatment period, calculated as a weighted mean across the 
12 hours, taking the actual time periods between the measurements into account (corresponding 
to calculating the area under the curve [AUC] and dividing by the length of the time period, 
i.e., weighted mean IV GIR). The IV GIR endpoint is expressed as glucose in mg/kg/min, i.e., 
data reported from different concentrations of the glucose used for infusion will be transformed 
to this standardized unit prior to analysis. 
The primary analysis is defined by the estimand based on the treatment policy (de-facto) 
strategy, where the actual GIR measurement reported irrespective of adherence to treatment or 
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use of subsequent therapy is used. The reduction in weighted mean IV GIR between placebo and 
dasiglucagon will be estimated. 
The weighted mean IV GIR will be analyzed using a mixed-model regression approach, with 
treatment and period as fixed effects and patient as a random effect. The 2-sided 95% confidence 
interval (CI) for the treatment difference will be calculated from the mixed regression model. 
Missing data will be imputed using the following methodology: if the weighted mean IV GIR is 
missing for the placebo period, it will be imputed using the baseline weighted mean IV GIR; if 
the weighted mean IV GIR is missing for the dasiglucagon period, it will be imputed using the 
placebo-weighted mean IV GIR for that patient. As a sensitivity analysis, the primary endpoint 
will be re-analyzed as follows: 1) using only complete cases (i.e., weighted mean IV GIR is 
non-missing for both placebo and dasiglucagon) and 2) imputing missing weighted mean IV GIR 
using the baseline weighted mean IV GIR and 3) imputing missing dasiglucagon values during 
one period with the placebo value for that patient and imputing missing placebo values with the 
mean values of placebo patients for that period. 
13.4.3.2. 
Key Secondary Analyses 
The hypothesis: 
H12:  Total amount (g) of carbohydrates administered (regardless of the route) per day  
dasiglucagon = total amount (g) of carbohydrates administered (regardless of the route) 
per day placebo  
between the 2 treatment groups will be analyzed by using a mixed-model regression approach, 
with treatment and period as fixed effects and patient as a random effect. The total amount (g) of 
carbohydrates administered (regardless of the route) per day is the sum of the last 48 hours of 
each period in Part 1. 
For the key secondary endpoint, 2-sided 95% CIs for the treatment differences will be estimated 
from the mixed-model. Missing dasiglucagon values during one period will be imputed with the 
placebo value for that patient and missing placebo values will be imputed with the mean values 
of placebo patients for that period. In addition, a sensitivity analysis will be performed using 
complete cases. 
13.4.3.3. 
Secondary and Other Efficacy Analyses 
Part 1 
A mixed-model regression approach will be used to analyze the weighted mean IV GIR over 48-
hour treatment period during Part 1 (dasiglucagon or placebo administration) similar to the 
primary analysis for the primary endpoint. 
A generalized estimating equation (GEE) method with a logit link function will be used to 
analyze the weighted mean IV GIR below 10 mg/kg/min in the last 12 hours of each treatment 
period during Part 1 (yes/no) (dasiglucagon or placebo administration) to account for repeated 
observations in patients. In case of non-convergence, a Mc Nemar test will be used. 
No sensitivity analysis will be used on these endpoints. 
Part 2 
Due to the potential impact of pancreatectomy on the secondary endpoints during Part 2, any 
endpoint assessment after pancreatectomy will not be included in the primary analyses 
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(endpoints set to missing after pancreatectomy). Sensitivity analyses will be run on those 
endpoints including all assessments in the descriptive analyses. 
For Part 2 efficacy endpoints, continuous and categorical endpoints will be presented using 
summary statistics or frequencies, respectively; no formal testing will be performed. For the time 
to complete weaning off IV GIR, the time to actual hospital discharge and the time to pancreatic 
surgery, Kaplan-Meier curves will be produced. 
13.4.4. Safety and Tolerability Analyses 
Safety analyses will be conducted using data from the Safety Population (as defined in 
Section 13.3). Safety assessments will include the evaluation of AEs; clinical laboratory 
assessments (hematology, biochemistry, and ADAs); vital signs, physical examinations; ECGs, 
echocardiography, and local tolerability issues. No formal inferential analyses will be conducted 
for safety variables, unless otherwise noted. 
Baseline is defined as the last nonmissing assessment before the first exposure to trial drug in the 
trial. 
All safety analyses will be summarized by treatment received within treatment period and part 
and by trial visit, if applicable. 
13.4.4.1. 
Adverse Events 
Adverse events will be coded using the most current version of MedDRA.  
A treatment-emergent AE is defined as an AE with an onset at the time of or following the start 
of treatment with the trial drug through the Follow-up Visit or Early Termination Visit, 
whichever occurs first. 
The number and percentage of patients with AEs, as well as the number of AEs, will be 
displayed by system organ class, PT, and treatment group. The incidence of AEs will also be 
presented by severity and relationship to the trial drug. Serious AEs, AESIs and AEs resulting in 
discontinuation of trial drug will be summarized separately in a similar manner. Patient listings 
of AEs, SAEs, AESIs, and AEs causing discontinuation of trial drug and withdrawal from the 
trial will be produced. 
13.4.4.1.1. 
Serious Adverse Events Associated with Devices  
The number and percentage of patients with SADEs, as well as the number of SADEs, will be 
displayed by system organ class, PT and treatment group. Patient listing of SADEs will include 
information whether it was expected (yes/no), identification of the study device or a device 
procedure to which the SAE is considered related and will be produced in addition to listings of 
SADEs causing discontinuation of trial drug and withdrawal from the trial. 
Similar listings will be prepared for ADEs reported in German patients. 
13.4.4.2. 
Clinical Laboratory Evaluations 
Descriptive summaries (mean, SD, median, minimum, and maximum) of actual (absolute) values 
and changes from baseline values will be presented for clinical laboratory values. 
The number of patients with clinical laboratory values categorized as below, within, or above 
normal ranges will be tabulated showing change from baseline (shift tables) for each clinical 
laboratory analyte.  
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Laboratory values that are outside the normal range will also be flagged in the data listings, 
along with corresponding normal ranges. Any out-of-range values that are identified by the 
investigator as being clinically significant will also be shown in a data listing. 
13.4.4.3. 
Vital Signs 
Descriptive summaries (mean, SD, median, minimum, and maximum) of actual values and 
changes from baseline will be calculated for systolic blood pressure, diastolic blood pressure, 
heart rate, respiratory rate, and SpO2. 
The number of patients with vital signs values categorized Abnormal, Clinically Significant or 
Abnormal, Not Clinically Significant will be tabulated showing change from baseline (shift 
tables) for each parameter. 
13.4.4.4. 
Twelve-lead Electrocardiograms 
The number and percentage of patients with normal and abnormal ECG findings will be 
summarized. Abnormal results will be grouped as Abnormal, Clinically Significant or Abnormal, 
Not Clinically Significant. 
13.4.4.5. 
Echocardiograms 
The number and percentage of patients with normal and abnormal echocardiogram findings will 
be summarized. Abnormal results will be grouped as Abnormal, Clinically Significant or 
Abnormal, Not Clinically Significant. 
13.4.4.6. 
Physical Examination Findings 
The number and percentage of patients with normal and abnormal findings in the complete 
physical examination will be displayed. 
13.4.4.7. 
Local Tolerability 
The number and percentage of patients with local tolerability findings, collected separately from 
AEs, will be summarized. 
13.4.5. Interim Analysis 
No interim analysis is planned.  
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14. TRIAL CONDUCT 
The accuracy and reliability of data are ensured, among others, by the selection of qualified 
investigators and appropriate trial sites, review of protocol procedures with the investigator and 
associated personnel before the trial, periodic monitoring visits, and meticulous data 
management. 
14.1. Sponsor and Investigator Responsibilities 
14.1.1. Sponsor Responsibilities 
The sponsor is obligated to conduct the trial in accordance with strict ethical principles 
(Section 16). The sponsor reserves the right to terminate participation of a trial site at any time 
(Section 14.7), and/or to discontinue the trial (Section 14.6 for US studies and Section 14.6.2 for 
studies conducted outside of the US). 
The sponsor agrees to provide the investigator with sufficient material and support to permit the 
investigator to conduct the trial according to the trial protocol. 
14.1.2. Investigator Responsibilities 
By signing the Investigator’s Agreement (Section 18.2), the investigator indicates that he/she has 
carefully read the protocol, fully understands the requirements, and agrees to conduct the trial in 
accordance with the procedures and requirements described in this protocol. 
The investigator also agrees to conduct this trial in accordance with all laws, regulations, and 
guidelines of the pertinent regulatory authorities, including the November 2016 ICH Guidance 
for Industry E6(R2) GCP, and in agreement with the 2013 version of the Declaration of Helsinki. 
While delegation of certain aspects of the trial to subinvestigators and trial coordinators is 
appropriate, the investigator will remain personally accountable for closely overseeing the trial 
and for ensuring compliance with the protocol and all applicable regulations and guidelines. The 
investigator is responsible for maintaining a list of all persons that have been delegated 
trial-related responsibilities (e.g., subinvestigators and trial coordinators) and their specific 
trial-related duties. 
Investigators should ensure that all persons who have been delegated trial-related responsibilities 
are adequately qualified and trained in the protocol, trial drugs handling, and their specific duties 
within the context of the trial. Investigators are responsible for providing the sponsor with 
documentation of the qualifications, GCP training, and research experience for themselves and 
their staff as required by the sponsor and the relevant governing authorities. 
To ensure compliance with the guidelines, the trial may be audited by an independent person. 
The investigator agrees, by written consent to this protocol, to cooperate fully with compliance 
checks by allowing access to all trial documentation by authorized individuals. 
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14.2. Site Initiation 
Trial personnel may not screen or enroll patients into the trial until after receiving notification 
from the sponsor or its designee that the trial can be initiated at the trial site. The trial site will 
not be authorized for trial initiation until: 
1. The trial site has received the appropriate IRB/IEC approval for the protocol and the 
appropriate ICF. 
2. All regulatory documents have been submitted to and approved by the sponsor or its 
designee. 
3. The trial site has a Clinical Trial Agreement in place. 
4. Trial site personnel, including the investigator, have participated in a trial initiation meeting. 
The regulatory documents must be received from the investigator before the sponsor will 
authorize shipment of trial drug to the trial site, Regulatory Green Light. Copies of the 
investigator’s regulatory documents must be retained at the trial site in a secure location in the 
ISF. Additional documents, including a copy of the protocol and applicable amendment(s), the 
dasiglucagon IB, eCRF completion guidelines, copies of regulatory references, copies of 
IRB/IEC correspondence, and trial drug accountability records should also be retained in the ISF. 
It is the investigator’s responsibility to ensure that copies of all required regulatory documents 
are organized, current, and available for inspection. 
14.3. Screen Failures 
Patients who fail inclusion and/or exclusion criteria may be rescreened for the trial upon 
approval by the sponsor and medical monitor. Patients may only be rescreened once 30 days or 
more after the original Screening Visit. If a patient is eligible to enter the trial after having 
previously failed screening, the patient will be assigned a new patient identification number. 
14.4. Trial Documents 
All documentation and material provided by the sponsor for this trial are to be retained in a 
secure location and treated as confidential material. 
14.4.1. Investigator’s Regulatory Documents 
The regulatory documents will be maintained by the investigator in the ISF. 
14.4.2. Case Report Forms 
By signing the Investigator’s Agreement (Section 18.2), the investigator agrees to maintain 
accurate eCRFs and source documentation as part of the case histories for all patients who sign 
an ICF. 
Case report forms are considered confidential documents and should be handled and stored 
accordingly. The sponsor or its designee will provide the necessary training on the use of the 
specific eCRF system used during the trial to ensure that the trial information is captured 
accurately and appropriately. 
To ensure data accuracy, eCRF data for individual patient visits should be completed as soon as 
possible after the visit. All requested information must be entered in the EDC system according 
to the completion guidelines provided by the sponsor or its designee. 
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The eCRF must be signed by the investigator or a subinvestigator when all data are entered and 
cleaned. These signatures serve to attest that the information contained in the eCRF is accurate 
and true. 
14.4.3. Source Documents 
Information recorded in the eCRF should be supported by corresponding source documentation. 
Examples of acceptable source documentation include, but are not limited to, hospital records, 
clinic and office charts, laboratory notes, and recorded data from automated instruments, 
memoranda, and pharmacy dispensing records. 
Clinical laboratory data required by the protocol will be entered into the eCRF at the site. 
The investigator should permit trial-related monitoring, IEC review, regulatory inspections, and 
sponsor audit by providing direct access to source data and documents. 
14.5. Data Quality Control 
The sponsor and its designees will perform quality control checks on this clinical trial. 
14.5.1. Monitoring Procedures 
The sponsor and/or its designee will conduct site visits to monitor the trial and ensure (i) the 
safety and rights of the patients are respected, (ii) compliance with the protocol, GCP, and 
applicable regulations and guidelines, and (iii) that accurate, valid, and complete data are 
collected. The assigned CRA(s) will visit the investigator and trial site at periodic intervals and 
maintain periodic communication, this are described in detail in the Monitoring Plan. The 
investigator agrees to allow the CRA(s) and other authorized sponsor personnel access to ISF 
and source data (original documents, data, and records). The CRA(s) will maintain current 
personal knowledge of the trial through observation, review of trial records and source 
documentation, and discussion of the conduct of the trial with the investigator and staff. While 
on site, the CRA(s) will review: 
• 
regulatory documents 
• 
entries in the EDC system compared with the source documents 
• 
consents  
• 
adherence to the inclusion/exclusion criteria 
• 
AE records 
• 
storage and accountability of trial drug and trial materials 
• 
adherence to the protocol and ICH-GCP 
The CRA(s) will ask for clarification and/or correction of any noted inconsistencies. Procedures 
for correcting eCRFs are described in the Trial Reference Manual. As representatives of the 
sponsor, CRAs are responsible for notifying project management of any noted protocol 
deviations. 
By signing the Investigator’s Agreement (Section 18.2), the investigator agrees to meet with the 
CRA(s) during trial site visits; to ensure that trial staff is available to the CRA(s) as needed; to 
provide the CRA(s) access to all trial documentation, to the clinical supplies dispensing and 
storage area; and to assist the monitors in their activities, if requested. Further, the investigator 
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agrees to allow the sponsor or designee auditors or inspectors from regulatory agencies to review 
records, and to assist the inspectors in their duties, if requested. 
14.5.2. Data Management 
The sponsor or designee will be responsible for activities associated with the data management 
of this trial. The standard procedures for handling and processing records will be followed per 
GCP and Premier standard operating procedures. A comprehensive data management plan will 
be developed, including a data management overview, description of database contents, 
annotated eCRF, pre-entry review list, self-evident correction conventions, query contacts, and 
consistency checks. 
Trial site personnel will be responsible for providing resolutions to all data queries. The 
investigator will be required to document electronic data review to ensure the accuracy of the 
corrected and/or clarified data. Procedures for soliciting and documenting resolution to data 
queries are described in the trial manual. 
14.5.3. Quality Assurance/Audit 
This trial will be subject to audit by the sponsor/its designee or national/international regulatory 
authorities. Audits may be performed to check compliance with GCP guidelines, and can 
include: 
• 
site audits 
• 
trial master file audits 
• 
database audits 
• 
document audits (e.g., protocol and/or the clinical trial report [CTR]) 
The sponsor or its designee may conduct additional audits on a selection of trial sites, requiring 
access to patient notes, trial documentation, and facilities or laboratories used for the trial. 
The trial site, facilities, all data (including source data), and documentation will be made 
available for audit by quality assurance auditors and for IRB/IEC or regulatory authorities 
according to GCP guidelines. The investigator agrees to cooperate with the auditor during the 
visit and will be available to supply the auditor with eCRFs or other files necessary to conduct 
that audit. Any findings will be strictly confidential. 
If a regulatory authority informs the investigator that it intends to conduct an inspection, the 
investigator shall notify the sponsor immediately. 
14.6. Trial Termination 
The trial may be terminated at the sponsor’s discretion at any time and for any reason. 
14.6.1. Regular Trial Termination 
The end of this trial is defined as the date of the last visit of the last patient (last patient out or 
last patient last visit) participating in the trial. Within 90 days of the end of the clinical trial, the 
sponsor or its designee and/or site will notify the IRBs and IECs and regulatory authorities on the 
regular termination of the trial as required according to national laws and regulations.  
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14.6.2. Premature Trial Termination 
The trial may be terminated prematurely for any reason and at any time by the sponsor, the 
IRBs/IECs, regulatory authorities, respective steering committees, or the coordinating 
investigator. A decision to terminate the trial prematurely is binding to all investigators at all trial 
sites. 
Within 15 days of premature termination of a clinical trial, the sponsor or its designee and/or site 
will notify the IRBs/IECs and regulatory authorities on the premature termination as required 
according to national laws and regulations. The sponsor or its designee must clearly explain the 
reasons for premature termination. 
If the trial is terminated prematurely, all investigators must inform their patients and take care of 
their appropriate follow-up and further treatment to ensure protection of their interests. Trial sites 
may be asked to have all patients currently participating in the trial complete all of the 
assessments for an Early Termination Visit. 
14.7. Trial Site Closure 
At the end of the trial, all trial sites will be closed. The sponsor may terminate participation of a 
trial site at any time. Examples of conditions that may require premature termination of a trial 
site include, but are not limited to, the following: 
• 
Noncompliance with the protocol and/or applicable regulations and guidelines 
• 
Inadequate patient enrollment 
14.7.1. Record Retention 
After trial completion at sites in the US, the investigator shall retain and preserve 1 copy of all 
data generated in the course of the trial, specifically including, but not limited to, those defined 
by GCP as essential until: 
• 
At least 2 years after the last marketing authorization for the trial drug has been approved or 
the sponsor has discontinued its research with the trial drug, or 
• 
At least 2 years have elapsed since the formal discontinuation of clinical development of the 
trial drug 
However, these documents should be retained for a longer period if required by the applicable 
regulatory requirement(s) or if needed by the sponsor. 
At the end of such period, the investigator shall notify the sponsor in writing of his or her intent 
to destroy all such material. The sponsor shall have 30 days to respond to the investigator’s 
notice, and the sponsor shall have a further opportunity to retain such materials at the sponsor’s 
expense. 
After trial completion at sites in Europe, the sponsor will receive a copy of their data in 
electronic format (e.g., CD) and retain them for at least 25 years. 
One copy will remain with the investigator. The investigator shall arrange for the retention of the 
patient identification codes, patient files, and other source data until at least 5 years after the last 
approval of a marketing application in an ICH region and until there are no pending or 
contemplated marketing applications in an ICH region, or until at least 2 years have elapsed 
since the formal discontinuation of the clinical development of the product. These documents 
need to be retained for a longer period of time if required by applicable regulatory authorities or 
by agreement with the sponsor. 
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The investigator shall keep copies of these trial records (and all trial-related documents, 
including source data) for the maximum period of time permitted by the hospital, institution, or 
private practice. 
14.7.2. Sample Retention 
Samples will only be used for purposes related to this trial. 
All blood samples will be destroyed upon completion of the CTR, except for residual ADA 
samples, which will be stored until approval of market authorization because further 
characterization of the antibody response may be requested by the health authorities. Identifiable 
samples can be destroyed at any time at the request of the patient. 
14.8. Changes to the Protocol 
This protocol cannot be altered or changed except through a formal protocol amendment, which 
requires the written approval of the sponsor. The protocol amendment must be signed by the 
investigator and approved by the IRB/IEC before it may be implemented. Protocol amendments 
will be filed with the appropriate regulatory agency(s) having jurisdiction over the conduct of the 
trial. 
14.9. Use of Information and Publication 
All information concerning dasiglucagon, the sponsor’s operations, patent applications, 
formulae, manufacturing processes, basic scientific data, and formulation information supplied 
by the sponsor or its designee to the investigator and not previously published, is considered 
confidential and remains the sole property of the sponsor. Case report forms also remain the 
property of the sponsor. The investigator agrees to use this information for purposes of trial 
execution through finalization and will not use it for other purposes without the written consent 
of the sponsor. 
The information developed in this trial will be used by the sponsor in connection with the 
continued development of dasiglucagon and thus may be disclosed as required to other clinical 
investigators or government regulatory agencies. 
The information generated by this trial is the property of the sponsor. Publication or other public 
presentation of dasiglucagon data resulting from this trial requires prior review and written 
approval of the sponsor. Abstracts, manuscripts, and presentation materials should be provided to 
the sponsor for review and approval at least 30 days prior to the relevant submission deadline.  
It is agreed that the results of the trial will not be submitted for presentation, abstract, poster 
exhibition or publication by the investigator until the sponsor has reviewed and commented on 
such a presentation or manuscript for publication. 
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15. FINAL CLINICAL TRIAL REPORT  
The sponsor will retain ownership of the data. 
The final CTR will be prepared and reviewed in cooperation with the signatory investigator. The 
coordinating investigator will be appointed by the sponsor to review and sign the CTR on behalf 
of all participating investigators. This report will include a summary of the trial results based on 
a statistical evaluation and clinical assessment of the protocol-defined endpoints. 
The final CTR may be submitted to the regulatory authorities. 
16. ETHICAL AND LEGAL CONSIDERATIONS 
16.1. Declaration of Helsinki and Good Clinical Practice 
This trial will be conducted in compliance with the November 2016 ICH Guidance for Industry 
E6(R2) GCP (including archiving of essential trial documents), the 2013 version of the 
Declaration of Helsinki, and the applicable regulations of the country(ies) in which the trial is 
conducted. 
See Appendix B for regulation and guidelines. 
16.2. Patient Information and Informed Consent  
According to the Declaration of Helsinki and ICH GCP, patients’ parent(s)/guardian must 
provide their written informed consent prior to enrollment in a clinical trial and before any 
protocol-specified procedures are performed. Patients’ parent(s)/guardian must declare their 
consent by personally signing and dating the ICF. The written ICF will embody the elements of 
informed consent as described in the Declaration of Helsinki and will also comply with local 
regulations.  
Each patient’s parent(s)/guardian should be made aware by the investigator of the nature of the 
trial (objectives, methods, and potential hazards and benefits) and the procedures involved using 
the information on the ICF. Information should be given in both oral and written form whenever 
possible and deemed appropriate by the IRB/IEC. Patients’ relatives, or, if necessary, legal 
representatives must be given ample opportunity to inquire about details of the trial.  
Patient information and the ICF must be in a language fully comprehensible to the prospective 
patient’s parent(s)/guardian. The written information must be provided to the patient’s 
parent(s)/guardian to give him or her sufficient time to understand the information and to prepare 
questions before being asked for his or her consent. The investigator must confirm that the text 
was understood by the patient’s parent(s)/guardian. The patient’s parent(s)/guardian will then 
sign and date the IRB/IEC-approved consent form indicating that he or she has given his or her 
consent for his or her child to participate in the trial. The signature confirms that the consent is 
based on information that has been understood. The form will also be signed by the investigator 
obtaining the consent and annotated with the trial patient number. Each signed patient 
parent(s)/guardian ICF must be kept on file by the investigator for possible inspection by 
regulatory authorities, the sponsor, and/or the sponsor’s designee. Collection of informed consent 
has to be documented on the eCRF. 
Furthermore, the patient’s parent(s)/guardian will be informed that if he or she wishes to 
drop-out or withdraw his or her child (see Section 9.2.3) at any time during the trial, this will not 
have any negative consequences. Patients may be withdrawn by the investigator if any change 
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related to safety or ethics precludes further participation in the trial. Patients’ parent(s)/guardian 
will be asked to agree to a final assessment in the event of an early termination of the trial. 
If information becomes available that may be relevant to the patient’s willingness to continue 
participating in the trial, the investigator must inform the patients’ parent(s)/guardian in a timely 
manner, and a revised written informed consent must be obtained. 
Patients’ parent(s)/guardian will be informed that data from their children’s case may be stored 
in a computer without inclusion of their name and that such data will not be revealed to any 
unauthorized third party. Data will be reviewed by the monitor, an independent auditor, and 
possibly by representatives of regulatory authorities and/or IRBs/IECs. The terms of the local 
data protection legislation will be applied as appropriate. 
16.3. Approval by Institutional Review Board and Independent Ethics Committee 
For Investigational New Drug studies, the minimum standards of conduct and requirements for 
informed consent are defined in the FDA regulations. 
A valid IRB/IEC must review and approve this protocol before trial initiation. Written 
notification of approval is to be provided by the investigator to the sponsor’s monitor and project 
manager before shipment of investigational drug supplies, and will include the date of the 
committee’s approval and the chairperson’s signature. This written approval must consist of a 
completed sponsor form, IRB/IEC Approval Form, or written documentation from the IRB/IEC 
containing the same information. 
Until written approval by the IRB/IEC has been received by the investigator, no patient may 
undergo any procedure not part of routine care for the patient’s condition. 
Protocol amendments must also be reviewed and approved by the IRB/IEC. Written approval 
from the IRB/IEC, or a designee, must be received by the sponsor before implementation. This 
written approval will consist of a completed IRB Approval Form or written documentation from 
the IRB/IEC containing the same information. 
16.4. Finance and Insurance 
Details on finance and insurance will be provided in a separate agreement between the 
investigator and the sponsor. 
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28. Baumeister FA, et al. Glucose monitoring with long-term subcutaneous microdialysis in 
neonates. Pediatrics2001;108:1187–1192   
29. Kerr D, Hoogma RP, Buhr A, et al. Multicenter User Evaluation of ACCU-Chek® Combo, 
an Integrated System for Continuous Subcutaneous Insulin Infusion. J Diabetes Sci Technol 
2010;4(6):1400 7 
30. Heinemann L, Fleming GA, Petrie JR, et al: Insulin pump risks and benefits: a clinical 
appraisal of pump safety standards, adverse event reporting, and research needs: a joint 
statement of the European Association for the Study of Diabetes and the American Diabetes 
Association Diabetes Technology Working Group. Diabetes Care. 2015;38(4):716 22. 
31. Summary of Safety And Effectiveness Data (SSED) Continuous Glucose Monitoring 
System-FDA PMA 05OCT2012 
 
 
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18. ATTACHMENTS 
18.1. Schedule of Events 
Table 2 
Schedule of Events 
Period 
Screening 
Part 1 (2x48-hr period: double blind, 
randomized, placebo controlled) 
Part 2 (21-day Open-label Active) 
Follow-
upa 
Visit day 
  
1b 
2 
3 
4 
5 
6 
11c 
18c 
25 
Telephone 
Calld  
53 
Time window  
Day -28 to -1 
0 
0 
0 
0 
0 
0 
±2 
±2 
±3 
 
±3 
Visit # 
1 
2 
3 
4 
5 
6 
7 
 
8 
General assessments 
  
  
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/exclusion criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
Randomization exclusion criteria 
 
X 
 
 
 
 
 
 
 
 
 
 
Demography 
X 
 
 
 
 
 
 
 
 
 
 
 
Body weight and lengthe 
Xe 
X 
X  
X  
X  
X 
X 
X 
X 
Xe 
 
 
Medical history (including current 
illnessf) 
X 
 
 
 
 
 
 
 
 
 
 
 
Concomitant medication 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
Safety Assessment 
  
 
 
 
 
 
 
 
 
 
Electrocardiogram 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
Echocardiography 
Xg 
 
 
 
 
 
 
 
 
 
 
X 
Vital signs 
X 
Xh 
Xh 
Xh 
Xh 
Xh 
Xh 
X 
X 
X 
 
X 
Adverse events 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Local tolerabilty 
  
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Physical examination and 
neurological examination 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
Fluid balance assessmenti 
 
Continuous (when receiving IV Glucose) 
 
 
Laboratory 
  
 
 
 
 
 
 
 
 
 
Clinical laboratory testsj 
X 
 
 
 
 
X 
 
 
X 
 
X 
Anti-drug antibodies 
  
Xk 
 
 
 
 
 
 
 
X 
 
Xk 
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Period 
Screening 
Part 1 (2x48-hr period: double blind, 
randomized, placebo controlled) 
Part 2 (21-day Open-label Active) 
Follow-
upa 
Visit day 
  
1b 
2 
3 
4 
5 
6 
11c 
18c 
25 
Telephone 
Calld  
53 
Time window  
Day -28 to -1 
0 
0 
0 
0 
0 
0 
±2 
±2 
±3 
 
±3 
Visit # 
1 
2 
3 
4 
5 
6 
7 
 
8 
Pharmacokinetics/drug exposure 
 
 
 
 
 
Xl 
X 
 
 
X 
 
 
Efficacy 
  
  
 
 
 
 
 
 
 
 
Continuous glucose monitoring 
 X (for 24 hours 
prior to 
randomization) 
 
Continuous 
 
 
Self-monitoring plasma glucose 
 
X 
 
 
IV GIR adjustment 
  
Continuous (until weaned off) 
 
 
Trial Materials and Reminders 
 
 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
 
 
Dispense patient diary 
 
 
 
 
 
 
 
Upon dischargem  
 
 
Diary recording 
 
 
 
 
 
 
 
Continuous after 
discharge from hospital 
 
 
Dispensing of trial product 
 
X 
 
X 
 
X 
 
 
 
 
 
 
Drug accountability 
 
 
 
X 
 
X 
 
X 
X 
X 
 
 
Abbreviations: GIR = glucose infusion rate; IV = intravenous; SOC = standard of care; SpO2 = blood oxygen saturation level 
Note: Unscheduled visits can occur at any time if the investigator deems it necessary for patient safety. 
a 
The Follow-up Visit will only be performed for patients who will not enter the extension trial.  
b After screening, eligible patients will complete a minimum 24-hour run-in period to confirm the IV glucose randomization requirement (≥10 mg/kg/min). All non-nutritional 
carbohydrates and carbohydrate fortification of feeds are prohibited during this 24-hour run-in period.  
c 
Visits 5 (Day 11) and 6 (Day 18) can be converted to phone visits at the investigator’s discretion. 
d Patients who are discharged from the hospital before Day 25 will be contacted by the investigator by telephone the day after discharge. The investigator will ask the 
parent(s)/guardian if they have any questions about the trial procedures and if their child has experienced any AEs. 
e 
Body length will be measured at screening and at the End of Treatment visit. 
f 
For CHI diagnosis: Data on biochemical parameters, genotyping results, and information about PET-CT should be captured when available. 
g An echocardiogram performed within 1 month of screening can be used. 
h Vital signs should be measured at 6 ± 1, 12 ± 2, and 24 ± 4 hours after initiation of the trial drug and every 8 ± 2 hours hereafter.. 
i 
Fluid balance assessments are to be performed and documented every 8 hours as long as the patient is receiving IV glucose.  
j 
Clinical laboratory tests include hematology and biochemistry. 
k Blood test for anti-drug antibodies to be performed prior to dosing. Any anti-dasiglucagon antibody-positive patient (treatment induced or treatment boosted) will be monitored 
at an additional Follow-up Visit preferably 16 weeks after last ADA-positive sample. Patients completing the trial before the ADA screening and confirmatory assays have 
been approved by the FDA and who do not continue treatment in the long-term extension trial will have this additional visit 16 weeks after the end of trial visit (Visit 8). 
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l 
Sampling for drug exposure at Day 5 is only applicable for patients with a body weight of ≥4 kg. This sample should only be collected if it does not compromise the total 
amount of blood drawn according to Section 11.2.3.1. 
m The diary should be dispensed if a patient is discharged from the hospital during Part 2. At subsequent visits, the parent(s)/guardian will return the completed diary and obtain a 
new one. 
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18.2. Investigator’s Agreement 
PROTOCOL 
NUMBER: 
ZP4207-17103 
PROTOCOL TITLE: 
A Randomized Trial in 2 Parts: Double-Blind, Placebo-Controlled, 
Crossover Part 1 and Open-label Part 2, Evaluating the Efficacy and 
Safety of Dasiglucagon for the Treatment of Children with 
Congenital Hyperinsulinism 
FINAL PROTOCOL: 
Version 14.0, 04-Jun-2021 (Germany)  
The undersigned acknowledges possession of and has read the product information (e.g., IB) on 
the trial drug and have discussed these data with the trial monitor. Having considered fully all the 
available information, the undersigned considers that it is ethically justifiable to give the trial 
drug to selected patients in his or her care, according to the trial protocol. 
• 
He or she agrees to use the trial material, including trial drug, only as specified in the 
protocol. He or she understands that changes cannot be made to the protocol without prior 
written approval of Zealand. 
• 
He or she understands that any deviation from the protocol may lead to early termination of 
the trial. 
• 
He or she agrees to report to Zealand within time any clinical AE or abnormal laboratory 
value that is serious, whether or not considered related to the administration of trial drug. 
• 
He or she agrees to comply with Zealand and regulatory requirements for the monitoring 
and auditing of this trial. 
In addition, he or she agrees that the trial will be carried out in accordance with the revised 
Declaration of Helsinki (2013) and the local laws and regulations relevant to the use of new 
therapeutic agents. 
I, the undersigned, have carefully read this protocol and agree that it contains all the necessary 
information required to conduct the trial. 
Principal Investigator: 
 
Printed Name: 
 
 
 
 
 
 
 
 
Signature: 
 
 
 
 
 
 
 
 
Date: 
 
 
 
 
Investigator’s name and address (stamp) 
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19. APPENDICES 
A. 
Address List 
B. 
Regulations and Good Clinical Practice Guidelines 
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A. Address List 
Name: 
 
 
Address: 
 
 
 
E-mail: 
 
Telephone: 
 
Technical Complaints 
Name: 
Zealand Pharma A/S Quality Assurance 
Email: 
 
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B. Regulations and Good Clinical Practice Guidelines 
 Regulations 
Refer to the following United States Code of Federal Regulations (CFR): 
• 
FDA Regulations 21 CFR, Parts 50.20 – 50.27 
Subpart B – Informed Consent of Human Subjects 
• 
FDA Regulations 21 CFR, Parts 56.107 – 56.115 
Part 56 – Institutional Review Boards 
Subpart B – Organization and Personnel 
Subpart C – IRB Functions and Operations 
Subpart D – Records and Reports 
• 
FDA Regulations 21 CFR, Parts 312.50 – 312.70 
Subpart D – Responsibilities of Sponsors and Investigators 
Refer to the following European Directives [and applicable regulations/guidances]: 
• 
European Directive 2001/20/EC and related guidance documents 
• 
European Directive 2005/28/EC and related guidance documents 
 Good Clinical Practice Guidelines 
ICH GCP guidelines can be found at the following URL: 
http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/Efficacy/E6/E6_R2__
Step_4_2016_1109.pdf 
 
 
 
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20. ADDENDUM  
20.1. Administrative Information 
The Coordinating Investigator for Germany is: 
 
 
 
 
 
 
 
 
 
 
A list of all participating investigational sites, including name, address, and professional position 
of the Principal Investigator for each site is maintained in the trial master file.  
20.2. Device Information 
This clinical trial is being conducted solely to investigate the safety and efficacy of dasiglucagon 
usage in children with CHI. More information can be found in Section 6.2. 
This clinical trial is not being conducted to verify claims and new intended performance of the 
medical devices. No risks and device effects will be formally assessed, but only collected and, if 
appropriate, reported to the applicable bodies. The planned devices are only being used for the 
administration of dasiglucagon and to measure glucose levels since no other approved devices 
are available as an alternative for this rare disease. The protocol will be submitted to competent 
authorities and ethics committees for approval. If additional requirements are imposed by these 
bodies, those recommendations will be followed. 
20.2.1. Planned Devices 
20.2.1.1. 
Pump System Accu-Chek Spirit Combo  
The planned drug delivery pump Accu-Chek Spirit Combo System with its components as 
described in Section 10.3 will be used to administer the investigational drug dasiglucagon. The 
Accu-Chek Spirit Combo Pump is a portable, battery-operated pump indicated for subcutaneous 
or intraperitoneal continuous delivery of insulin for the management of diabetes mellitus in 
persons requiring insulin as prescribed by a physician. It is a CE-marketed Class IIb product 
under the EC directive 92/42/EEC and is also in conformity with the EU directive 1999/5/EC on 
radio and telecommunications terminal equipment. The manufacturer is Roche Diabetes Care 
GmbH, Sandhofer Str. 116, 68305 Mannheim - Germany.  
The pump system consists of the following components: 
• 
Programmable Accu-Chek Spirit Combo pump with a display screen 
• 
Adapter that connects the cartridge to the infusion set 
• 
Batteries and battery key 
• 
Sterile disposables: 
o Accu-Chek Spirit 3.15-mL cartridge with luer-lock connection 
o Infusion sets:  
▪ 
Accu-Chek FlexLink Infusion set  
▪ 
Accu-Chek Ultraflex 
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▪ 
Accu-Chek LinkAssist insertion tool 
▪ 
Accu-Chek Rapid-D Link Infusion set cannula 
▪ 
Accu-Chek Rapid-D Transfer Set 
The single-use disposable infusion sets and sterile cartridges are packed in sealed pouches and 
are sterilized with ethylene oxide. Pictures of the pump and system components are provided in 
the ZP4207-17103 Trial Materials Manual for further information. Additional available 
accessories for the Accu-Check Spirit Combo System are an alcantara pouch in black and a 
neoprene pouch in white with a belly belt. 
The trial sites will be supplied with the pumps and their components and will be asked to 
document receipt of this equipment. Each pump will be identified by a serial number that will be 
used for accountability and traceability; the device will be labelled “for investigational use only.” 
The trial sites must store the devices in a secure area with restricted access and at the storage 
conditions indicated in the user manual (+5°C – 45°C). After a patient is enrolled into the trial, 
one (1) pump device will be allocated exclusively to this patient; disposables are not accounted 
for. Upon completion of the trial and if the patient is not continuing in the ZP4207-17106 trial, 
the pump must be returned to the site. The site will ship all returned pumps (with the exception 
of those continuing in 17106 trial) back to the sponsor upon completion of the trial. 
The Roche pump is CE-marked and marketed in Germany, and it can administer very low doses. 
The pump is designed to deliver 0.05 to 25.0 units of U-100 insulin per hour in basal rates, which 
corresponds to 2 to 1000 μg dasiglucagon per hour. This dosing accuracy allows reliable dosing 
of dasiglucagon between 10 and 70 μg per hour in the clinical trial. Further, this pump has been 
used in pediatric diabetes treatment in the EU since 2010. However, the Accu-Chek Spirit 
Combo pump system will not be used within its approved indication. The pump will be used for 
the administration of the investigational glucagon analogue dasiglucagon for the indication of 
CHI. Additional compatibility testing and assessments were performed to ensure that the 
Accu-Check Spirit Combo pump system and its components are not adversely affected by using 
dasiglucagon instead of insulin. Also, testing was performed to ensure that dasiglucagon is stable 
and effective when administered via this pump system. The general management of the device, 
as well as the duration of contact of the pump material and infusion sets with human tissue, will 
be based on the approved intended use of the device. The complete infusion set will be changed 
every 2 days (48 hours) for the Accu-Chek Rapid-D link infusion set, and every 3 days 
(72 hours) as a maximum for the Accu-Chek FlexLink infusion set. Only the application and 
dosage of dasiglucagon via the Accu-Chek pump system requires an off-label change in practice 
compared to the procedure described in the general instruction for use for Accu-Chek Spirit 
Combo pump system. The pump is programmed to reflect doses of insulin in units (U), whilst 
dasiglucagon requires weight-based dose administration (μg). The site staff and the patient’s 
parent(s)/guardian(s) will be instructed on the procedures for filling the content of the trial drug 
vials into the cartridge to be used in the infusion pump and how to convert dasiglucagon (μg) 
into units (U) as shown on the pump display. For this purpose an extensive, trial-specific 
instruction for use was developed to accommodate the training of site staff and the patient’s 
parent(s)/guardian(s) as described in Section 10.12.  
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20.2.1.2. 
Self-Monitoring Plasma Glucose StatStrip Xpress2 
To assess plasma glucose levels and events of hypoglycemia, SMPG measurements will be 
taken. The plasma glucose level will be assessed at least 3 times daily and in cases of suspected 
hypoglycemia throughout the trial.  
The hand-held StatStrip Xpress2 meter GLU/KET from Nova Biomedical is to be used to 
measure glucose and ketone levels in the design of the trial. The ketone measurement will only 
be performed by trial staff when the patient is in the clinic.  
The SMPG meter manufactured by Nova Biomedical is a small (size of 98.0 × 64.0 × 22.9 mm 
and a weight of 78.5 g) battery-powered meter. Blood sample strips are inserted and glucose (in 
mg/dl or mmol/L) and ketone values (in mmol/l) will be displayed on the screen. Function and 
data selection are done by choosing 1 of 3 buttons. Up to 400 measurements can be stored in the 
device memory. 
The test strip is designed with an electrode that measures glucose levels. Glucose in the blood 
sample mixes with reagent on the test strip, which produces an electric current. The amount of 
current that is produced depends on the amount of glucose in the blood. The electrical current is 
detected by the monitor and displayed as the glucose value. The test strip is designed such that 
when a drop of blood touches the end of the strip, the blood is drawn into the reaction space via 
capillary action. Test strips are available in cartons of 100 strips: 50 strips/vial. Additionally a 
QC control glucose/ketone solution is provided to test device functionality. 
The manufacturer Nova Biomedical Corporation, 200 Prospect Street, Waltham, MA 
02454-9141 – USA (European Authorized Representative Nova Biomedical U.K.; Innovation 
House Aston Lane South, Runcorn, Cheshire WA7 3FY, UK) have self-declared conformity 
with the EU Directive 98/79/EC In Vitro Diagnostic Medical Device Directive. This SMPG 
device is marketed as an In Vitro Diagnostic Device. The SMPG device is intended for in-vitro 
diagnostic use by health care professionals and for point-of-care usage in the quantitative 
measurement of glucose in fresh capillary, venous, arterial, and neonate whole blood; it can also 
be used for quantitative determination of beta-hydroxybutyrate-ketone in fresh capillary and 
venous blood samples. It is not intended for diagnosing or screening for diabetes. 
The SMPG device is reusable with single-use test strips. The SMPG device is not sterile; 
however, the strips themselves are in sterile packaging. Once the vial containing the strips is 
opened, the single strips may be used for 180 days or until the expiration date printed on the 
label has been reached, whichever comes first. The patient’s blood will be drawn via single-use 
lancing devices and a drop is applied to the strip. The strip is then inserted into the device and the 
glucose level is displayed.  
The rationale for selecting this device for the clinical trial is that this blood glucose meter is the 
only one approved for use in neonates in an intensive care unit setting, based on its accuracy and 
extensive testing for possible concomitant medication interference. No BG meter for use by lay 
person in the home care setting is approved for the age group <1 year. To ensure consistency of 
data between the hospitalized and home-care periods in the trial, it was deemed preferable to 
continue with the same BG meter, rather than change to ones approved for use by lay persons in 
home-care settings, but that were not approved for this specific age group. 
The trial sites will be supplied with the StatStrip Glucose Xpress2 meter and the StatStrip 
Glucose and ketone test strips by the sponsor, and are asked to document the receipt of the 
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material. Each SMPG is identified by a serial number that will be used for accountability and 
traceability and the device is labelled as “for investigational use only.” The trial sites are asked to 
store the devices in a secure area with restricted access at the storage conditions indicated in the 
user manual (+1°C – 30°C); the QC Control GLU/KET solution must be stored between +15 –
30°C. After a patient is enrolled into the trial, 1 SMPG device is exclusively allocated to that 
patient; disposable accessories are not accounted for. Upon completion of the trial and if the 
patient is not continuing in the ZP4207-17106 trial, the SMPG device has to be returned to the 
site. The site will ship all returned SMPG devices back to the sponsor upon completion of the 
trial. 
The same SMPG StatStrip Glucose Xpress2 meter will be used for each enrolled patient during 
the hospital stay and at home. The home assessments will be performed by the 
parent(s)/guardian(s); however, the use of the device by a lay-person is outside the intended 
purpose. The risk resulting from this deviation from the intended purpose will be minimized by 
offering extensive training of the parent(s)/guardian(s) by the site staff, before independent 
measurements are performed.  
Upon return to the site, the SMPG data will be uploaded to a tablet provided to the site 
personnel. The trial tablet is loaded with the applicable software for sending the SMPG data to 
the Vitalograph Web Portal.  
20.2.1.3. 
Dexcom G6 Continuous Glucose Monitoring System 
In Germany, only the Dexcom G6 CGM will be used. The Dexcom G6 is indicated for detecting 
trends and tracking patterns in patients (aged 2 and older) with diabetes. The system is intended 
for use by patients at home and in healthcare facilities. It is designed to replace fingerstick blood 
glucose testing for diabetes treatment decisions. The system aids in the detection of episodes of 
hyperglycemia and hypoglycemia, facilitating both acute and long-term therapy adjustments, 
which may minimize their excursions. Interpretation of CGM results should be based on the 
trends and patterns noted in several sequential readings over time. 
The G6 system components include the following:  
• 
Sensor (Disposable) – comprises a sensor applicator, an adhesive pad, transmitter mount, 
and the sensor probe. The sensor can be worn for up to 10 days. The sensor is a sterile 
device inserted by the user into the subcutaneous tissue of the abdomen or buttucks using 
the applicator for that purpose. The applicator is attached to the surface of the skin with a 
standard medical grade adhesive pad. The applicator is a 26-gauge introducer needle that 
contains the sensor probe. The needle is not exposed, or even visible, to the user during the 
insertion process. After deployment of the introducer needle, the needle is retracted back 
into the applicator. The sensor probe remains beneath the surface of the skin and uses the 
enzyme glucose oxidase to convert the glucose in the interstitial fluid around the sensor into 
an electrical current proportional to the ambient glucose concentration. The applicator is 
detached and discarded by the user, exposing a transmitter mount ready for placement of the 
transmitted current and signal. 
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• 
Transmitter – The G6 transmitter transmits data with Bluetooth wireless technology. After 
sensor insertion and removal of the applicator, the user manually places the transmitter into 
the transmitter mount on the adhesive pad already attached to the skin. The transmitter 
contains all the electrical circuitry necessary for the operation of the electrochemical sensor 
and to transmit the sensor signal to the receiver via Bluetooth wireless technology. The 
transmitter collects the small electrical current from the sensor and transmits the sensor 
signal wirelessly to the receiver at regular 5-minute intervals. The transmitter is reusable and 
can be used for repeated 10-day sessions by a single user for up to three months. 
• 
Receiver – The G6 receiver is a small hand-held device that receives the Bluetooth wireless 
technology signals from the transmitter. The receiver contains a rechargeable battery. In 
typical use, the receiver may last approximately 2 days before requiring recharging. The 
user must maintain the receiver within 6 meters or less of the transmitter, which is attached 
to the sensor on the body. The receiver also contains calibration and signal processing 
algorithms required to convert the sensor electrical signal to glucose values.  
Other accessories include the following: 
• 
Receiver USB charging / download cable 
• 
Alternating current (AC) power adapter 
• 
User’s guides 
• 
Training checklist 
The manufacturer is Dexcom, Inc. located at 6340 Sequence Drive – San Diego, CA 92121 
United States of America. The European Authorized Representative is MediTech Strategic 
Consultants B.V., Maastrichterlaan 127-129, 6291 EN Vaals, the Netherlands. The following 
device classifications and rules were applied to demonstrate compliance with the Medical Device 
Directives: 
• 
Sensor: Class IIb: Rule 8 according to Annex IX of the MDD 93/42/EEC & 2007/47/EC 
• 
Transmitter: Class IIa, Rule 10 according to Annex IX of the MDD 93/42/EEC and 
2007/47/EC 
• 
Receiver: Class IIb, Rule 10 according to Annex IX of the MDD 93/42/EEC and 
2007/47/EC 
• 
Dexcom G6 Mobile System: Class IIb, Rule 8 according to Annex IX of the 
MDD 93/42/EEC and 2007/47/EC 
The associate notified body is the British Standards Institution. The device has been marketed 
since 2018. 
The system components (applicator, transmitter housing, insertion needle and sensor are sterilized 
via electron beam radiation using the (VD)max25 method. Transmitters and receivers are not sterile 
products. 
The trial sites will be supplied with the Dexcom CGM system by the sponsor and are asked to 
document the receipt of the material. Each CGM is identified by a serial number which will be 
used for accountability and traceability and the device is labelled as “for investigational use 
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only.” The trial sites are asked to store the devices in a secure area with restricted access at the 
storage conditions indicated in the user manual: 
• 
Sensors (+2°C – 25°C) 
• 
Transmitter and receiver (0°C – 45°C)  
After the patient is enrolled into the trial, a CGM device is allocated exclusively to this patient; 
disposable materials are not accounted for. Upon completion of the trial, the CGM must be 
returned to the site. The site will ship all returned CGMs back to the sponsor upon completion of 
this trial.  
Congenital hyperinsulinism is characterized by frequent, often severe episodes of hypoglycemia 
due to over-secretion of insulin regardless of blood glucose. Therefore, CHI closely mimics the 
exogenous insulin overdose occurring in insulin-dependent diabetes management. The 
CGM device is being used in this clinical trial to confirm potential treatment effects on a 
continuous basis.  
The rationale for selecting the Dexcom G6 CGM device for this clinical trial is that it can be used 
in a blinded mode. By using the blinded mode, the patient’s parent(s)/guardian(s) and the 
investigator will not be able to make any treatment decisions or change behavior based on the 
CGM readings. 
The Dexcom G6 CGM system will be used by the patient during the hospital stay, as well as at 
home. For the purpose of this trial the device will be used outside the intended purpose in regard 
to the age of the patients (7 days to 12 months instead of 2 years and older) and in regard to the 
indication (CHI instead of Diabetes). No mechanical or design changes have been made to the 
device. The CGM device is used as intended according to the CE mark, except for the age group 
and the disease. The essential requirements testing performed for CE marking is assessed 
applicable for proposed use. Additionally, literature shows that CGMs have been successfully used 
in infants and neonates.26 The risk resulting from this deviation from the intended purpose, in terms 
of age, will be minimized by offering extensive training to parent(s)/guardian(s) by the site staff, 
before the device and its components are used independently. 
The results of the CGM assessments are blinded for review by patient(s)/parent(s)/guardians and 
trial staff. The display will be visible and the menu functions available for the user, but the display 
will not show any measurements nor will any alarm go off based on the measurements. The 
Dexcom G6 CGM does not require calibration. 
At every patient’s onsite visit, the site staff will transfer data of the CGM device via the CENDUIT 
Data Agent, after the device has been initially registered within the CENDUIT IRT system. Full 
instructions on data transfer are available in the CENDUIT user manual. 
20.2.1.4. 
Other Medical Devices 
The following medical devices will be used within their intended purpose during this trial: 
• 
BD Lancet – BD Microtainer® CAL – contact-activated lancet 
• 
Disinfecting wipes (alcohol pads) 
• 
Disinfecting wipes – Diabete ezy 
The provided devices are disposable; they will be provided to the patient but not accounted for. 
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20.2.2. Risk Evaluation for Off-label Use of Devices 
20.2.2.1. 
Anticipated Clinical Benefit of Planned Devices 
The main aim of this clinical trial is to assess the safety and efficacy of the investigational drug 
dasiglucagon. To achieve this, the Accu-Chek Spirit Combo Pump system, the Self-Monitoring 
Plasma Glucose StatStrip Xpress2 and Dexcom G6 CGM device are utilized in this trial outside 
their intended use. There is no direct clinical benefit anticipated by using the Accu-Chek  Spirit 
Combo Pump except the administration of dasiglucagon and therefore, only an indirect benefit can 
be anticipated, resulting from the drug administration as referenced in Section 6.3.5. The clinical 
benefit of the SMPG is to help to assess if patients undergo hyper/hypoglycemic events requiring 
adjustments to gastric and oral feeds or dose. For the usage of the CGM, there is no direct clinical 
benefit anticipated for the patients, but the CGM data will help to confirm treatment effects 
independent from parents’/guardians’ ability to suspect hypoglycemia.  
20.2.2.2. 
Risks Associated with the Planned Devices and their Control 
A risk analysis according to EN ISO 14971:2012 was performed specifically for risks related to 
the off-label use of the planned devices, to identify and mitigate potential risks due to the off-label 
use of the devices. The analysis rated risks based on their probability of occurrence and the severity 
of their consequence. Unacceptable risk levels were defined and risks, meeting this definition were 
mitigated as far as possible to get to an acceptable level. Results of the risk analysis were entered 
into a risk management report. The identified risks were evaluated and risk mitigation measures 
were and will be implemented throughout this trial. The main task to mitigate the risks is to educate 
site staff, parents and guardians on the proper use of the devices to minimize the risks associated 
with the off-label use. 
The following residual risks were identified, which will be specifically addressed in the planned 
training of the users and thereby risks will be mitigated: 
Accu-Chek® Spirit Combo Pump System and Self-Monitoring Plasma Glucose (SMPG) 
meter (Nova Biomedical / Xpress2 GLU/KET) 
Training will cover the following aspects: 
• 
Recognition of hypo- and hyperglycemia in the patient 
• 
Response to hypo- and hyperglycemia 
• 
Usage of the devices according to the instructions for use in the trial 
• 
Communication between patients/parents/guardians and the medical professionals of the 
trial team. 
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Dexcom G6 Continuous Glucose Monitoring (CGM) device 
The training will cover the following aspects: 
• 
Avoid to cover the sensor by the diaper in babies  
• 
Avoid that the transmitter is grabbed by baby by covering it with bandage or clothes 
• 
Avoid that the transmitter is misplaced under diaper area or child pollutes around diaper 
area 
Additionally, the assessment identified other risks caused by potential Accu-Chek® Spirit Combo 
pump system/drug interaction e.g. unintentional misappropriation of drug delivery or hazards 
caused by direct drug/device interactions. These potential risks were assessed by additional 
compatibility and in-use stability testing and no unacceptable risk was noticed. Flow-rate 
assessments were performed and a conversion table for the use of dasiglucagon in the 
Accu-Chek® Spirit Combo pump system was developed and tested in a Human Factor trial. This 
conversion table was included with further instructions in a trial specific “Instruction for Use”  
for the combination of dasiglucagon with the pump system. By this measure the risk of 
misappropriation of drug delivery was reduced to an acceptable level. 
20.2.2.3. 
Possible Interactions with Concomitant Medical Treatment 
The use of the planned devices is not expected to interfere with other concomitant medical 
treatments, except those treatments referenced in Section 10.11.2. 
20.2.2.4. 
Risk/Benefit Assessment 
At the present time there are no known CE Marked devices intended for the delivery of 
dasiglucagon for the treatment of CHI. Additionally, there are no known devices intended to 
monitor glycemic control in children with CHI. Since there are no devices currently approved to 
treat this condition, off-label use of the Accu-Chek Combo Insulin pump system, Dexcom G6 
CGM and Nova Biomedical / Xpress2 GLU/KET for the purpose of delivering dasiglucagon and 
monitoring glucose levels potentially presents a beneficial alternative to the standard clinical 
practices of current treatment options, continuous gastric infusion and pancreatectomy for 
controlling CHI. 
The most relevant risks resulting from the off-label use in terms of their potential to cause harm in 
relationship to their probability are the following: 
• 
Lay persons using devices which are not used according to their intended use e.g. perform 
and interpret blood glucose measurements 
• 
Lay person applying devices which require invasive procedures at home for very young 
children in skin areas which might be contaminated due to the expectable uncleanliness of 
babies and the fact that they might carry diapers. 
To evaluate the risks and the benefits of the clinical trial, the duration of the trial and the effect of 
the foreseeable risks during the trial period are compared to the current standard of care (SoC) 
treatment for CHI. This comparison is done without taking the possible positive results of the 
trial into account. A positive trial outcome would most likely result in a change in the treatment 
of CHI towards a continuous delivery of dasiglucagon with devices that are proven to be save in 
use by children. 
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In general, the current SoC treatment for patients with CHI bears higher risks than risks 
associated with the clinical trial participation. The current risks associated with the SoC 
treatment result from: 
• 
Continuous application of glucose rich liquids via intravenous infusion (infection, skin 
injury, thrombi, contamination, dosage and content errors, risk of volume overload) 
• 
Frequent tube feedings or gastric infusions 
• 
For patients on diazoxide treatment, the more common side effects comprise hypertrichosis, 
fluid retention, and gastrointestinal symptoms 
• 
For patients on somatostatin analog (octreotide or lanreotide [long acting]) possible side 
effects include necrotizing enterocolitis, gallstones, and hepatitis 
• 
Pancreatectomy (and its related exo/endocrine complications, particularly the development 
of insulin-dependent diabetes) 
• 
Local wound infection  
Irrespective if the patient participates in the planned clinical trial or is treated by SoC, 
parent(s)/guardian(s) need to be able to detect and respond to hypoglycemic events, therefore the 
risk of not noticing such a situation is not increased by participating in the trial. The blood 
glucose measurements are performed by SMPGs, where the general functionality of the device 
can be considered as being equivalent to the proposed Nova Biomedical SMPG. It can be 
concluded, that there will be no additional risks for the clinical trial participants by using the 
Nova Biomedical SMPG compared to patients who do not take part in the clinical trial, provided 
the users are adequately trained.  
The primary objective of this clinical trial is to evaluate the efficacy of dasiglucagon in reducing 
glucose requirements in children with persistent CHI requiring continuous IV glucose 
administration to prevent/manage hypoglycemia. The clinical trial aims to determine practicable 
procedures for treating CHI with dasiglucagon that can eliminate, minimize or postpone the need 
for continuous application of glucose via intravenous infusions, frequent tube feedings or 
continuous gastric infusions and finally, pancreatectomy in the treatment of children with CHI. 
This will significantly reduce the risks for the patient’s health. The nature of the residual risks 
introduced by the off-label use of the devices selected for the clinical trial is similar to the risks 
which already exist in the treatment of these patients and their severity is only minor. The most 
relevant risks result from the usage of the CGM device which is not intended to be used directly 
for the patient care in the trial. However, the duration of the trial will be shorter than the duration 
of the disease or of its long-term side-effects (either of the disease or the treatment). Thus, the 
potential benefit of a positive trial outcome is estimated higher than the risks introduced, 
especially when taking into account the risks which are present by the current SoC treatment of 
CHI. 
20.3. Device-related Safety Section 
20.3.1. Anticipated Adverse Device Effects 
The following anticipated ADEs may be associated with the use of these medical devices, 
together with those associated with the application of dasiglucagon. All AEs and ADEs will be 
assessed if they meet the requirements for competent authority reporting.  
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The following device-related possible complications/AEs are anticipated: 
20.3.2. Pump System Accu-ChekSpirit Combo  
• 
Ketoacidosis, hypo- or hyperglycemic events resulting from incorrect pump usage, a 
damaged pump, or infusion set blockage27,28 
• 
At infusion site: 
- 
Local infection 
- 
Irritation 
- 
Local pain 
- 
Redness  
- 
Swelling 
- 
Lumps 
- 
Heat 
• 
Strangulation if tubing becomes wrapped around the neck 
20.3.3. Self-monitored Plasma Glucose StatStrip Xpress2 
Since the StatStrip Xpress 2 Blood Glucose Monitoring System is intended for use outside the 
body, only the following limited ADEs are expected: 
• 
Hypo- or hyperglycemic events due to incorrect usage or damaged meter or strips 
• 
Indirectly related to SMPG: Local infections caused by the single-use lancing devices to 
obtain blood 
20.3.4. Continuous Glucose Monitoring Dexcom G6 
The following events are possible ADEs of inserting a sensor or wearing the adhesive patch: 
• 
Local infection 
• 
Inflammation 
• 
Pain or discomfort 
• 
Bleeding at the glucose sensor inserting site 
• 
Bruising 
• 
Itching 
• 
Scarring or skin discoloration 
• 
Hematoma 
• 
Tape irritation 
• 
Sensor or needle fracture during insertion, wear of removal 
The following risks are inherent to the device, but not anticipated for the trial since the device 
will be used in a blinded manner and no treatment decisions will be based on the CGM results. 
However, there are potential risks due to missed alerts, false alerts, false-negative hypoglycemia, 
hyperglycemic readings, false-positive hypoglycemia, and hyperglycemia readings by the device. 
There are additional possible risks if the system inaccurately calculates the rate of change of 
glucose.29 
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20.4. Protocol Clarifications 
20.4.1. Informed Consent 
A patient is considered enrolled in the trial as soon as the patients’ parent(s)/guardian(s) 
(according to local law) have signed the EC-approved ICF.  
20.4.2. Vulnerable Population 
As discussed in Section 8.1 children between the ages of 7 days and 12 months with CHI will be 
enrolled in this clinical trial. The informed consent process is referenced in Section 9.2.1, 
Inclusion Criteria, Section 11, Trial Procedures, and Section 16.2, Patient Information and 
Informed Consent. No vulnerable patients other than children are planned to be enrolled in this 
trial and no enrollment under an emergency situation is allowed. 
20.4.3. Addition to Statistical Section 
• 
Drop-out rate: The drop-out rate is expected to be low as the trial period is short and the 
primary endpoint is evaluated within the first 96 hrs after randomization. 
• 
Pass/fail criteria: No pass/fail criteria were defined since no trial endpoints are device 
related. 
• 
Criteria for termination of trial on statistical grounds: N/A. Please refer to 
Section 13.4.5 Interim Analysis. 
• 
Procedures for reporting deviation from statistical plan: Since no medical device data 
will be evaluated statistically, no reporting of deviations from statistical plan are anticipated 
in regard to the devices. 
• 
Enrollment rate per investigational site: Anticipated enrollment for the German clinical 
trial sites is 0 – 5 patients per German site. For analysis involving trial site, if the number of 
patients per site is small, sites may be pooled for analysis, or omitted from statistical 
models. The final determination will be made prior to database lock. 
20.4.4. Protocol Deviations 
A protocol deviation is defined as an event where the investigator or site personnel did not 
conduct the trial according to the protocol. Investigators are not allowed to deviate from the 
protocol unless it is necessary to protect the life or physical well-being of a patient in an 
emergency situation. Those emergency situations or other unforeseen circumstances that are 
beyond the investigator’s control, e.g., the patient did not attend scheduled visits or blood 
samples were lost by the laboratory, are still considered deviations. Deviations will be reported 
to the sponsor, regardless of whether or not they are medically justifiable or done to protect the 
patient in an emergency. All deviations will be reported in a timely manner on a protocol 
deviation form.  
In addition, the investigator is required to adhere to the ethics committee procedures for 
reporting protocol deviations. International regulatory body regulations require that investigators 
maintain accurate, complete, and current records, including documents showing the dates of and 
reasons for each deviation from the trial protocol. The site will receive a list of all site-specific 
deviations upon completion of the trial. 
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Deviations include, but are not limited to the following list: 
• 
Failure to obtain informed consent prior to conducting trial-specific activities 
• 
Incorrect version of patient information and/or ICF used 
• 
Patient did not attend a visit or the visit was outside the required time frame 
• 
Assessments as detailed in the Schedule of Events (Table 2) were not conducted or were 
performed incorrectly 
• 
Adverse events and deficiency with SADE potential not reported by investigators within the 
required timeframe as specified in the protocol 
• 
Source data were permanently lost 
As addressed in Section 14.5.1 of the protocol, the CRA will review the site compliance with 
regard to deviations at each monitoring visit. The monitor will discuss any deviations directly 
with the investigator and will summarize the findings in a follow-up letter to the site.  
If a trial site deviates from the protocol, those deviations will be analyzed and re-training on the 
particular topic(s) will be initiated as appropriate, e.g., training on the informed consent process, 
training on visit window adherence, and planned assessments, etc. Such trainings will be 
documented on the training logs for the applicable roles. If despite all training efforts an 
investigational site continues to deviate from the trial protocol, a site can be discontinued from 
the trial as agreed upon by the Principal Investigator according to his or her signature on the 
Investigator’s Agreement in Section 18.2. 
 
 
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PROTOCOL 
 
PRODUCT 
NAME/NUMBER: 
Dasiglucagon 
PROTOCOL NUMBER: 
ZP4207-17103 
IND NUMBER: 
135869 
EUDRACT NUMBER: 
2017-004545-24 
DEVELOPMENT PHASE: 
Phase 2/3 
PROTOCOL TITLE: 
A Randomized Trial in 2 parts: Double-Blind, Placebo-
Controlled, Crossover Part 1 and Open-label Part 2, Evaluating 
the Efficacy and Safety of Dasiglucagon for the Treatment of 
Children with Congenital Hyperinsulinism 
PROTOCOL DATE: 
Original Protocol Version 1.0, 14-Dec-2017 
Final Version 13.0, 04-Jun-2021 (All countries except 
Germany) 
SPONSORED BY: 
Zealand Pharma A/S 
Sydmarken 11 
2860 Soeborg (Copenhagen) 
Denmark 
Telephone: +45 88 77 36 00 
CONTRACT RESEARCH 
ORGANIZATION: 
Premier Research  
One Park Drive 
Suite 150 
Durham, NC 27709 USA 
 
This trial will be performed in compliance with Good Clinical Practices (GCP) and applicable 
regulatory requirements, including the archiving of essential documents. Information contained 
in this protocol is confidential in nature, and may not be used, divulged, published, or otherwise 
disclosed to others, except to the extent necessary to obtain approval of the institutional review 
board or independent ethics committee, or as required by law. Persons to whom this information 
is disclosed should be informed that this information is confidential and may not be further 
disclosed without the express permission of Zealand Pharma A/S. 
 
 
 
 
 
 
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1. REVISION HISTORY 
PROTOCOL TITLE: 
A Randomized Trial in 2 parts: Double-Blind, Placebo-
Controlled, Crossover Part 1 and Open-label Part 2, 
Evaluating the Efficacy and Safety of Dasiglucagon for the 
Treatment of Children with Congenital Hyperinsulinism 
PROTOCOL DATE: 
Original Protocol Version 1.0, 14-Dec-2017 
This updated protocol version 13.0 is applicable for all 
countries except Germany, and includes: 
AMENDMENT No. 1 
Final Version 2.0, 20-Jun-2018 (All countries) 
AMENDMENT No. 2 
Final Version 3.0, 25-Jul-2018 (France, Germany, Israel, 
United Kingdom) 
AMENDMENT No. 3 
Final Version 4.0, 15-Apr-2019 (All countries) 
AMENDMENT No. 4 
Final Version 5.0, 03-Jun-2019 (All countries) 
AMENDMENT No. 5 
Final Version 6.0, 05-Jul-2019 (Germany) 
AMENDMENT No. 5.1 
Final Version 6.1, 05-Mar-2020 (Germany) 
AMENDMENT No. 6 
Final Version 7.0, 19-Sep-2019 (All countries except 
Germany) 
AMENDMENT No. 7 
Final Version 8.0, 11-Oct-2019 (Germany) 
AMENDMENT No. 8 
Final Version 9.0, 29-Apr-2020 (Germany) 
AMENDMENT No. 9 
Final Version 10, 08-Jul-2020 (All countries except 
Germany) 
AMENDMENT No. 10 
Final Version 11.0, 27-Aug-2020 (Germany) 
AMENDMENT No. 11 
Final Version 12.0, 05-Nov-2020 (Germany) 
AMENDMENT No. 12 
Final Version 13.0, 04-Jun-2021 (All countries except 
Germany) 
 
 
 
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2. APPROVAL SIGNATURES 
PROTOCOL 
NUMBER: 
ZP4207-17103 
PROTOCOL TITLE: 
A Randomized Trial in 2 parts: Double-Blind, Placebo-Controlled, 
Crossover Part 1 and Open-label Part 2, Evaluating the Efficacy and 
Safety of Dasiglucagon for the Treatment of Children with Congenital 
Hyperinsulinism 
I, the undersigned, have read this protocol and confirm that to the best of my knowledge it 
accurately describes the planned conduct of the trial. 
 
 
 
 
 
 
 
Clinical Trial Manager 
Zealand Pharma A/S 
 
 
 
 
Date 
 
 
Medical Director 
Zealand Pharma A/S 
 
 
 
Date 
 
 
Senior Manager, Biostatistics 
Premier Research 
 
Date 
 
05-Jun-2021 | 11:37:02 CEST
07-Jun-2021 | 00:56:01 EDT
10-Jun-2021 | 02:06:01 PDT
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3. SYNOPSIS 
PRODUCT 
NAME/NUMBER 
Dasiglucagon 
PROTOCOL 
NUMBER 
ZP4207-17103 
EUDRACT 
NUMBER 
2017-004545-24 
DEVELOPMENT 
PHASE 
Phase 2/3 
PROTOCOL TITLE 
A Randomized Trial in 2 parts: Double-Blind, Placebo-Controlled, Crossover Part 1 and 
Open-label Part 2, Evaluating the Efficacy and Safety of Dasiglucagon for the 
Treatment of Children with Congenital Hyperinsulinism 
INDICATION 
Congenital hyperinsulinism (CHI) 
OBJECTIVES 
Primary: To evaluate the efficacy of dasiglucagon in reducing glucose requirements in 
children with persistent CHI requiring continuous IV glucose administration to 
prevent/manage hypoglycemia. 
Secondary: To evaluate the safety and tolerability of dasiglucagon administered as a 
subcutaneous (SC) infusion in patients with CHI. 
TRIAL DESIGN 
This is a combined phase 2 and 3, randomized, multinational trial to evaluate the 
efficacy and safety of individually titrated dasiglucagon in children ≥7 days and <1 year 
of age who have been diagnosed with CHI, comprising 2 parts, a crossover (2 periods, 
48 hours each), double-blind, placebo-controlled Part 1, and an open-label, single-arm 
Part 2 of 21 days. 
After screening, eligible patients will complete a minimum 24-hour run-in period to 
confirm the IV glucose randomization requirement (≥10 mg/kg/min). All 
non-nutritional carbohydrates and carbohydrate fortification of feeds are prohibited 
during this 24-hour run-in period. After the run-in period, patients will be randomly 
assigned in a double-blind fashion to receive dasiglucagon or placebo for 48 hours, after 
which they will be crossed over to the other trial treatment for an additional 48 hours. At 
the time of crossover, the trial drug will be initiated from the starting dose of 10 µg/hr, 
and IV glucose infusion rate (GIR) will be set to the rate obtained at the end of the run-
in period and titrated accordingly. 
There will be no washout between the 2 periods in Part 1 to limit the length of time in 
which patients are reliant on IV GIR as their only means of preventing/treating 
hypoglycemia. This is deemed acceptable because: 
• 
The half-life (t½) of dasiglucagon is short (~30 minutes for the 0.6 mg dose and 
potentially shorter for lower doses, ~22 minutes) relative to the 48-hour duration of 
each crossover period. Moreover, for the primary endpoint, only the last 12 hours of 
the 48-hour period will be used for endpoint assessment. 
• 
Assuming a positive effect of dasiglucagon, the absence of washout is more 
conservative with respect to key secondary endpoints since a potential carry over 
effect of dasiglucagon in Period 2 is attributed to placebo. 
During Part 1, the trial drug and IV GIR should be adjusted according to the 
protocol-specified algorithm. Non-nutritional carbohydrates and/or carbohydrate 
fortification of feeds during Part 1 is only allowed when the maximum tolerable volume 
and concentration of IV glucose for the patient is reached, and should be limited to the 
minimum needed to ensure the patient’s safety. All feedings (administered as parenteral 
nutrition, by nasogastric [NG] tube, gastrostomy, or normal route), will be recorded 
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during this period. Safety assessments will be performed daily after initiation of the trial 
drug (active or placebo). 
After Part 1, patients will continue in open-label Part 2 to receive dasiglucagon for 
21 days. Additional CHI treatments can be introduced during Part 2 if needed, if 
up-titration of dasiglucagon is not possible because of undesirable side effects or if the 
maximum dose level (70 µg/hr) has been reached. Gradual transfer from IV glucose to 
oral and gastric carbohydrates should be initiated in Part 2, enabling weaning of IV 
glucose and hospital discharge. Patients will continue to be hospitalized until IV GIR is 
weaned off; however, as soon as local site criteria for discharge are met, patients can be 
discharged to continue the treatment period at home. Visits are planned at Day 11 and 
Day 18 in Part 2. These visits can be converted to telephone visits if appropriate, at the 
investigator’s discretion. On Day 25, the End of Treatment Visit will take place, and 
based on the investigator’s confirmation of continued positive benefit-risk balance, 
patients will be offered the opportunity to participate in the long-term extension trial 
(Trial ZP4207-17106) to continue dasiglucagon treatment. Patients who do not enter the 
long-term extension trial will have a Follow-up Visit 28 days after their last dose of trial 
drug. 
PLANNED 
NUMBER OF 
PATIENTS 
A total of 12 patients is planned to be randomized 1:1 to receive either placebo first and 
then dasiglucagon or vice versa. 
TRIAL ENTRY 
CRITERIA 
Eligible patients will be ≥7 days and <12 months of age at screening with a body weight 
of ≥2.0 kg (4.4 lbs.) and a diagnosis of CHI established based on the following: 
•
Hyperinsulinemia (plasma insulin above the limit of detection of the assay
documented during an event of hypoglycemia), and/or
•
Hypofattyacidemia (plasma free fatty acid <1.7 mmol/L), and/or
•
Hypoketonemia (beta-hydroxy-butyrate <1.8 mmol/L), and/or
•
Glycemic response (increase in plasma glucose [PG] of >30 mg/dL after 1 mg IV
or intramuscular [IM] glucagon administration).
Eligible patients will be dependent on continuous IV glucose to prevent hypoglycemia. 
INVESTIGATIONAL 
PRODUCTS 
Dasiglucagon injection 4 mg/mL in a 3 mL vial containing 1 mL for injection. 
Matching placebo for dasiglucagon injection in a 3 mL vial containing 1 mL for 
injection.  
REFERENCE 
PRODUCT 
None 
TREATMENT 
REGIMENS 
As long as the patient is receiving IV glucose, PG will be measured and reviewed 
hourly using a hand-held PG meter. The IV GIR will be titrated to achieve glycemia of 
at least 70 mg/dL (3.9 mmol/L) (minimum GIR will be established as the rate up-titrated 
after the patient drops at least once below 70 mg/dL, or 3.9 mmol/L). When the patient 
is no longer on IV GIR, the PG will be checked according to local practice, but at least 
3 times daily. The PG will be measured using the same trial-supplied hand-held PG 
meter during the entire trial. 
Additionally, blinded continuous glucose monitoring (CGM) will be started 24 hours 
prior to randomization (using the Dexcom G4 or G6 system) and continued until the end 
of Part 2. 
Dosing of trial drug 
Dosing of dasiglucagon will approximate continuous infusion by delivering small doses 
at frequent intervals via a trial-supplied infusion pump. The adjustment of trial drug 
dosing is closely linked to the PG level achieved, which in turn will determine the 
adjustments to the IV GIR. 
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Part 1 (Crossover, double-blind, randomized, placebo-controlled) 
The starting dose of trial drug is 10 µg/hr at t=0. Every 2 hours (t=2, 4, 6h, etc.), the 
dose will be increased by an additional 10 µg/hr until either: 
•
The patient is totally weaned off IV glucose, or
•
PG during the last 2 hours was constantly above 120 mg/dL (6.7 mmol/L), or
•
IV GIR has not decreased despite 2 sequential dose increases (in this situation the
dose of trial drug product should be maintained until the IV GIR can be further
decreased or until crossover or the end of the treatment period), or
•
The maximum dose of 70 µg/hr is reached, or
•
Adverse events (AEs) emerge that are considered to be related to the trial drug
(e.g., nausea/change in feeding patterns or increased vomiting) and that are limiting
further dose escalation.
The 2-hour dose-adjustment interval will allow drug plasma levels to approach steady 
state before the dose is further increased. 
The cumulative dose will not exceed 1.26 mg over the first 24 hours and 1.68 mg for the 
subsequent 24-hour periods. 
At the time of crossover from the first 48-hour period to the second 48-hour period, the 
trial drug will again be titrated from the starting dose of 10 µg/hr, and IV GIR will be 
set to the rate obtained at the end of the run-in period and titrated accordingly. 
Part 2 (Open-label) 
After Part 1, all patients will continue in open-label Part 2 to receive dasiglucagon for 
an additional 21 days. Since treatment allocation during Part 1 remains blinded, all 
patients are required to initiate dasiglucagon dosing at 10 µg/hr in Part 2, while IV GIR 
in Part 2 should be started at the rate obtained at the end of the run-in period. During 
Part 2, the dasiglucagon dose, the amount and route of administration of carbohydrates 
(IV GIR, parenteral nutrition, gastric carbohydrate infusions, and carbohydrates from 
oral feeds) can be adjusted at the discretion of the investigator. Plasma glucose should 
be monitored at least hourly to adjust the IV GIR as appropriate and to avoid 
hypoglycemia. Additional concomitant medications, including somatostatin analogs 
and/or sirolimus/mechanistic target of rapamycin (mTOR) inhibitors, may be introduced 
at the investigator’s discretion if the maximum dose level of dasiglucagon (70 µg/hr) 
has been reached or if further up-titration is not possible due to undesirable side effects. 
Adjustment of total carbohydrates administered (IV glucose, parenteral nutrition, gastric 
carbohydrate infusions, and carbohydrates from oral feeds) should continue throughout 
this period according to local practice to maintain PG levels in the range of 70 mg/dL to 
120 mg/dL (3.9-6.7 mmol/L). The aim will be to obtain stable glucose levels with 
minimum rescue/hypoglycemia-prevention carbohydrates administered by invasive 
routes and to encourage/optimize oral feeds, and achieve weaning off IV glucose. 
Regardless of their discharge status, all patients will be offered the opportunity to 
participate in the long-term safety extension trial (ZP4207-17106), providing the 
investigator attests to the positive benefit-risk balance of continued dasiglucagon 
treatment. 
PLANNED TRIAL 
SITES 
Five to 7 sites in the United States, Europe, and Israel 
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ENDPOINTS 
Primary endpoint 
Part 1 (Day 1 to 4) 
•
Mean IV GIR in the last 12 hours of each treatment period during Part 1
(dasiglucagon or placebo administration)
Key secondary endpoints 
Part 1 (Day 1 to 4, for each 48-hour treatment period) 
•
Total amount (g) of carbohydrates administered (regardless of the route) per day.
STATISTICAL 
METHODS 
Continuous endpoints will be summarized with number (n), mean, standard deviation 
(SD), median, minimum, and maximum. In addition, change from baseline values will 
be calculated at each time point and summarized descriptively; the exception to this is 
the time of PG within prespecified ranges, which will not have a baseline value. For 
categorical endpoints, descriptive summaries will include counts and percentages. 
All data will be presented in the data listings. 
Analysis Populations 
Four analysis populations have been defined for this trial: 
Safety analysis set: defined as all patients administered any randomized treatment. 
Full analysis set (FAS): defined as all patients in the Safety Set who have a valid 
baseline efficacy assessment. Patients will be analyzed according to randomized 
treatment (Part 1) or overall patients (otherwise). 
Per protocol (PP) set: defined as all patients in the FAS without any major protocol 
deviations. Patients will be excluded from the PP set if they do not receive both 
treatments and/or do not have efficacy data available to evaluate the primary endpoint 
for both treatments. 
Pharmacokinetic Set (PK): defined as all patients in the Safety Set who have at least 1 
measurement with quantifiable plasma concentration of dasiglucagon. 
Efficacy Analyses 
The primary analyses of the primary and the key secondary endpoint will be based on 
the FAS. Supportive analyses of the primary endpoint will be based on the PP. 
Primary Endpoint 
Part 1, Day 1 to 4 
The mean IV GIR in the last 12 hours of each treatment period will be calculated as a 
weighted mean across the 12 hours, taking the actual time periods between the 
measurements into account (corresponding to calculating the area under the curve 
(AUC) and dividing it by the length of the time period, i.e., weighted mean IV GIR). 
The IV GIR endpoint is expressed as glucose in mg/kg/min, i.e., data reported from 
different concentrations of the glucose used for infusion will be transformed to this 
standardized unit prior to analysis. 
The primary analysis is defined by the estimand based on the treatment policy (de-facto) 
strategy, where the actual GIR measurement reported irrespective of adherence to 
treatment or use of subsequent therapy is used. The reduction in weighted mean IV GIR, 
as determined as the difference in weighted mean IV GIR between placebo and 
dasiglucagon, will be estimated. 
The weighted mean IV GIR will be analyzed using a mixed-model regression approach, 
with treatment and period as fixed effects and patient as a random effect. The 2-sided 
95% confidence interval (CI) for the treatment difference will be calculated from the 
mixed regression model. 
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Handling of missing data and sensitivity analyses are defined in the body of the 
protocol. 
Key Secondary Endpoint 
Part 1, Day 1 to 4 
The key secondary endpoint of total amount of gastric carbohydrates administered will 
be analyzed by using a mixed-model regression approach, with treatment and period as 
fixed effects and patient as a random effect. 
Safety Analyses 
Adverse events will be coded using the latest version of the Medical Dictionary for 
Regulatory Activities (MedDRA). Adverse events that begin after the first dose of trial 
drug will be defined as treatment emergent. The overall incidence of AEs will be 
displayed by system organ class, preferred term, and treatment. The incidence of AEs 
will also be presented by severity and by relationship to the trial drug. Vital signs, 
clinical laboratory measures (including hematology, biochemistry, and incidence of 
anti-drug antibodies [ADAs]), 12-lead electrocardiograms (ECGs), echocardiography, 
physical examinations, and local tolerability data will be summarized by treatment, 
where applicable. Out-of-range safety endpoints may be categorized as low or high, 
where applicable. 
Safety results will be summarized by treatment received within treatment period and 
part and by trial visit, if applicable. 
A formal statistical analysis plan (SAP) will be prepared to provide further details on 
the methods for statistical analysis. 
No interim analysis is planned. 
SAMPLE SIZE 
DETERMINATION 
A total of 12 patients will be randomized in this crossover trial on the basis of the 
following considerations: 
The GIR results from 40 infants treated with IV glucagon for 24 hours published in the 
JIMD Research Report “The Effect of Continuous Intravenous Glucagon on Glucose 
Requirements in Infants with Congenital Hyperinsulinism” (Hawkes et al 2019). 
“Overall there was a statistically significant reduction in the median (IQR) GIR during 
the 24h following initiation of continuous glucagon infusion compared to 24 h before 
initiation (18.5 (12.9, 22.8) to 11 (6.6, 17.5) mg/kg/min…” 
This trial is powered to detect an effect in GIR for dasiglucagon after 48 hours 
compared to placebo of at least this effect size. Based on the longer infusion and 
titration of dasiglucagon in this trial, this is considered a conservative approach, 
allowing for some uncertainty when translating the published data into a clinical trial 
setting. Using unpublished individual patient data from the above-referenced study, the 
difference in GIR between the 2 treatment groups is assumed to follow a normal 
distribution. Assuming the true mean difference is 7.5 mg/kg/min with a standard 
deviation of differences of 7.36, the trial will have 89% power using a one-sample t-test 
with 12 patients randomized to receive either placebo first and then dasiglucagon or 
vice versa. 
TRIAL AND 
TREATMENT 
DURATION 
The sequence and maximum duration of the trial periods will be as follows: 
1.
Screening Period: up to 28 days, including a minimum 24-hour run-in period
2.
Part 1 (2x48-hour period: double-blind, randomized, placebo-controlled): 96 hours
3.
Part 2 (Open-label Active Treatment Period): 21 days
4.
Follow-up Period: Patients who do not enter the extension trial will have a
Follow-up Visit 28 days after their last dose of trial drug
The maximum trial duration for each patient is 81 days. 
The maximum treatment duration for each patient is 25 days. 
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4.
TABLE OF CONTENTS
1.
REVISION HISTORY .............................................................................................................2 
2.
APPROVAL SIGNATURES ...................................................................................................3 
3.
SYNOPSIS ...............................................................................................................................4 
4.
TABLE OF CONTENTS .........................................................................................................9 
4.1. LIST OF TABLES ........................................................................................................13 
4.2. LIST OF FIGURES ......................................................................................................13 
5.
LIST OF ABBREVIATIONS .................................................................................................14 
6.
INTRODUCTION ..................................................................................................................16
6.1. Background and Rationale ............................................................................................16 
6.2. Current Treatment and Unmet Medical Need ...............................................................16 
6.3. Dasiglucagon for the Treatment of Congenital Hyperinsulinism .................................17 
6.3.1. Dasiglucagon .....................................................................................................17 
6.3.2. Nonclinical Experience .....................................................................................18 
6.3.3. Clinical Experience ...........................................................................................18 
6.3.4. Literature Data ...................................................................................................20 
6.3.5. Anticipated Medical Benefit of Dasiglucagon in the Treatment of CHI ..........21 
6.3.6. Anticipated Risks of Dasiglucagon in the Treatment of CHI ...........................21 
6.3.7. Summary of Potential Benefits and Risks .........................................................22 
7.
OBJECTIVES AND ENDPOINTS ........................................................................................23 
7.1. Objectives ......................................................................................................................23 
7.1.1. Primary Objective ..............................................................................................23 
7.1.2. Secondary Objectives ........................................................................................23 
7.2. Endpoints ......................................................................................................................23 
7.2.1. Primary Endpoint ..............................................................................................23 
7.2.2. Key Secondary Efficacy Endpoint ....................................................................23 
7.2.3. Secondary Efficacy Endpoints ..........................................................................23 
7.2.4. Safety Endpoints ................................................................................................24 
8.
TRIAL DESIGN .....................................................................................................................25 
8.1. Overall Trial Design and Plan .......................................................................................25 
8.2. Discussion of Trial Design ............................................................................................26 
8.3. Trial Sites ......................................................................................................................26 
8.4. Point of Contact ............................................................................................................27 
9.
PATIENT POPULATION ......................................................................................................27 
9.1. Selection of Trial Population ........................................................................................27 
9.2. Trial Entry Criteria ........................................................................................................27 
9.2.1. Inclusion Criteria ...............................................................................................27 
9.2.2. Exclusion Criteria ..............................................................................................27 
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9.2.3. Randomization Exclusion Criteria ....................................................................28 
9.3. Premature Patient Withdrawal ......................................................................................28 
9.4. Treatment Discontinuation ............................................................................................29 
9.5. Rescue Criteria ..............................................................................................................29 
9.6. Patient Replacement Criteria.........................................................................................29 
10. TREATMENTS ......................................................................................................................30 
10.1. Identification of Investigational Product .......................................................................30 
10.1.1. Packaging and Labeling ....................................................................................30 
10.2. Treatments Administered ..............................................................................................30 
10.3. Trial Supplies ................................................................................................................32 
10.4. Dispensing and Storage .................................................................................................33 
10.5. Method of Assigning Patients to Treatment Groups .....................................................33 
10.6. Blinding and Unblinding Treatment Assignment .........................................................34 
10.7. Selection of Doses in the Trial ......................................................................................34 
10.8. Selection of Timing of Dose for Each Patient ..............................................................34 
10.9. Dose Adjustment Criteria ..............................................................................................35 
10.10. Treatment Compliance ................................................................................................35 
10.11. Permitted and Prohibited Therapies ............................................................................35 
10.11.1. Permitted Therapies ......................................................................................35 
10.11.2. Prohibited Therapies .....................................................................................35 
10.12. Discharge of Patients for Home Treatment .................................................................36 
10.13. Treatment After End of Trial ......................................................................................37 
11. TRIAL PROCEDURES ..........................................................................................................37 
11.1. Trial Duration ................................................................................................................37 
11.2. Assessments ..................................................................................................................37 
11.2.1. Efficacy .............................................................................................................37 
11.2.1.1. Plasma Glucose Monitoring ..................................................................37 
11.2.1.2. Continuous Glucose Monitoring ...........................................................38 
11.2.1.3. Diary ......................................................................................................38 
11.2.2. Pharmacokinetics/Drug Exposure .....................................................................38 
11.2.3. Safety .................................................................................................................39 
11.2.3.1. Laboratory Safety Assessments ............................................................39 
11.2.3.2. Clinical Examinations ...........................................................................40 
11.2.3.3. Reporting of Hypoglycemia Events ......................................................41 
11.2.4. Technical Complaints ........................................................................................42 
11.2.4.1. Adverse Events .....................................................................................43 
12. ADVERSE EVENTS ..............................................................................................................43 
12.1. Definitions .....................................................................................................................43 
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12.1.1. Adverse Events ..................................................................................................43 
12.1.2. Severity ..............................................................................................................43 
12.1.3. Causality ............................................................................................................44 
12.1.4. Outcome ............................................................................................................44 
12.1.5. Serious Adverse Events .....................................................................................44 
12.1.6. Other Important Events .....................................................................................45 
12.1.7. Nonserious Adverse Events ...............................................................................45 
12.1.8. Adverse Events of Special Interest ....................................................................45 
12.1.9. Suspected Unexpected Serious Adverse Reactions ...........................................45 
12.2. Collection, Recording, and Reporting of Adverse Events ............................................45 
12.2.1. Contact Information ..........................................................................................46 
12.3. Follow-up of Adverse Events........................................................................................46 
12.4. Precautions ....................................................................................................................47 
12.5. Safety Committee ..........................................................................................................48 
12.6. Independent Data Monitoring Committee ....................................................................48 
13. STATISTICS ..........................................................................................................................49 
13.1. Statistical Hypotheses ...................................................................................................49 
13.2. Sample Size Determination ...........................................................................................49 
13.3. Analysis Populations .....................................................................................................50 
13.4. Statistical Analyses .......................................................................................................50 
13.4.1. Trial Patients and Demographics ......................................................................51 
13.4.1.1. Disposition and Withdrawals ................................................................51 
13.4.1.2. Protocol Deviations ...............................................................................51 
13.4.1.3. Demographics and Other Baseline Characteristics ...............................51 
13.4.2. Duration of Exposure and Compliance .............................................................51 
13.4.3. Efficacy Analyses ..............................................................................................51 
13.4.3.1. Primary Analysis ...................................................................................51 
13.4.3.2. Key Secondary Analyses ......................................................................52 
13.4.3.3. Secondary and Other Efficacy Analyses ...............................................52 
13.4.4. Safety and Tolerability Analyses ......................................................................53 
13.4.4.1. Adverse Events .....................................................................................53 
13.4.4.2. Clinical Laboratory Evaluations ...........................................................53 
13.4.4.3. Vital Signs .............................................................................................53 
13.4.4.4. Twelve-lead Electrocardiograms ..........................................................54 
13.4.4.5. Echocardiograms ...................................................................................54 
13.4.4.6. Physical Examination Findings .............................................................54 
13.4.4.7. Local Tolerability ..................................................................................54 
13.4.5. Interim Analysis ................................................................................................54 
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14. TRIAL CONDUCT ................................................................................................................55 
14.1. Sponsor and Investigator Responsibilities ....................................................................55 
14.1.1. Sponsor Responsibilities ...................................................................................55 
14.1.2. Investigator Responsibilities .............................................................................55 
14.2. Site Initiation .................................................................................................................56 
14.3. Screen Failures ..............................................................................................................56 
14.4. Trial Documents ............................................................................................................56 
14.4.1. Investigator’s Regulatory Documents ...............................................................56 
14.4.2. Case Report Forms ............................................................................................56 
14.4.3. Source Documents .............................................................................................57 
14.5. Data Quality Control .....................................................................................................57 
14.5.1. Monitoring Procedures ......................................................................................57 
14.5.2. Data Management ..............................................................................................58 
14.5.3. Quality Assurance/Audit ...................................................................................58 
14.6. Trial Termination ..........................................................................................................58 
14.6.1. Regular Trial Termination .................................................................................58 
14.6.2. Premature Trial Termination .............................................................................59 
14.7. Trial Site Closure ..........................................................................................................59 
14.7.1. Record Retention ...............................................................................................59 
14.7.2. Sample Retention ..............................................................................................60 
14.8. Changes to the Protocol ................................................................................................60 
14.9. Use of Information and Publication ..............................................................................60 
15. FINAL CLINICAL TRIAL REPORT ....................................................................................61 
16. ETHICAL AND LEGAL CONSIDERATIONS ....................................................................61 
16.1. Declaration of Helsinki and Good Clinical Practice .....................................................61 
16.2. Patient Information and Informed Consent ...................................................................61 
16.3. Approval by Institutional Review Board and Independent Ethics Committee .............62 
16.4. Finance and Insurance ...................................................................................................62 
17. REFERENCES .......................................................................................................................63 
18. ATTACHMENTS ...................................................................................................................65 
18.1. Schedule of Events ........................................................................................................65 
18.2. Investigator’s Agreement ..............................................................................................68 
APPENDICES ...............................................................................................................................69 
A. 
Address List ..................................................................................................................70 
B. 
Regulations and Good Clinical Practice Guidelines .....................................................71 
1. 
Regulations ........................................................................................................71 
2. 
Good Clinical Practice Guidelines ....................................................................71 
 
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4.1. LIST OF TABLES 
Table 1 
Algorithm to Maintain Plasma Glucose ............................................................31 
Table 2 
Schedule of Events ............................................................................................65 
 
4.2. LIST OF FIGURES 
Figure 1 
Design of Trial ZP4207-17103 ..........................................................................25 
 
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5. LIST OF ABBREVIATIONS 
 
ADA 
anti-drug antibody 
A&E 
accident and emergency 
AE 
adverse event 
AESI 
adverse event of special interest 
ANOVA 
analysis of variance 
AUC 
area under the curve 
AUC0-inf 
area under the plasma concentration-time curve from time zero to infinity 
AUCglucose 
area over the glucose curve 
CGM 
continuous glucose monitoring 
CHI 
congenital hyperinsulinism 
CI 
confidence interval 
Cmax 
maximum observed concentration 
CRA 
clinical research associate 
CRF 
case report form 
CRO 
contract research organization 
CTR 
clinical trial report 
DMC 
independent data monitoring committee 
ECG 
electrocardiogram 
eCRF 
electronic case report form 
EDC 
electronic data capture  
ER 
emergency room 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GI 
gastrointestinal 
GIR 
glucose infusion rate 
GLMM 
generalized linear mixed-model  
H 
hypothesis 
ICF 
informed consent form 
ICH 
International Council for Harmonisation of Technical Requirements for 
Pharmaceuticals for Human Use 
IEC 
independent ethics committee 
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IM 
intramuscular(ly) 
IRB 
institutional review board 
ISF 
investigator site file 
IV 
intravenous(ly) 
MedDRA 
Medical Dictionary for Regulatory Activities 
mTOR 
mechanistic target of rapamycin 
NG 
nasogastric 
NME 
necrolytic migratory erythema 
PD 
pharmacodynamic(s) 
PG 
plasma glucose 
PK 
pharmacokinetic(s) 
PT 
preferred term 
RSI 
Reference Safety Information 
SAE 
serious adverse event 
SAP 
statistical analysis plan 
SC 
subcutaneous(ly) 
SMPG 
self-monitored plasma glucose 
SpO2 
peripheral capillary oxygen saturation 
SUSAR 
suspected unexpected serious adverse reaction 
t1/2 
half-life 
TMM 
trial materials manual 
Zealand 
Zealand Pharma A/S 
 
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6. INTRODUCTION 
6.1. Background and Rationale 
Congenital hyperinsulinism (CHI) is a rare and challenging disorder in which β-cells in the 
pancreas secrete insulin irrespective of plasma glucose (PG) concentration, resulting in persistent 
and often severe hypoglycemia.1 Congenital hyperinsulinism affects up to 1 in 50,000 newborns. 
It is typically diagnosed on the basis of signs and symptoms of hypoglycemia during the neonatal 
period or in infancy; however, the diagnosis may be made later in childhood. Mutations in 
several different β-cell genes have been described to cause CHI. Hypoglycemia that results from 
CHI is of particular concern because it is an important cause of brain injury in neonates, infants, 
and children with this disease, which leads to long-term neurological impairments.1,2 Up to 
approximately 50% of children with CHI experience neurodevelopmental abnormalities caused 
by severe hypoglycemia that results from inadequate treatment and/or delays in diagnosis.1,3 
Severe brain damage is the consequence of severe hypoglycemia, which presents as coma and/or 
long-lasting epileptic seizures in neonates. Major intellectual disability is, therefore, most 
frequent in patients with neonatal initial onset, whereas hypoglycemia is usually less severe and 
brain damage less frequent in children with CHI diagnosed later in childhood.1 Since symptoms 
and severity of hypoglycemia can vary and pose a diagnostic challenge in neonates, infants, and 
children with CHI, prompt recognition and treatment of hypoglycemia is critical to reduce the 
risk of long-term neurological consequences. 
6.2. Current Treatment and Unmet Medical Need 
Medical treatment for CHI is focused on chronic therapies to avoid hypoglycemia, as well as on 
rescue therapy during acute episodes of severe hypoglycemia. Available medical therapies 
(mainly diazoxide, octreotide, or glucagon alone or in combination with glucose infusion) are 
often inadequate and accompanied by inability to control PG, as reflected in a large proportion of 
patients requiring sub-total pancreatectomy.4,5,6 With the exception of surgery for focal CHI, 
which is curative in the vast majority of patients, sub-total pancreatectomy for diffuse CHI has 
substantial inadequacies. A recent retrospective chart review7 showed that 60% of patients who 
underwent near-total pancreatectomy had persistent hypoglycemia after surgery. Moreover, 
96% had developed insulin-dependent diabetes within 11 years after surgery. 
First-line medical treatment of CHI is diazoxide, which is the only EU- and US-approved drug 
for treatment of hyperinsulinemic hypoglycemia. Diazoxide acts to open KATP channels of the 
pancreatic β-cells, thereby inhibiting insulin secretion. Unfortunately, many patients with CHI 
are resistant to diazoxide because of mutations in the genes encoding the KATP channel of the 
pancreatic β-cells.6 For those who respond to diazoxide treatment, the more common side effects 
comprise hypertrichosis, fluid retention, and gastrointestinal (GI) symptoms; however, side 
effects are usually not severe. In diazoxide nonresponders, second-line (and off-label) treatment 
is a somatostatin analog (octreotide or lanreotide [long acting]), which (among other effects) 
inhibits secretion of insulin and glucagon from the pancreas and suppresses GLP-1 secretion. 
Factors that limit their use comprise tachyphylaxis, as well as possible side effects, including 
necrotizing enterocolitis, gallstones, and hepatitis.6 
The glycogenolytic effect of glucagon and its ability to increase PG levels has been confirmed in 
children with CHI or neonatal hypoglycemia.8,9 Administration of marketed glucagon 
(intravenous [IV] or subcutaneous [SC] injection) is often used in the diagnostic phase of CHI to 
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stabilize patients before surgery or initiation of other medical treatments.10 In a retrospective 
review of 55 neonates with resistant hypoglycemia, native glucagon IV infusion achieved a 
median rise in plasma glucose of 45 mg/dL (2.5 mmol/L) after an hour of administration, 
regardless of the underlying cause for the persistent neonatal hypoglycemia.9 Furthermore, 
glucagon is administered as single SC doses to treat severe hypoglycemic episodes. While IV 
administration of glucagon to patients with CHI is used short-term in the hospital setting, 
e.g., before pancreatectomy,2,10,11 long-term glucagon treatment is challenging since currently 
available glucagon products are unstable and form fibrils within hours after reconstitution.12 
Catheter obstruction and occlusion because of glucagon instability were observed daily to 2 to 
3 times weekly in a retrospective review of 9 patients with CHI receiving continuous SC infusion 
of glucagon for weeks or months.11 In another series of patients, 60% of the patients treated with 
short-term SC glucagon experienced catheter occlusion.6 Instability of currently available 
glucagon products and the associated risk of dosing errors contributing to hypoglycemic events 
is a major barrier for using glucagon for long-term treatment of patients with CHI. 
When successfully administered, long-term home treatment with subcutaneously infused 
glucagon over extended periods (years) has been beneficial, with a potentially good safety profile 
as compared to diazoxide and octreotide.6,11,13 
6.3. Dasiglucagon for the Treatment of Congenital Hyperinsulinism 
6.3.1. Dasiglucagon 
Dasiglucagon is a peptide analog of human glucagon in development for the treatment and 
prevention of hypoglycemia in patients with diabetes mellitus and CHI via SC or intramuscular 
(IM) administration. Dasiglucagon is a stable analog of glucagon that has been specifically 
designed to overcome the issues with fibril formation and instability in solution observed with 
marketed glucagon products. Compared to native human glucagon, dasiglucagon also comprises 
29 amino acids. As a result of chemical modifications (7 amino acid substitutions compared to 
human glucagon), the pronounced tendency of glucagon to form fibrils and aggregate has been 
effectively prevented in dasiglucagon. In addition, the chemical stability in aqueous media at 
physiological pH has been improved. 
To support the use of dasiglucagon in the pump for this trial, compatibility/in-use studies have 
been performed with dasiglucagon 4 mg/mL in Roche Accu-Chek® Combo pump using the 
Accu-Chek® Spirit 3.15 mL cartridge system and the Accu-Chek® FlexLink infusion set. The 
studies support an in-use time for up to 6 days at 37ºC. 
Dasiglucagon has been granted orphan drug designation by the European Commission on 
20 June 2017 for the ‘treatment of congenital hyperinsulinism.’ Furthermore, the FDA granted 
an orphan drug designation for the ‘treatment of hypoglycemia in patients with congenital 
hyperinsulinism (CHI)’ on 10 August 2017. 
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6.3.2. Nonclinical Experience 
The completed nonclinical pharmacology program has determined that dasiglucagon is a specific 
glucagon receptor agonist with comparable in vitro potency to glucagon, promoting a rapid onset 
of PG increase in both normoglycemic and insulin-induced hypoglycemic animals, similar to that 
of glucagon. 
Results of the toxicity studies with dasiglucagon are comparable to what has been reported for 
glucagon. Those from chronic toxicity studies with dasiglucagon in rats and dogs are in line with 
the results of short-term toxicity studies, indicating that long-term treatment with dasiglucagon is 
safe and that the pharmacodynamic (PD) effects noted do not adversely affect organ function 
following chronic use. 
6.3.3. Clinical Experience 
Dasiglucagon is being developed to manage patients with CHI 1) as an initial short-term therapy 
to stabilize PG levels and reduce glucose infusion needs, and 2) as a long-term treatment to help 
maintain euglycemia. Dasiglucagon has not previously been studied in patients with CHI. 
Clinical experience with dasiglucagon comes from the following studies in healthy subjects and 
type 1 diabetics. 
The safety, tolerability, pharmacokinetic (PK), and PD characteristics of dasiglucagon were 
investigated in 2 phase 1 trials, 3 phase 2 trials, and 2 phase 3 trials. 
ZP4207-14013 was a phase 1 randomized, double-blind, 2-part, single-dose trial designed to 
evaluate the pharmacokinetics, PD, safety, and tolerability of dasiglucagon compared to 
GlucaGen®. Part 1 consisted of SC and IM administration of single ascending doses of 
dasiglucagon in 64 adult healthy volunteers. Part 2 consisted of 20 adult patients with type 1 
diabetes using a crossover design with IM administration of 0.7 mg dasiglucagon. 
GlucaGen 1.0 mg was used as a comparator in both parts of the trial. 
ZP4207-15007 was a phase 1 randomized, placebo-controlled, double-blind, multiple-dose trial 
designed to evaluate the PK, PD, safety, and tolerability of repeated doses of dasiglucagon SC in 
24 healthy adult volunteers. The trial included 3 dose cohorts of 8 healthy volunteers each. In 
each cohort, patients were randomly assigned in a 3:1 ratio to receive 5 repeated daily doses of 
0.1, 0.3, and 1.0 mg dasiglucagon (n=6) or placebo (n=2). 
After the 2 phase 1 trials were completed, the composition of the dasiglucagon formulation was 
optimized with respect to its excipients (buffer, tonicity adjusting agent, and stabilizer). The PK 
and PD properties, safety, and tolerability of the optimized formulation were evaluated in the 
phase 2 trials. 
ZP4207-15126 was a phase 2 randomized, double-blind, single-dose trial designed to evaluate 
the PK, PD, safety, and tolerability of a single SC dose of dasiglucagon in the optimized 
formulation (0.1, 0.3, 0.6, and 1.0 mg) or GlucaGen (0.5 and 1.0 mg) in 58 adult patients with 
type 1 diabetes. 
ZP4207-16051 was a phase 2 open-label, randomized, crossover trial designed to evaluate the 
feasibility of using dasiglucagon 1 mg/mL SC in conjunction with insulin in a pump setting 
using an iLet algorithm as part of an automated dual hormone pump delivery system in 
12 patients with type 1 diabetes. The primary objective was to evaluate the safety and tolerability 
of dasiglucagon compared to marketed glucagon (Lilly Glucagon™). The trial also aimed to 
demonstrate the functionality and accuracy of the iPhone-based bionic pancreas in a controlled, 
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clinical setting. Patients were randomly assigned to two 1-day treatment arms: dasiglucagon or 
Lilly Glucagon in the iPhone-based bionic pancreas. 
ZP4207-16098 was a phase 2 randomized, crossover, double-blind trial designed to evaluate the 
safety, tolerability, PK, and PD of dasiglucagon in 23 patients with type 1 diabetes using a 
4 mg/mL formulation of dasiglucagon (0.03 mg, 0.08 mg, 0.2 mg, and 0.6 mg) compared to an 
active comparator, Lilly Glucagon. 
ZP4207-16136 was a phase 3 randomized, double-blind parallel-group safety trial designed to 
evaluate the immunogenicity of dasiglucagon compared to GlucaGen in 111 adult patients with 
type 1 diabetes. 
ZP4207-16137 was a phase 3 randomized, double-blind, parallel-group trial designed to confirm 
the clinical efficacy and safety of a single dose of dasiglucagon (0.6 mg) for the rescue treatment 
of hypoglycemia compared to placebo and with reference to GlucaGen (1 mg) in 168 adult 
patients with type 1 diabetes. 
Overall, no safety concerns were observed for dasiglucagon at the doses investigated in these 
clinical trials. The most frequently reported adverse event (AE) in each trial was nausea, which is 
a known side effect after administration of glucagon, and appeared at a similar frequency to 
marketed glucagon, which was used as active comparator in some of the trials. No local 
tolerability issues were reported. Injection site reactions were observed only sporadically after 
administration with dasiglucagon, placebo, or marketed glucagon in trials with SC or IM 
administration, and all events were mild and transient. No treatment-induced or 
treatment-boosted anti-drug antibodies (ADAs) were noted in any of the reported trials, except 
for trial ZP4207-16098, in which 1 patient tested positive for both anti-dasiglucagon and 
anti-glucagon antibodies. Due to the crossover nature of this trial, the induction of ADAs could 
not be associated with a specific treatment. 
Dose proportionality for dasiglucagon PK using the 1 mg/mL formulation was confirmed in the 
clinical trials, with doses ranging between 0.1 and 1.0 mg, characterized by a fast absorption 
with a peak plasma concentration obtained after 35 minutes. The median time to maximum 
concentration was later for dasiglucagon compared to marketed glucagon (GlucaGen) 
(35 vs 20 minutes). In the phase 2 trial ZP4207-15126, doses of 0.3 mg dasiglucagon and 0.5 mg 
GlucaGen and also 0.6 mg dasiglucagon and 1.0 mg GlucaGen were similar with regard to 
maximum observed concentration (Cmax). The total exposure in terms of area under the 
concentration-time curve (AUC) from time zero to infinity (AUC0-inf) was consistently higher for 
dasiglucagon compared to GlucaGen. This was likely due to a higher bioavailability of 
dasiglucagon since nonclinical data consistently show that the bioavailability of dasiglucagon is 
higher compared to marketed glucagon formulations. For the 4 mg/mL formulation, 
dose-proportionality of dasiglucagon doses between 0.03 and 0.6 mg was indicated for 
AUC0-240min and AUC0-inf in trial ZP4207-16098. Pharmacokinetic parameters were all similar for 
dasiglucagon administration under both euglycemic and hypoglycemic conditions. An 
approximately 30 to 40% greater exposure in terms of AUC0-inf and Cmax was observed with the 
4 mg/mL formulation as compared with the 1 mg/mL formulation. 
In the phase 2 trial ZP4207-15126, all patients achieved a PG level of at least 70 mg/dL 
(3.9 mmol/L) at all dose levels of dasiglucagon after insulin-induced hypoglycemia, as well as an 
increase in PG by at least 20 mg/dL (1.1 mmol/L) within 30 minutes postdose. The PD responses 
of 0.3 mg of dasiglucagon and 0.5 mg of marketed glucagon (GlucaGen) were similar in the first 
30 minutes postdose, as were the PD responses of 0.6 mg of dasiglucagon and 1.0 mg of 
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GlucaGen. The PD response over the entire observation time (0-360 minutes) was significantly 
greater after dosing with dasiglucagon than with GlucaGen for all prespecified dose 
comparisons. This was likely an effect of the higher total drug exposure (AUC0-inf) of 
dasiglucagon mentioned previously. 
In the phase 3 trial ZP4207-16137, the primary endpoint was time to plasma glucose recovery 
after insulin-induced hypoglycemia, which was defined as first increase in plasma glucose of 
≥20 mg/dL (1.1 mmol/L) from baseline. Superiority was shown for dasiglucagon relative to 
placebo, with a median time to plasma glucose recovery of 10 versus 40 minutes. The median 
time to recovery for GlucaGen was 12 minutes. All patients in the dasiglucagon and GlucaGen 
treatment arms recovered from insulin-induced hypoglycemia within 30 minutes. All patients but 
one receiving dasiglucagon and one receiving GlucaGen had recovered within 20 minutes 
(dasiglucagon: 99% and GlucaGen: 98%). At 15 minutes, 99% of patients receiving 
dasiglucagon and 95% of those receiving GlucaGen had recovered. At 10 minutes, 65% of 
patients receiving dasiglucagon and 49% of those receiving GlucaGen had recovered. 
No major differences in PD responses were observed between dasiglucagon doses under 
euglycemic or hypoglycemic conditions in phase 2 trial ZP4207-16098. Under euglycemic 
conditions, all patients achieved an increase in PG of at least 20 mg/dL (1.1 mmol/L) within 
30 minutes postdose with 0.08 mg dasiglucagon and above, while this target was reached only 
for 0.2 mg of marketed glucagon (Lilly Glucagon). Under hypoglycemic conditions, 
dasiglucagon met the target at doses of 0.2 mg and above. The PD response over the entire 
observation time of 240 minutes was significantly higher with dasiglucagon than with Lilly 
Glucagon at the same doses. In the bionic pancreas feasibility trial ZP4207-16051, results 
demonstrated comparable autonomous glycemic control with dasiglucagon compared to 
Lilly Glucagon. This was despite the stressed conditions of the trial in terms of fasted patients 
being on up to twice their basal insulin rate to stimulate glucagon use during the 8-hour test, and 
inclusion of a structured exercise period. With dasiglucagon, patients obtained a glucose value 
within target (70-180 mg/dL [3.9-10.0 mmol/L]) 70.9% of the time vs 65.6% with Lilly 
Glucagon. 
6.3.4. Literature Data 
In a retrospective review of 223 cases of diffuse or focal CHI, glucagon was reported to be used 
in 55% of patients with diffuse CHI and in 31% of patients with focal CHI.10 In an observational 
trial of 55 newborns who received glucagon because of hypoglycemia after birth, applied doses 
were mainly in the range of 0.5 to 1.0 mg/day, and results indicated an increase in PG from a 
mean of 36.3 md/dL to a mean of 93.0 mg/dL, observed within 4 hours after the start of glucagon 
infusion.9 The frequency of hypoglycemic episodes was significantly reduced, and no further 
episodes of severe hypoglycemia were observed. 
In another retrospective chart review of 40 children with CHI who received continuous IV 
glucagon for prevention of hypoglycemia,14 a median (inter quartile range) glucagon dose of 
205 (178, 235) mcg/kg/day over a median duration of 5 (3, 9) days enabled a glucose infusion 
rate (GIR) reduction from 18.5 (12.9, 22.8) to 11 (6.6, 17.5) mg/kg/min per 24 h (p < 0.001), and 
reduced hypoglycemia frequency from 1.9 (1.3, 2.9) to 0.7 (0.3, 1.2) episodes per day. 
The long-term use of glucagon in patients with CHI is limited by the instability of marketed 
glucagon after reconstitution. A literature review on the long-term medical treatment of CHI 
revealed that only 1% of 619 patients identified received glucagon as part of their medical 
management.6 A retrospective review of 9 children with CHI who received continuous SC 
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infusion of glucagon for weeks or months showed that introduction of glucagon allowed the 
reduction or discontinuation of central glucose infusion in all patients.11 Six of 9 patients were 
discharged with continued glucagon therapy that their parents were able to continue without 
further symptomatic hypoglycemia, convulsions, or unconsciousness. In 3 children, glucagon 
therapy was continued for 1 to 4 years, which led to stable euglycemia. 
The data reported on marketed glucagon use in patients with CHI indicate that continuous SC 
infusion of a glucagon agonist could provide therapeutic benefit to patients by stabilizing PG 
levels and reducing the frequency of hypoglycemic episodes.5,6,9,10,11 
6.3.5. Anticipated Medical Benefit of Dasiglucagon in the Treatment of CHI 
With its physio-chemical stability in liquid formulation, dasiglucagon could provide significant 
added benefit in the treatment of CHI relative to currently marketed glucagon by enabling 
long-term reliable IV infusion. Long-term subcutaneous infusion of dasiglucagon through a 
pump may be an attractive alternative or addition to diazoxide and octreotide since it may reduce 
the dependency on intensive nutritional support, both IV and gastric (NG tube or gastrostomy), 
whilst maintaining euglycemia by harnessing physiological mechanisms for combating 
hypoglycemia. Furthermore, if long-term euglycemia is achieved with medical therapy, 
pancreatectomy for the treatment of diffuse CHI could eventually be avoided. In one cohort of 
nonsurgically treated children, the mean clinical remission rate was 5 (1.5-12) years for diffuse 
CHI.5 This suggests that a significant proportion of infants with CHI could avoid surgery if 
medical treatment allowed for the effective long-term control of hyperinsulinism. 
The target population in this trial is children with CHI who are especially challenging to treat, 
and who need continuous IV glucose infusion to prevent or treat hypoglycemia, necessitating 
ongoing hospitalization. These children have limited options in terms of other treatments, and 
represent very high unmet medical need group within already ultra-rare CHI population. 
6.3.6. Anticipated Risks of Dasiglucagon in the Treatment of CHI 
So far, there is no previous clinical experience with dasiglucagon SC infusion for the treatment 
of CHI. The following anticipated risks are derived from other clinical trials with dasiglucagon 
conducted in other indications, from marketed glucagon labelling information, and from native 
glucagon’s physiological effects. 
In clinical trials with dasiglucagon conducted up to now, the most frequent treatment-related AEs 
were nausea and vomiting, followed by headache. 
Glucagon exerts positive inotropic and chronotropic effects and may, therefore, cause 
tachycardia and hypertension. Transient increases in heart rate and hypertension have been 
observed in clinical trials with dasiglucagon. Additionally, several episodes of hypotension and 
bradycardia have been noted in the clinical program, often in association with nausea and/or 
vomiting. 
Accidental overdose may occur due to inappropriate handling of the infusion pump or due to 
pump malfunction. Overdose may result in nausea, vomiting, inhibition of GI tract motility, 
short-term increase in heart rate or blood pressure, and/or hypokalemia. Symptomatic care for 
nausea and vomiting, as well as monitoring of heart rate, blood pressure, and hypokalemia is 
advised. 
Injection site reactions are seen with many injectable peptides. Injection site reactions have been 
reported across trials, with similar frequency in all treatment groups (dasiglucagon, marketed 
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glucagons, and placebo), irrespective of dose. The injection site reactions were generally mild 
and transient. 
Overall, the clinical trial data indicate that dasiglucagon has a low risk for induction of ADAs. 
Out of more than 350 doses of dasiglucagon administered to more than 200 patients, only 
1 low-titer transient ADA incident has been reported to date, in a patient following 
administration of 11 SC doses of dasiglucagon or Lilly Glucagon ranging from 0.03 to 0.6 mg, 
with low binding and low in vitro neutralizing capability. No apparent clinical effects on PK, PD, 
or AEs were noted. Due to the crossover trial design, the ADA induction could not be ascribed to 
a specific treatment. Based on the current clinical experience and the product characteristics, the 
risk of dasiglucagon inducing an ADA response is considered low. 
Administration of glucagon or dasiglucagon may be associated with a risk of allergic reactions 
similar to those observed for other therapeutic peptides or proteins. 
Data on the risks of chronic administration of dasiglucagon are not available. From sporadic 
reports of extended SC/IV infusion of marketed glucagon and in glucagonoma patients,15 
sustained exposure to high levels of glucagon may lead to development of the skin condition 
necrolytic migratory erythema (NME), a highly specific migrating, erythematous rash with 
predilection for perioral, perianal, and lower leg distribution.11 
For further information on risks, please refer to the current version of the investigator’s brochure 
(IB). 
6.3.7. Summary of Potential Benefits and Risks 
As with all treatment interventions, the anticipated benefits to trial patients should be balanced 
against the potential risks. The accumulated experience from nonclinical studies and clinical 
trials with dasiglucagon supports that dasiglucagon is a specific glucagon receptor agonist and is 
well tolerated. Glucagon and its analogs belong to a well-known drug class with known mode of 
action. The clinical investigators involved in the trial will all have had experience with use of 
glucagon in patients with CHI. 
The investigator will inform the patients/parent(s)/guardian of the potential risks of dasiglucagon 
treatment and other trial-related procedures before they enter the trial. The investigator must 
become familiar with all sections of the dasiglucagon IB before the start of the trial. 
In this trial population, the major and clinically relevant benefit is the expected reduction and 
eventually elimination of need for IV glucose, together with the reduction in gastric nutritional 
interventions while avoiding hypoglycemia. The reduced volume of nutritional interventions 
should limit the risk of volume overload. Furthermore, by removing the invasive methods of 
nutrition, the children should better retain or re-establish orality – the intake of nutrients by 
mouth. 
In summary, with its marked improvements in stability in solution and solubility in aqueous 
media compared to currently marketed glucagon products, dasiglucagon is expected to have 
significant clinical benefits in the treatment of CHI and to substantially reduce the disease burden 
in these patients. This includes discharge from the hospital by enabling convenient and reliable 
long-term treatment via a pump device in a home setting, together with the potential to delay and 
ultimately avoid pancreatectomy and its related exo/endocrine complications, particularly the 
development of insulin-dependent diabetes. 
Overall, the benefit to risk ratio for patients entering the ZP4207-17103 trial is considered 
acceptable. 
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7. OBJECTIVES AND ENDPOINTS 
7.1. Objectives 
7.1.1. Primary Objective 
To evaluate the efficacy of dasiglucagon in reducing glucose requirements in children with 
persistent CHI requiring continuous IV glucose administration to prevent/manage hypoglycemia. 
7.1.2. Secondary Objectives 
To evaluate the safety and tolerability of dasiglucagon administered as an SC infusion in patients 
with CHI. 
7.2. Endpoints 
7.2.1. Primary Endpoint 
Part 1 (Day 1 to 4) 
• 
Mean IV GIR in the last 12 hours of each treatment period during Part 1 (dasiglucagon or 
placebo administration) 
7.2.2. Key Secondary Efficacy Endpoint 
Part 1 (Day 1 to 4, for each 48-hour treatment period) 
• Total amount (g) of carbohydrates administered (regardless of the route) per day. 
7.2.3. Secondary Efficacy Endpoints 
Part 1 (Day 1 to 4, for each 48-hour treatment period) 
• Mean IV GIR for each 48-hour treatment period during Part 1 (dasiglucagon or placebo 
administration) 
• Mean IV GIR below 10 mg/kg/min in the last 12 hours of each treatment period during Part 1 
(yes/no) (dasiglucagon or placebo administration) 
 
Part 2 (Day 5 to 25, assessed from the start of treatment in part 2) 
• 
Time to complete weaning off IV GIR. 
• 
Hypoglycemia event rate, defined as number of hypoglycemic events (PG <70 mg/dL or 
3.9 mmol/L), as detected by SMPG. 
• 
Clinically significant hypoglycemia event rate, defined as number of events <54 mg/dL 
(3.0 mmol/L), as detected by SMPG. 
• 
Time to actual hospital discharge. 
• 
Time to pancreatic surgery (sub-total or total pancreatectomy). 
• 
Total amount (g) of carbohydrates administered (regardless of the route) per day, together 
with amounts (g) of carbohydrates administered per day: 
o 
via IV glucose infusion or bolus (not as part of total parental nutrition), 
o 
as part of total parenteral nutrition (if applicable), 
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o 
via oral route, and 
o 
via NG tube or gastrostomy. 
• 
CGM percent time in range 70-180 mg/dL (3.9-10.0 mmol/L). 
• 
CGM percent time in hypoglycemia (<70 mg/dL or 3.9 mmol/L). 
• 
CGM percent time in clinically significant hypoglycemia (<54 mg/dL or 3.0 mmol/L). 
• 
Rate of hypoglycemia episodes, defined as number of episodes <70 mg/dL (3.9 mmol/L) for 
15 min or more, as measured by CGM. 
• 
Rate of clinically significant hypoglycemia episodes, defined as number of episodes 
<54 mg/dL (3.0 mmol/L) for 15 min or more, as measured by CGM. 
• 
Extent of hypoglycemia (area over the glucose curve [AOCglucose] below 70 mg/dL 
[3.9 mmol/L]) as measured by CGM. 
• 
Extent of clinically significant hypoglycemia (AOCglucose below 54 mg/dL [3.0 mmol/L]) as 
measured by CGM. 
• 
CGM percent time in hyperglycemia (>180 mg/dL or 10.0 mmol/L). 
7.2.4. Safety Endpoints 
By Part 1 or 2 of the trial: 
• 
Adverse events 
• 
Changes in clinical evaluations: 
o 
Vital signs 
o 
Physical examination 
o 
12-lead ECG 
o 
Echocardiogram 
• 
Changes in clinical laboratory assessments: 
o 
Hematology 
o 
Biochemistry 
• 
ADA 
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8. TRIAL DESIGN 
8.1. Overall Trial Design and Plan 
This is a combined phase 2 and 3, randomized, multinational trial to evaluate the efficacy and 
safety of individually titrated dasiglucagon in children ≥7 days and <1 year of age who have 
been diagnosed with CHI, comprising 2 parts, a crossover (2 periods, 48 hours each), 
double-blind, placebo-controlled Part 1, and an open-label, single-arm Part 2 of 21 days 
(Figure 1). 
Abbreviations: Min = minimum 
Figure 1 
Design of Trial ZP4207-17103 
After screening, eligible patients will complete a minimum 24-hour run-in period to confirm the 
IV glucose randomization requirement (≥10 mg/kg/min). All non-nutritional carbohydrates and 
carbohydrate fortification of feeds are prohibited during this 24-hour run-in period. After the 
run-in period, patients will be randomly assigned in a double-blind fashion to receive 
dasiglucagon or placebo for 48 hours, after which they will be crossed over to the other trial 
treatment for an additional 48 hours. At the time of crossover, the trial drug will be initiated from 
the starting dose of 10 µg/hr, and IV GIR will be set to the rate obtained at the end of the run-in 
period and titrated accordingly. 
There will be no washout between the 2 periods in Part 1 to limit the length of time in which 
patients are reliant on IV GIR as their only means of preventing/treating hypoglycemia. This is 
deemed acceptable because: 
• The half-life (t½) of dasiglucagon is short (~30 minutes, for the 0.6 mg dose, and potentially 
shorter for lower doses, ~22 minutes) relative to the 48-hour duration of each crossover 
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period. Moreover, for the primary endpoint, only the last 12 hours of the 48-hour period will 
be used for endpoint assessment. 
• Assuming a positive effect of dasiglucagon, the absence of washout is conservative with 
respect to key secondary endpoints since a potential carry over effect of dasiglucagon in 
Period 2 is attributed to placebo. 
During Part 1, the trial drug and IV GIR should be adjusted according to the protocol-specified 
algorithm (see Section 10.2). Non-nutritional carbohydrates and/or carbohydrate fortification of 
feeds during Part 1 is only allowed if the maximum tolerable volume and concentration of IV 
glucose for the patient is reached, and should be limited to the minimum needed to ensure the 
patient’s safety (Section 9.5). All feedings (administered as parenteral nutrition, by NG tube, 
gastrostomy, or normal route), will be recorded during this period. Safety assessments will be 
performed daily after initiation of the trial drug (active or placebo). 
After Part 1, patients will continue in open-label Part 2 to receive dasiglucagon for 21 days. 
Additional CHI treatments can be introduced during Part 2 if needed, if up-titration of 
dasiglucagon is not possible due to undesirable side effects or if the maximum dose level 
(70 µg/hr) has been reached. Gradual transfer from IV glucose to oral and gastric carbohydrates 
should be initiated in Part 2, enabling weaning of IV glucose and hospital discharge. Patients will 
continue to be hospitalized until IV GIR is weaned off; however, as soon as local site criteria for 
discharge are met, patients can be discharged to continue the treatment period at home. Visits are 
planned on Day 11 and Day 18 in Part 2. These visits can be converted to telephone visits if 
appropriate, at the investigator’s discretion. On Day 25, the End of Treatment Visit will take 
place, and based on the investigator’s confirmation of continued positive benefit-risk balance, 
patients will be offered the opportunity to enter the long-term extension trial (Trial ZP4207-
17106) to continue dasiglucagon treatment. Patients who do not enter the long-term extension 
trial will have a Follow-up Visit 28 days after their last dose of trial drug. 
8.2. Discussion of Trial Design 
The initial 2x48-hour treatment period (Part 1) is double-blind and placebo-controlled to avoid 
bias in the assessment of the effect of dasiglucagon on GIR. A crossover design has been chosen 
to limit the influence of inherent variability of the population, which allows for recruitment of 
fewer patients compared to a parallel-group design, reflecting the ultra-rare status of the disease. 
All patients will receive dasiglucagon in open-label Part 2. According to International Council 
for Harmonisation (ICH) guidelines, for the conduct of clinical trials in rare diseases, where the 
anticipated likelihood of considerable benefit is high, such design has some potential efficiencies 
because all patients will be exposed to test drug, which is of particular importance in rare 
diseases.16 
8.3. Trial Sites 
The trial will take place at 5 to 7 sites in the US and Europe that are experienced in the treatment 
of CHI. A total of 12 patients with CHI is planned to be randomized and exposed to the trial 
product. Patients who withdraw prematurely will not be replaced. 
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8.4. Point of Contact 
A point of contact will be identified to provide information to each patient’s parent(s)/guardian 
about where to obtain information on the trial, the patient’s rights, and whom to contact in case 
of trial-related injury. This information will be provided in the patient information and informed 
consent form (ICF). 
9. PATIENT POPULATION 
9.1. Selection of Trial Population 
A screening log of potential trial candidates must be maintained at each trial site. 
9.2. Trial Entry Criteria 
9.2.1. Inclusion Criteria 
A patient will be eligible for trial participation if he or she meets all of the following criteria: 
1. CHI diagnosis established based on the following: 
a. Hyperinsulinemia: plasma insulin above the limit of detection of the assay documented 
during an event of hypoglycemia, and/or 
b. Hypofattyacidemia: plasma free fatty acid <1.7 mmol/L, and/or 
c. Hypoketonemia: Beta-hydroxybutyrate <1.8 mmol/L, and/or 
d. Glycemic response: an increase in PG of >30 mg/dL (1.7 mmol/L) after 1 mg IV or 
IM glucagon administration 
2. Male or female, age ≥7 days and <12 months at screening 
3. Body weight of ≥2.0 kg (4.4 lbs.) 
4. Continuous IV glucose requirement to prevent hypoglycemia 
5. One or both parents* or guardians of the patient must provide signed informed consent before 
any trial related activity is performed. (*according to local regulations) 
9.2.2. Exclusion Criteria 
A patient will be excluded from the trial if he or she meets any of the following criteria: 
1. Is suspected of having a transient form of CHI (e.g., transient hyperinsulinism due to 
maternal diabetes or perinatal stress) 
2. Was born preterm below 34 weeks of gestational age 
3. Presence of hypertension or hypotension, including circulatory instability requiring 
supportive medication or presence of pheochromocytoma 
4. Known or suspected presence of severe brain damage 
5. Evidence of metabolic, endocrine, or syndromic causes of hypoglycemia not due to 
hyperinsulinism 
6. Use of systemic corticosteroids, e.g., hydrocortisone >20 mg/m2 body surface area or 
equivalent within 5 days before screening 
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7. Prior use of lanreotide, sirolimus (mechanistic target of rapamycin [mTOR inhibitors]), 
anti-inflammatory biological agents, or other immune-modulating agents. Prior use of 
octreotide is allowed after a minimum of 48-hour washout before randomization. 
8. Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >2.5 X the upper limit 
of normal (ULN), or estimated glomerular filtration rate (eGFR) <30 mL/min/1.73m2 
adjusted by a pediatric formula (e.g., Schwartz formula) 
9. Any clinically significant abnormality identified on echocardiogram that in the opinion of the 
investigator would affect the subject’s ability to participate in the trial 
10. Known history of laboratory test results obtained before screening that show presence of 
HIV, hepatitis B surface antigen, hepatitis C antibody, or hepatitis A immunoglobulin M 
11. Any recognized clotting or bleeding disorder 
12. Previous administration of dasiglucagon (previously referred to as ZP4207) 
13. Known or suspected allergy to the trial drug or related products 
14. Previous participation (randomization) in the clinical program (Trials ZP4207-17103 
or -17109) 
15. Has participated in an interventional clinical trial (investigational or marketed product) 
within 30 days of screening, or plans to participate in another clinical trial, except for 
18F-Dopa PET CT/MRI investigation (where performed as a part of a research trial), which 
is allowed for diagnosis of focal CHI 
16. The use of prescription or non-prescription medications known to cause QT prolongation 
9.2.3. Randomization Exclusion Criteria 
A screened patient will not be randomized if: 
1. Mean IV glucose requirement is <10 mg/kg/min to maintain glycemia above 70 mg/dL 
(3.9 mmol/L) during the previous 24 hours prior to randomization 
2. Use of glucagon within 24 hours before randomization. 
3. Use of additional enteral glucose within 24 hours before randomization. Patients should be 
transitioned to IV glucose infusions only at least 24 hours before randomization. 
4. Is not sufficiently clinically stable on IV GIR only (± diazoxide, as applicable), in the 
opinion of the investigator, to undergo the placebo-controlled randomized Part 1 of the trial 
(2x48 hours). 
The Randomization Visit may be rescheduled once if Randomization Exclusion Criterion 2 is 
met. 
9.3. Premature Patient Withdrawal 
Randomization day exclusion criteria are described in Section 9.2.3. 
Patients’ parent(s)/guardian will be advised that they are free to withdraw their child from 
participation in this trial at any time, for any reason, and without prejudice. Every reasonable 
attempt should be made by the investigator to keep patients in the trial to obtain data for the 
primary endpoint in Part 1 and for safety follow-up even if trial treatment has been discontinued. 
However, patients must be withdrawn from the trial if their parent(s)/guardian withdraw consent 
to participate. 
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Investigators must attempt to contact patients’ parent(s)/guardian who fail to attend scheduled 
visits by telephone or other means to exclude the possibility of an AE being the cause of 
withdrawal. Attempts to contact the patient must be documented. At least 3 phone calls and 
3 written attempts to contact the patient will be made prior to considering them lost to follow-up. 
Should an AE be the cause of withdrawal, it must be documented, reported, and followed up as 
described in Section 12.3. 
If a patient/parent(s)/guardian withdraws consent, the reason for withdrawal and the date of 
withdrawal will be recorded on the appropriate page of the electronic case report form (eCRF). 
Whenever possible and reasonable, the evaluations that were to be conducted at the completion 
of the trial should be performed at the time of premature withdrawal. 
9.4. Treatment Discontinuation 
To prevent missing data, patients should, to the extent possible, be kept in the trial; therefore, 
treatment discontinuation is often the preferred option in case of, e.g., substantial noncompliance 
with trial procedures or initiation of prohibited treatment that interferes with the efficacy and 
safety evaluation. If it is an investigator’s decision to discontinue the patient’s treatment, the 
investigator should, whenever possible, discuss the potential discontinuation of the treatment 
with the medical monitor. If the patient is discontinued from trial treatment by the investigator or 
by parent/guardian’s decision, the reason for treatment discontinuation and the date of treatment 
discontinuation will be recorded on the appropriate page of the eCRF. The patient should be 
asked to continue in the trial by following the planned visit schedule and to have trial 
assessments performed according to the Schedule of Events. This is especially important during 
Part 1 of the trial where the primary endpoint is evaluated. As a minimum, the patient will be 
asked to attend the Follow-up Visit 28 days (± 3 days) after discontinuation of trial treatment. 
9.5. Rescue Criteria 
During Part 1, the IV glucose concentration and rate of infusion can be increased to avoid 
hypoglycemia. When the maximum (or maximum tolerable) dose of trial drug has been reached 
and the necessary amount of GIR to prevent hypoglycemia is likely to cause (in the 
investigator’s opinion) a moderate or severe AE (e.g., volume overload), oral/gastric 
non-nutritional carbohydrates can be introduced to ensure the patient’s safety whilst maintaining 
the maximum tolerable concentration and infusion rate of IV glucose. 
During Part 2, patients are allowed to initiate and titrate oral/gastric non-nutritional 
carbohydrates, and initiate any CHI treatment. 
9.6. Patient Replacement Criteria 
Patients who withdraw from the trial prematurely will not be replaced. If a substantial number of 
patients withdraw prematurely, the sponsor will evaluate the need for developing replacement 
criteria. 
Enrolled patients (defined as randomized) who are subsequently withdrawn from the trial may 
not re-enter. The patient number for a withdrawn patient will not be reassigned to another 
patient. 
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10. TREATMENTS 
10.1. Identification of Investigational Product 
Dasiglucagon Injection, 4 mg/mL will be supplied by the sponsor in a 3 mL vial containing 1 mL 
of drug product. 
Matching placebo for dasiglucagon injection will be supplied by the sponsor in a 3 mL vial 
containing 1 mL of drug product. 
Dasiglucagon and matching placebo will be provided in the form of solution for injection for 
subcutaneous administration through an infusion pump. 
The trial drug product, as applicable, must be transferred from the vial to the Accu-Chek Spirit 
Cartridge. The amount of drug product dosed via the pump will vary among patients. 
Cartridges and infusion sets should be filled and replaced as indicated in the instructions for use. 
10.1.1. Packaging and Labeling 
Trial drug products will be packaged and labeled by the sponsor. 
Part 1 dispensing unit configuration: 3 vials containing dasiglucagon, 4 mg/mL or placebo for 
dasiglucagon, packed in an outer carton. The vials and carton will be packaged and labeled in 
local language without revealing the treatment. 
Part 2 dispensing unit configuration: 3 vials containing dasiglucagon, 4 mg/mL, packed in an 
outer carton. The vials and carton will be packaged and labeled in local language, revealing the 
treatment. 
The storage conditions for trial drug products will be described on the trial drug product label. 
The labels will supply no information about patients. Each dispensing unit (3 vials) will have a 
unique Dispensing Unit Number for drug allocation, drug accountability, and traceability 
purposes. 
Labelling will be performed according to Annex 13 of the Good Manufacturing Practice 
guidelines of the European Commission, ICH Good Clinical Practice (GCP) guidelines, local 
laws, and regulations. 
10.2. Treatments Administered 
As long as the patient is receiving IV glucose, the PG will be measured and reviewed hourly 
using a hand-held PG meter. The IV GIR will be titrated to achieve glycemia of at least 
70 mg/dL (3.9 mmol/L) (a minimum GIR will be established as the rate up-titrated after the 
patient drops at least once below 70 mg/dL [3.9 mmol/L]). When the patient is no longer on 
IV GIR, the PG will be checked according to local practice, but at least 3 times daily. The PG 
will be measured using the same trial-supplied hand-held PG meter during the entire trial. 
Additionally, blinded CGM will be started 24 hours prior to randomization (using the 
Dexcom G4 or G6 system) and continued until the end of Part 2. 
Dosing of dasiglucagon will approximate continuous infusion by delivering small doses at 
frequent intervals via the infusion pump. The adjustment of trial drug dosing is closely linked to 
the PG level achieved, which in turn will govern the IV GIR. In Part 1 the algorithm in Table 1 
should be used. 
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The pump administers 0.000025 mL/dose ~ 0.1 µg/dose (4 mg/mL formulation): 
• 10 µg/hr ~ 0.5 µg every 3 min 
• 20 µg/hr ~ 1 µg every 3 min 
• 30 µg/hr ~ 1.5 µg every 3 min 
• 40 µg/hr ~ 2µg every 3 min 
• 50 µg/hr ~ 2.5µg every 3 min 
• 60 µg/hr ~ 3µg every 3 min 
• 70 µg/hr ~ 3.5µg every 3 min 
Table 1 
Algorithm to Maintain Plasma Glucose 
Plasma Glucose 
(mg/dL) 
Plasma Glucose 
(mmol/L) 
Action 
<50 
<2.8 
Give 200 mg/kg of dextrose as a bolus and increase IV GIR by 
2 mg/kg/min 
50-59 
2.8-3.3 
Increase IV GIR by 2 mg/kg/min 
60-69 
3.3-3.9 
Increase IV GIR by 1 mg/kg/min 
70-80 
3.9-4.4 
No change 
81-90 
4.4-5.0 
Reduce IV GIR by 0.5 mg/kg/min 
91-100 
5.0-5.5 
Reduce IV GIR by 1 mg/kg/min 
101-120 
5.5-6.7 
Reduce IV GIR by 1.5 mg/kg/min 
>120 
>6.7 
Reduce IV GIR by 2 mg/kg/min 
Abbreviations: GIR = glucose infusion rate; IV = intravenous 
The IV GIR will be reviewed, evaluated, and adjusted (if indicated) every hour according to the 
above PG-driven algorithm to maintain a PG of >70 mg/dL (>3.9 mmol/L). Rechecks of PG are 
allowed. 
Part 1 (Crossover, double-blind, randomized, placebo-controlled) 
The starting dose of trial drug is 10 µg/hr at t=0. Every 2 hours (t=2, 4, 6, etc.), the dose will be 
increased by an additional 10 µg/hr until either: 
• The patient is totally weaned off IV glucose, or 
• Plasma glucose during the last 2 hours was constantly above 120 mg/dL (6.7 mmol/L), or 
• IV GIR has not decreased despite 2 sequential dose increments of trial drug (in this situation, 
the dose of trial drug should be maintained until the IV GIR can be further decreased or until 
crossover or the end of Part 1), or 
• The maximum dose of 70 µg/hr is reached, or 
• AEs emerge that are considered to be related to dasiglucagon (e.g., nausea/change in feeding 
pattern or increased vomiting) that are limiting further dose escalation. 
The 2-hour dose-adjustment interval will allow drug plasma levels to approach steady-state 
before the dose is further increased. The cumulative dose will not exceed 1.26 mg over the first 
24 hours and 1.68 mg for each of the subsequent 24-hour periods. 
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At the time of crossover from the first 48-hour period to the second 48-hour period, the trial drug 
will again be titrated from the starting dose of 10 µg/hr, and IV GIR will be set to the rate 
obtained at the end of the run-in period and titrated accordingly. 
Part 2 (Open-label) 
After Part 1, patients will continue in open-label Part 2 to receive dasiglucagon for a further 
21 days. Since treatment allocation during Part 1 remains blinded, all patients are required to 
initiate dasiglucagon dosing at 10 µg/hr in Part 2, while IV GIR should be started at the rate 
obtained at the end of the run-in period. 
During Part 2, the dasiglucagon dose, the amount and route of administration of carbohydrates 
(IV GIR, parenteral nutrition, gastric carbohydrate infusions, and carbohydrates from oral feeds) 
can be adjusted at the discretion of the investigator. The PG should be monitored at least hourly 
to adjust the IV GIR as appropriate and to avoid hypoglycemia. Additional concomitant 
medications, including somatostatin analogs and/or sirolimus/mTOR inhibitors, may be 
introduced at the investigator’s discretion if the maximum dose level of dasiglucagon (70 µg/hr) 
has been reached or if further up-titration is not possible due to undesirable side effects. 
Adjustment of total carbohydrate administered (IV glucose, parenteral nutrition, carbohydrate 
infusions, and carbohydrates from oral feeds) should continue throughout this period according 
to local practice to maintain PG levels in the range of 70 mg/dL to 120 mg/dL (3.9-6.7 mmol/L). 
The aim will be to obtain stable glucose levels with minimum rescue/hypoglycemia-preventative 
carbohydrates administered by invasive routes, and to encourage/optimize oral feeds, and 
achieve weaning off IV glucose. Regardless of their discharge status, all patients will be offered 
the opportunity to participate in the long-term safety extension trial (ZP4207-17106), providing 
the investigator attests to the positive benefit-risk balance of continued dasiglucagon treatment. 
10.3. Trial Supplies 
The device and ancillaries listed in the following table will be supplied by the sponsor 
throughout the trial. Trained trial personnel will train parent(s)/guardian on the use of the 
devices. 
Instructions for the use of all these supplies will be provided in separate manuals. 
Item 
Name 
Manufacturer 
Pump 
Accu-Chek Spirit Combo 
Hoffman-La Roche AG, Basel, Switzerland 
Cartridge 
Accu-Chek Spirit 3.15 mL Cartridge system 
Hoffman-La Roche AG, Basel, Switzerland 
Infusion sets 
Accu-Chek FlexLink Infusion set (Accu-Check 
UltraFlex Infusion set in US) 
and 
Accu-Chek Rapid-D Link Infusion set 
Hoffman-La Roche AG, Basel, Switzerland 
Infusion set 
inserter 
Accu-Chek LinkAssist Insertion device (can be 
used with FlexLink & UltraFlex) 
Hoffman-La Roche AG, Basel, Switzerland 
SMPG  
StatStrip Xpress2 
Nova Biomedical, Waltham, MA, USA 
CGM 
Dexcom G4 
Dexcom G6 
Dexcom Inc., San Diego, CA, USA 
 
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The infusion pump system is CE-marked for the management of diabetes mellitus in persons 
requiring insulin, as prescribed by a physician. In this trial, the pump system is used outside of 
the CE-marked intended use since the pump system will be delivering dasiglucagon to patients 
with CHI. The PG meter is used as intended according to the CE mark, except for the use by a 
lay person in a home care setting. The CGM devices are used as intended according to the CE 
mark, except for the age group and the disease. 
The pump, the SMPG, and the CGM will be labeled for use in an investigational trial. 
10.4. Dispensing and Storage 
The trial drug products supplied by the sponsor is to be dispensed exclusively to patients 
randomized in this clinical trial according to the instructions of this protocol and the pharmacy 
manual/trial materials manual (TMM). The investigator is responsible for dispensing the trial 
drug product according to the dosage scheme. Trial drug products will be allocated using an 
interactive automated web response system (IWRS), according to Section 10.5. 
Dasiglucagon and placebo for dasiglucagon injection must be stored at 2–8°C in a refrigerator. 
The investigator must ensure the availability of proper storage conditions. All trial drug products 
provided for this trial will be stored at the trial site in a secure area with restricted access. 
The temperature should be monitored by recording the actual, minimum, and maximum 
temperatures using a calibrated thermometer or thermocouple, or by continuous recording using 
a qualified temperature monitoring system. The temperature should be evaluated and 
documented at least on working days on a temperature log. This log must be included in the 
Investigator Site File (ISF) upon trial termination. 
The investigator must contact the clinical research associate (CRA) in case of temperature 
deviations outside the acceptable range. 
Please see the pharmacy manual/TMM for additional information on handling of the trial drug. 
The investigator must maintain adequate records showing the receipt, dispensing, return, or other 
disposition of the trial drug, including the date, quantity, batch or code number, and 
identification of patients (patient number) who received the trial drug. The investigator will not 
supply the trial drug to any person except subinvestigators, designated trial personnel, and 
patients in this trial. The trial drug may not be relabeled or reassigned for use by other patients. If 
any of the trial drug is not dispensed, is lost, stolen, spilled, unusable, or is received in a 
damaged container, this information must be documented and reported to the sponsor and the 
appropriate regulatory agencies as required. 
10.5. Method of Assigning Patients to Treatment Groups 
For Part 1, patients will be randomly assigned 1:1 in a double-blind fashion to 1 of 2 sequences: 
• 
Dasiglucagon 4 mg/mL for 48 hours, followed by placebo for dasiglucagon for 48 hours, or 
• 
Placebo for dasiglucagon for 48 hours, followed by dasiglucagon 4 mg/mL for 48 hours. 
Randomization will be performed using a block randomization scheme stratified by region 
(US/non-US). The randomization scheme will be generated prior to the initiation of the trial by 
an independent statistician/programmer who will not be a member of the trial team; investigators 
will not be aware of the block size of the randomization scheme. 
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Patients will be randomly assigned to a trial treatment sequence using an IWRS that has been 
validated for the intended use under the International Society of Pharmaceutical Engineers Good 
automated manufacturing practice guidelines, 21CFR Part 11 (FDA regulation for Electronic 
Records and Electronic Signatures), and the ICH Guidance E6 for Industry on Good Clinical 
Practice. 
After completing Part 1, patients will continue in Part 2 to receive active treatment for a 
maximum of 21 days. 
10.6. Blinding and Unblinding Treatment Assignment 
Trial personnel will endeavor to safeguard the integrity of the trial blind to minimize bias in the 
conduct of the trial. Treatment unblinding is discouraged if knowledge of the treatment 
assignment will not materially change the planned management of a medical emergency. 
Unblinding will be permitted in a medical emergency that requires immediate knowledge of the 
patient’s treatment assignment. 
For emergency unblinding, the investigator will use the measures provided through the IWRS. 
Unblinding should be discussed in advance with the medical monitor if possible. If the 
investigator is not able to discuss treatment unblinding in advance, then he or she must notify the 
medical monitor as soon as possible about the unblinding incident without revealing the patient’s 
treatment assignment. 
The investigator or designee must record the date and reason for unblinding on the appropriate 
eCRF page for that patient. 
10.7. Selection of Doses in the Trial 
Both the starting dose and the maximum allowed doses are based on experience with marketed 
glucagon products in this patient population.11 
At present, no pediatric PK data are available for dasiglucagon. However, an approximate 
estimation of expected drug concentration in a 3 kg patient has been made by extrapolation of a 
previously made PK model for pediatric patients with weights between 25 and 45 kg.17 
In this trial, dasiglucagon will be titrated to meet the needs of the individual patient on the basis 
of PD effects in regards to efficacy and tolerability, and it is expected that the majority of 
patients will be adequately treated with a dasiglucagon infusion rate of approximately 
20 to 40 μg/hr. The up-titration will stop when IV glucose is completely weaned, if undesirable 
side effects arise, or when no additional PD effects are observed as the dasiglucagon infusion 
rate is increased. 
Based on the current PK/PD model, the predicted plasma concentration is expected to result in a 
medium PD response at the lowest dose level and be approaching maximum effect at the highest 
dose level. The PD response of patients will be monitored closely in this trial, and the 
appropriateness of the applied titration algorithm will be evaluated. 
Although the PK of dasiglucagon has been shown to be dose-proportional in adults and in all 
toxicologically tested species over a wide range of doses, limited PK sampling at each dose level 
is planned based on the limited available blood volume in this population. 
10.8. Selection of Timing of Dose for Each Patient 
Dosing details are provided in Section 10.2. 
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10.9. Dose Adjustment Criteria 
Dose adjustment criteria are presented in Section 10.2. 
10.10. 
Treatment Compliance 
Compliance data will be collected. Infusion details will be recorded in the patient’s eCRF and 
drug accountability will be performed as detailed in the pharmacy manual/TMM. 
10.11. 
Permitted and Prohibited Therapies 
All concomitant medications used (including over-the-counter medications and herbal 
supplements) will be recorded in the source document and on the appropriate eCRF. 
Caution is advised when beta-blockers, indomethacin, anticholinergic drugs, and warfarin are 
prescribed due to reports of interaction with marketed glucagon products. 
10.11.1. 
Permitted Therapies 
Regarding diazoxide, patients entering the trial either: 
• Have tried diazoxide, but discontinued due to lack of efficacy. Minimum of 6 days’ washout 
is required prior to randomization. 
• Have tried diazoxide, but discontinued due to adverse events, or family choice, even if 
efficacy was established. Minimum of 6 days’ washout is required prior to randomization. 
• Have initiated diazoxide prior to screening, and continue on the treatment. Diazoxide dose 
should remain stable during Part 1 of the trial. Diazoxide should not be initiated during 
screening. 
• Have never tried diazoxide. Diazoxide should not be initiated during screening or Part 1 of 
the trial. 
Prior use of octreotide is allowed after a minimum 48-hour washout prior to randomization. 
Washout is required to eliminate the effect of octreotide during Part 1, where adjustment of GIR 
has to follow the protocol-defined PG-driven algorithm (Table 1) and the primary endpoint on 
mean GIR is assessed. 
Somatostatin analogs and/or diazoxide can be introduced during Part 2 if needed, at the 
investigator’s discretion, when the maximal limit of dasiglucagon (70 µg/hr) has been reached or 
if further up-titration is not possible due to undesirable side effects. 
Addition of other CHI-specific treatments (e.g., sirolimus/mTOR inhibitors) during Part 2 need 
to be discussed with the medical monitor. 
10.11.2. 
Prohibited Therapies 
The following therapies are prohibited: 
During the entire trial: 
• Systemic corticosteroids, e.g., hydrocortisone >20 mg/m2 body surface area or equivalent 
within 5 days before screening 
• Anti-inflammatory biological agents or other immune-modulating agents 
• Use of paracetamol/acetaminophen is strongly discouraged for the duration of trial when 
patients are using the Dexcom G4 CGM because it interferes with the accuracy of the device. 
Parent(s)/guardian should contact the trial site before dosing child with 
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paracetamol/acetaminophen. Both the site staff and the parent(s)/guardian should explore 
other options of treating fever and mild pain before deciding paracetamol/acetaminophen is 
needed 
When patients are using the Dexcom G6 CGM the use of paracetamol/acetaminophen is 
allowed 
• Other investigational agents. 
• Marketed glucagon products within the last 24 hours prior to randomization and throughout 
the trial unless necessary for rescue therapy in case of severe hypoglycemia, as per local 
standard of care. 
• Prescription or non-prescription medications known to cause QT prolongation. 
During Screening and Part 1: 
• Somatostatin analogs and sirolimus (mTOR inhibitors). No new CHI treatment is to be 
initiated during screening and Part 1. Octreotide is allowed in the screening period if 
discontinued at least 48 hours before randomization. 
During Part 2 and follow-up: 
• Initiation of somatostatin analogs, diazoxide and sirolimus (mTOR inhibitors) unless the 
maximum dose level of dasiglucagon (70 µg/hr) has been reached or further dasiglucagon 
up-titration is not possible due to undesirable side effects 
10.12. 
Discharge of Patients for Home Treatment 
Patients can be discharged during Part 2 to complete the treatment at home as soon as IV GIR 
has been weaned off and local site criteria for discharge are met. Discharge for home treatment is 
contingent on the parent(s)/guardian being capable of taking care of the administration of 
investigative product via pump at home, can use SMPG and CGM devices, and are able to attend 
planned assessment visits at the hospital. 
Before discharge of patients from hospital care, the investigator will ensure: 
• Appropriate training of patient’s parent(s)/guardian in the use of dasiglucagon in the Accu-
Chek Spirit Combo pump based on the training material provided. The first pump infusion 
set change should be performed at the hospital 
• Parent(s)/guardian are trained appropriately on the handling of CGM device 
• Parent(s)/guardian are trained appropriately on how to perform SMPG measurements and 
how to complete the diary. They will check their child’s SMPG at least 3 times daily 
(preferably before main meals) and in case of suspected hypoglycemia 
• Parent(s)/guardian are instructed not to change the dose of trial drug without prior 
consultation with the investigator 
• Parent(s)/guardian are instructed how to recognize and handle signs of hypoglycemia 
• Parent(s)/guardian are instructed to call the investigator/site staff in case of questions 
Patients who are discharged from hospital before Day 25 will be contacted by the investigator by 
telephone the day after discharge. The investigator will ask the parent(s)/guardian if they have 
any questions about the trial procedures and if their child has experienced any AEs. 
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10.13. 
Treatment After End of Trial 
On Day 25, the End of Treatment Visit will take place. Based on the investigator’s confirmation 
of continued positive benefit-risk balance, patients will be offered the opportunity to enter the 
long-term extension trial (Trial ZP4207-17106) to continue dasiglucagon treatment. Patients who 
do not enter the long-term extension trial will have a Follow-up Visit 28 days after their last dose 
of trial drug and return to standard of care as per investigator discretion. No further treatment 
with dasiglucagon will be offered. 
11. TRIAL PROCEDURES 
Patients’ parent(s)/guardian (according to local law) must provide written informed consent 
before any trial-related procedures are initiated, including the cessation of prohibited 
concomitant therapy. 
For the timing of assessments and procedures throughout the trial, refer to the Schedule of 
Events (Section 18.1). Throughout the trial, trial personnel should make every reasonable effort 
to follow the timing of assessments and procedures in Section 18.1 for each patient. If a patient 
misses a trial visit for any reason, it should be rescheduled as soon as possible. 
11.1. Trial Duration 
The sequence and maximum duration of the trial periods will be as follows: 
1. Screening Period: up to 28 days, including a minimum 24-hour run-in period 
2. Part 1 (2x48-hour period: double-blind, randomized, placebo-controlled): 96 hours 
3. Part 2 (Open-label Active Treatment Period): 21 days 
4. Follow-up Period: Patients who do not enter the extension trial will have a Follow-up Visit 
28 days after their last dose of trial drug 
The maximum trial duration for each patient is 81 days. The maximum treatment duration for 
each patient is 25 days. 
11.2. Assessments 
11.2.1. Efficacy 
11.2.1.1. Plasma Glucose Monitoring 
As long as the patient is receiving IV glucose, the GIR will be reviewed hourly, based on an 
hourly PG check performed by the StatStrip Xpress2 meter. The IV GIR will be reviewed, 
evaluated, and adjusted (if indicated) according to the IV GIR algorithm based on PG levels 
specified in Table 1. If IV glucose has been stopped, PG will be checked according to local 
practice, but at least 3 times daily. 
Blood for PG check can be obtained either by finger or heel sticks or by an indwelling peripheral 
line. However, if using an indwelling peripheral line, the total blood volume drawn during a 
28-day period should be considered according to Section 11.2.3.1. 
At each visit, the investigator will ensure that SMPG data are downloaded from the patient’s 
device. The investigator will check for patient compliance in SMPG measurements. The 
procedure for download of SMPG data will be described in the pharmacy manual/TMM. 
Adjustments to the trial drug will be made as outlined in Section 10.2. 
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11.2.1.2. Continuous Glucose Monitoring 
Dexcom CGMs (Dexcom G4 and Dexcom G6), configured and labeled for use in the trial, will 
be provided. The Dexcom G4 will be taken off the market by the supplier during 2020 and 
patients enrolled thereafter will be using the Dexcom G6 CGM. Patients using the Dexcom G4 
CGM will continue using this device throughout the trial and should not switch to the Dexcom 
G6 device. 
The CGM will be started at least 24 hours prior to randomization and will be used during Parts 1 
and 2 in a blinded mode to evaluate efficacy in terms of hypoglycemic episodes. Short pauses of 
1 to 3 days due to skin irritation or discomfort are allowed during Part 2 of the trial after 
consultation with the investigator. 
The CGM devices should be calibrated and used according to the manufacturer’s instructions; 
the Dexcom G4 should be calibrated 2 times per day, the Dexcom G6 does not require 
calibration. 
At each visit, the investigator will ensure that CGM data are downloaded from the patient’s 
device. The procedure for download of CGM data will be described in the pharmacy 
manual/TMM. 
The contract research organization (CRO) or delegate will handle the device sourcing, 
configuration for use in this trial, procedures for blinded data extraction, device service, and 
handling of potential returns. 
11.2.1.3. Diary 
For patients who are discharged during the trial, the parent(s)/guardian will receive a paper diary 
to be completed at home. The investigator will instruct the patient’s parent(s)/guardian on how to 
complete the diary. The following information should be recorded in the diary: 
• Type and volume of fluid administered through NG tube/gastrostomy 
• Hypoglycemic events, including related SMPG measurements 
• Concomitant medications 
• AEs 
• Hospitalizations, visits to health care providers or emergency room (ER)/accident & 
emergency (A&E) department, and visits by paramedics 
• Data regarding suspicion of NME and neurological findings 
Diary entries should be reviewed at each visit and the review documented in the diary. Data from 
the diary entries should be transcribed to the eCRF on an ongoing basis. 
11.2.2. Pharmacokinetics/Drug Exposure 
Blood samples will be collected in Part 2 to measure dasiglucagon levels at steady-state 
(Schedule of Events; Section 18.1). The blood samples should be collected after a minimum of 
4 hours without changes to the dasiglucagon infusion rate. For patients with a body weight above 
4 kg, an additional PK sample should be collected at Day 5. However, the total amount of blood 
collected should always be considered according to Section 11.2.3.1. 
Details on sampling/collection, shipment, and analysis will be provided in the laboratory manual. 
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11.2.3. Safety 
Safety assessments will include the evaluation of AEs, clinical laboratory assessments 
(hematology, biochemistry, and ADAs), vital signs, physical examinations, ECGs, 
echocardiography, and local tolerability. 
11.2.3.1. Laboratory Safety Assessments 
Trial procedures require a maximum total of 8.8 to 9.2 mL of blood in a 28-day period. Where 
this exceeds the 2.5 mL/kg maximum,18,19 safety laboratory tests (2 mL per sampling) will be 
prioritized over immunogenicity (1 mL) and drug exposure (0.4 mL) samples. 
All measurements described in this section are recognized standard methods. 
Hematology and Biochemistry 
Samples for hematology and biochemistry will be collected at the time points specified in the 
Schedule of Events (Section 18.1). 
Hematology: 
hemoglobin, hematocrit, red blood cell (RBC) count, RBC indices, mean 
corpuscular hemoglobin, mean corpuscular hemoglobin concentration, 
platelet count (or estimate), white blood cell count, including differential 
Biochemistry: 
albumin, total bilirubin, total protein, calcium, alkaline phosphatase, 
alanine aminotransferase, aspartate aminotransferase, blood urea 
nitrogen, creatinine, glucose, sodium, potassium, chloride, eGFR, 
ketones (measured with PG meter) 
Standard of care blood samples can be used as screening samples if they were collected within 
1 week of screening. 
Laboratory specimens will be analyzed at local laboratories. 
Immunogenicity 
Blood samples will be collected to test for antibodies against dasiglucagon at Visit 2 (Day 1, 
prior to dosing), Visit 7 (Day 25 ±3), and at the Follow-up Visit (Visit 8, Day 53 ±3) 
(Section 18.1) and processed and shipped according to instructions provided in the laboratory 
manual. 
The samples will be stored until the ADA screening and confirmatory assays have been approved 
by the FDA. Afterwards, the ADA samples will be analyzed in batches during the trial. The 
ADA samples will be analyzed at a specialty laboratory. 
The clinical ADA assays specific for dasiglucagon and glucagon have been validated in 
accordance with existing guidelines and recommendations.19,21,22,23 
Samples will be measured in anti-dasiglucagon antibody screening and confirmatory assays. Due 
to the limited sample volume, the ADA characterization of confirmed positive samples will be 
conducted according to the following priority: 
• Establishment of anti-dasiglucagon binding titer. 
• Cross-reactivity against endogenous glucagon. 
The neutralizing potential in samples from ADA-positive patients will be evaluated on the basis 
of drug exposure/PD data (steady-state exposure and PG). 
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The ADA samples will be analyzed in batches during the trial and any anti-dasiglucagon 
antibody-positive patients (treatment induced or treatment boosted, titer increase above 5-fold) 
will be monitored at an additional Follow-up Visit, preferably 16 weeks after last ADA-positive 
sample. Patients who complete the trial before the ADA screening and confirmatory assays have 
been approved by the FDA and who do not continue treatment in the long-term extension trial 
will have this additional visit 16 weeks after the end of trial visit (Visit 8). Patients who are 
tested ADA-positive after the additional Follow-up Period will be categorized as having 
persistent antibodies. 
It will not be possible to collect back-up ADA samples for long-term storage due to limited 
blood volume in these patients. However, any residual serum samples may be stored until 
approval of market authorization since further characterization of the antibody response may be 
requested. 
Specimen Handling Requirements 
The transmission of infectious agents may occur through contact with contaminated needles and 
blood or blood products. Consequently, appropriate blood and body fluid precautions should be 
employed by all trial personnel involved in the collection of blood and handling of specimens in 
both the clinic and laboratory settings. Refer to current recommendations of the appropriate 
authorities. 
In addition to appropriate handling of patient samples, specific regulations exist regarding the 
shipment of biologic/etiologic samples. Procedures and regulations for the packaging and 
shipping of infectious samples are outlined in the laboratory manual. The investigator is 
responsible for ensuring that all trial samples that are to be transported to another location are 
packed and shipped appropriately according to the applicable regulations. 
Evaluation of Laboratory Values 
The normal ranges of values for the laboratory assessments in this trial will be provided by the 
responsible laboratories and submitted to the sponsor before the beginning of the trial. They will 
be regarded as the reference ranges on which decisions will be made. 
If a laboratory value is out of the reference range, the investigator must evaluate if the value is 
clinically significant and record his or her assessment in the appropriate eCRF. 
All laboratory values that in the investigator’s opinion are clinically relevant during or after 
termination of the treatment have to be reported as AEs and followed, as described in 
Section 12.3. 
11.2.3.2. Clinical Examinations 
Vital Signs 
Vital signs, including blood pressure, heart rate, respiratory rate, and SpO2 will be measured 
while the child is sleeping or in a calm state at times specified in the Schedule of Events 
(Section 18.1). Vital signs can be performed using the bedside monitoring device as per standard 
of care. 
Twelve-lead Electrocardiogram 
A standard 12-lead ECG will be performed while the child is sleeping or in a calm state at times 
specified in the Schedule of Events (Section 18.1). If it is not practical or possible, then a 2-lead 
ECG may be used.24 If arrhythmia is detected on a 2-lead ECG, this should be followed by 
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12-lead ECG. All ECG recordings will be identified with the patient number, date, and time of 
the recording and will be attached to his or her medical record. 
The ECG parameters (heart rate, PQ, QRS, QT, and QTcF) and any abnormality will be recorded 
and described in the eCRF, including the investigator’s assessment of clinical significance 
(Abnormal, Clinically Significant; or Abnormal, Not Clinically Significant). At subsequent 
visits, any clinically significant deterioration of a pre-existing condition, as well as any new 
clinically significant findings, will be recorded as AEs. 
Echocardiogram 
An echocardiogram will be performed according to the time points specified in the Schedule of 
Events (Section 18.1). 
Physical Examination and Neurological Examination 
A complete physical examination of body systems according to standard of care and an 
age-appropriate neurological examination will be performed according to the Schedule of Events 
(Section 18.1). 
Local Tolerability 
Local tolerability data will be collected separately from AEs. Within the eCRF, data will be 
collected on the nature of any reaction (erythema, pain, swelling, etc.), the severity (mild, 
moderate, or severe), and any action taken (e.g., no action, interruption of infusion). The likely 
cause of the reaction will also be collected (e.g., insertion site, drug, adhesive dressing). 
Other skin findings will be collected along other AEs. If clinical suspicion of NME is made, data 
describing the lesion(s) will be collected as an AE of special interest (AESI) (see Section 12.1.8), 
together with a photograph or series of photographs of the lesion(s) uploaded to a central 
repository. 
Assessment of Fluid Balance for Patients Receiving IV Glucose 
Fluid balance assessments are to be performed and documented at least every 8 hours as long as 
the patient is hospitalized and receiving IV glucose. These assessments will include administered 
IV and oral fluids, fluid loss from stools and urine by weighing of diapers, and vital signs of fluid 
balance status. Furthermore, daily body weight will also be part of the individualized assessment 
based on the patients overall status, at investigator’s discretion. According to Section 9.5, the 
investigator should evaluate whether the IV glucose concentration should be increased to avoid 
volume overload or whether oral/gastric non-nutritional carbohydrates are to be introduced to 
ensure the patient’s safety whilst maintaining the maximum tolerable concentration and infusion 
rate of IV glucose. 
All details on IV GIR (including any bolus given) will be recorded in the eCRF. 
11.2.3.3. Reporting of Hypoglycemia Events 
All hypoglycemic episodes are to be reported via the dedicated hypoglycemia eCRF form. 
Hypoglycemic episodes that fulfill the definition of a serious adverse event (SAE) should also be 
recorded as an SAE. The following information should be collected: 
• Date, start time 
• PG value 
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•
Selected symptoms (e.g., unconsciousness, seizures)
•
Intervention, type, and amount of food; route of administration (oral vs. NG
tube/gastrostomy); and use of marketed glucagon as rescue therapy
•
Subsequent PG measurements
•
End time and PG value (time when PG exceeded a threshold of 70 mg/dL [3.9 mmol/L])
•
Contact to trial doctor or emergency services, paramedic visit, ER admission, hospitalization,
if applicable
A single hypoglycemia episode is defined as up until 60 minutes from the start of the episode. If 
normoglycemia (>70 mg/dL) is not reached within this time, a new episode of hypoglycemia will 
be recorded. 
11.2.4. Technical Complaints 
Reporting of Technical Complaints 
Technical complaints should be reported to the sponsor on any of the following products if 
technical issues occur between the first and last use: 
•
Dasiglucagon 4 mg/mL / placebo vial containing 1 mL
•
Accu-Chek Spirit pump
•
Accu-Chek Spirit 3.15 mL Cartridge system, Accu-Chek Flex-Link Infusion set
(Accu-Check UltraFlex Infusion set in the US), and Accu-Check Rapid-D Link infusion set
•
Accu-Chek Link-Assist Insertion device
•
SMPG meter, StatStrip Xpress2
•
Dexcom G4/G6 systems
The investigator must report whether the technical complaint is associated with any AEs or 
SAEs. Any AE/SAE associated with a technical complaint must be reported in accordance with 
Section 12.2; the relationship between the technical complaint and the AE/SAE must be assessed 
by the investigator. 
Technical complaints must be reported on a dedicated technical complaint form. 
The investigator must complete the technical complaint form in the eCRF according to the 
following timelines, starting from the time the trial site becomes aware of the technical 
complaint: 
•
Technical complaint assessed as related to an SAE within 24 hours
•
All other technical complaints within 5 calendar days
Use the Trial paper technical complaint form when reporting a technical complaint for an item
that is not yet allocated to a patient. The form should be sent by e-mail to e-mail address in the 
Appendix A. 
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Collection, Storage, and Shipment of Technical Complaint Items 
The investigator must collect and store the item(s) and notify the CRA (including photo 
documentation) within 5 calendar days of obtaining the item at the trial site. Upon request, the 
CRA must coordinate the shipment as per instruction from the sponsor. 
11.2.4.1. Adverse Events 
The definitions and management of and special considerations for AEs are provided in 
Section 12. 
12. ADVERSE EVENTS 
Timely, accurate, and complete reporting and analysis of safety information from clinical trials 
are crucial for the protection of patients, investigators, and the sponsor, and are mandated by 
regulatory agencies worldwide. 
12.1. Definitions 
12.1.1. Adverse Events 
An AE is any untoward medical occurrence in a clinical trial patient administered a medicinal 
(investigational or noninvestigational) product and which does not necessarily have a causal 
relationship with this treatment. An AE can therefore be any unfavorable and unintended sign 
(including an abnormal laboratory finding), symptom, or disease temporally associated with the 
use of a product, whether or not related to the product. 
AEs include: 
• A clinically significant worsening of a concomitant illness 
• A clinical laboratory AE: a clinical abnormality which is clinically significant, i.e., any 
abnormality that suggests a disease and/or organ toxicity and is of a severity that requires 
active management. Active management includes active treatment or further investigations, 
e.g., change of dose or more frequent follow-up due to the abnormality. 
The following should not be considered as AEs: 
• Pre-existing conditions, including those found as a result of screening procedures 
(pre-existing conditions should be reported as medical history or concomitant illness). 
• Preplanned procedure, unless the condition for which the procedure was planned has 
worsened from the first trial-related activity after the patient has signed the informed consent. 
12.1.2. Severity 
When assessing the severity of an AE, the following definitions are used: 
Mild: No or transient symptoms, no interference with the patient's daily activities 
Moderate: Marked symptoms, moderate interference with the patient's daily activities 
Severe: Considerable interference with the patient's daily activities, which the patient find 
unacceptable. A severe reaction does not necessarily deem the AE as serious (SAE), and an SAE 
is not always severe in nature. 
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12.1.3. Causality 
When assessing the cause of an AE, the following definitions are used: 
Probable: Good reason and sufficient documentation to assume a causal relationship 
Possible: A causal relationship is conceivable and cannot be dismissed 
Unlikely: The event is most likely related to etiology other than the product 
Not related: No relationship to product. 
Causality will take into consideration whether the cause of the AE was related to the trial drug, 
device, or procedures. 
12.1.4. Outcome 
When assessing the outcome of an AE, the following definitions are used: 
Recovered/resolved: The patient has fully recovered, or by medical or surgical treatment, the 
condition has returned to the level observed at the first trial-related activity after the patient 
signed the ICF 
Recovering/resolving: The condition is improving and the patient is expected to recover from 
the event. This term is only applicable as final outcome of an event if the patient has completed 
the trial or has died from another AE 
Recovered/resolved with sequelae: The patient has recovered from the condition, but with 
lasting effect due to a disease, injury, treatment, or procedure. If a sequela meets an SAE 
criterion, the AE must be reported as an SAE 
Not recovered/not resolved: The condition of the patient has not improved and the symptoms 
are unchanged, or the outcome is not known 
Fatal: This term is only applicable if the patient died from a condition related to the reported 
AE. Outcomes of other reported AEs in a patient before he/she died should be assessed as 
“recovered/resolved,” “recovering/resolving,” “recovered/resolved with sequelae,” or “not 
recovered/not resolved.” An AE with fatal outcome must be reported as an SAE 
Unknown: This term is only applicable if the patient is lost to follow-up. 
12.1.5. Serious Adverse Events 
An SAE is any untoward medical occurrence that at any dose results in any of the following: 
• results in death 
• is life-threatening 
• requires inpatient hospitalization or prolongation of existing hospitalization 
• results in persistent or significant disability or incapacity 
• is a congenital anomaly or birth defect 
• is otherwise medically important and may not result in death, be life-threatening, or require 
hospitalization may be considered an SAE when (based on appropriate medical judgement) it 
may jeopardize the patient and may require medical or surgical intervention to prevent one of 
the outcomes listed in the definition of an SAE. Examples could be ER or home treatment of 
allergic bronchospasm or convulsion 
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12.1.6. Other Important Events 
The following events must always be reported in the electronic data capture (EDC) system on a 
dedicated form, regardless of whether it is related to an AE: 
• suspicion of transmission of infectious agents via the trial product 
• overdose of the trial product 
• medication error involving the trial product 
• inadvertent or accidental exposure to the trial product 
12.1.7. Nonserious Adverse Events 
A nonserious AE is any AE that does not fulfill the definition of an SAE. 
12.1.8. Adverse Events of Special Interest 
For this trial, the following events are to be regarded as AESIs, with data collected under a 
specific eCRF form: 
• Suspicion of NME 
• Risk of liver injury defined as ALT or AST >3 x UNL AND total bilirubin >2 x UNL, where 
no alternative etiology exists (Hy’s law) 
• Loss of consciousness, partial, and generalized seizures 
• Clinically significant changes in blood pressure or heart rate 
12.1.9. Suspected Unexpected Serious Adverse Reactions 
An AE is considered a suspected unexpected serious adverse reaction (SUSAR) if the nature or 
severity is not consistent with the applicable product Reference Safety Information (RSI). For 
dasiglucagon, the expectedness of an AE will be determined by whether or not it is listed in the 
RSI section of the investigator’s brochure. 
12.2. Collection, Recording, and Reporting of Adverse Events 
All AEs, whether serious or nonserious, will be reported from the time a signed and dated ICF is 
obtained until the end of the posttreatment follow-up period (which may include contacts for 
follow-up of safety) or inclusion in the ZP4207-17106 trial. Parent(s)/guardian will be asked 
about their child’s condition by open questioning, such as “How has your child been feeling 
since you were last asked?” at each contact with the trial site (visit or telephone). 
Parent(s)/guardian will also be encouraged to spontaneously report AEs occurring at any other 
time during the trial. In addition, patients will be observed for any signs or symptoms. 
All AEs, regardless of seriousness, severity, or presumed relationship to the trial drug, must be 
recorded and evaluated by the investigator. Whenever possible, diagnoses should be given when 
signs and symptoms are due to a common etiology. If no diagnosis can be made, the investigator 
should record each sign and symptom as individual AEs. Investigators must record their opinion 
concerning the relationship of the AE to the trial drug. All measures required for AE 
management must be recorded in the source document and reported according to sponsor 
instructions. 
Each AE must be reported on the AE eCRF within 5 days of the investigator becoming aware of 
the event. 
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All AE information should at a minimum include the following: 
• Date and time of onset 
• Date and time of investigator's first information about the AE 
• Seriousness 
• Severity 
• Causal relationship with trial product 
• Measures taken due to AE 
• Interruption or discontinuation of treatment with trial product 
• Date and time of resolution and final outcome 
Each AE will be coded using the latest version of the Medical Dictionary for Regulatory 
Activities (MedDRA). 
All SAEs, including those spontaneously reported to the investigator within 30 days after the last 
dose of trial drug, must be reported within 24 hours after obtaining knowledge about the event by 
completing the SAE form in the EDC system. A separate SAE form should be completed for 
each SAE. 
All SAEs will be reported in EDC; for each reported event a system-generated e-mail will be 
sent to the safety CRO (
), medical monitor, sponsor medical director, and trial 
manager. 
Specific information about AESIs will be collected via the SAE form (if qualifying for an SAE), 
as well as via the dedicated AESI eCRF page(s). Reporting requirements for serious and 
nonserious AEs as described previously also apply for serious and nonserious AESIs. 
Other important events (Section 12.1.6) will be reported via a dedicated eCRF page. Reporting 
timelines will be within 24 hours if related to an SAE, and 5 calendar days for all other events. 
It is the responsibility of 
to report all SUSARs that occur in this trial to competent 
authorities, the institutional review board (IRB), or independent ethics committee (IEC) in 
accordance with the local requirements in force and ICH guideline for GCP. 
12.2.1. Contact Information 
Pharmacovigilance for this trial is outsourced to 
; refer to Appendix A for contact 
details. 
12.3. Follow-up of Adverse Events 
The investigator must record follow-up information on the eCRF for nonserious adverse event 
and on the SAE form for serious adverse events. Follow-up questions to investigators regarding 
serious adverse events are queried directly by 
 to the investigator. 
Follow-up information must be reported according to the following: 
• SAEs: All SAEs must be followed until the outcome of the events is “recovered/resolved,” 
“recovered/resolved with sequelae,” or “fatal,” and until all queries have been resolved. 
Cases of chronic conditions, cancer, or AEs that are ongoing at time of death (where death is 
due to another AE) may be closed with the outcome “recovering/resolving” or “not 
recovered/not resolved.” Cases can be closed with the outcome of “recovering/resolving” 
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when the patient has completed the follow-up period and is expected by the investigator to 
recover. 
The SAE follow-up information should only include new (e.g., corrections or additions) 
information and must be reported within 24 hours of the investigator's first knowledge of the 
information. This is also the case for previously nonserious AEs which subsequently become 
SAEs. 
• Nonserious AEs: Nonserious AEs must be followed until the outcome of the event is 
“recovered/resolved,” or “recovered/resolved with sequelae” or until the end of the follow-up 
period stated in the protocol, whichever comes first, and until all queries related to these AEs 
have been resolved. Cases of chronic conditions, cancer, or AEs that are ongoing at time of 
death (where death is due to another AE) may be closed with the outcome of 
“recovering/resolving” or “not recovered/not resolved.” Cases can be closed with the 
outcome of “recovering/resolving” when a patient has completed the follow-up period and is 
expected by the investigator to recover or if the patient continues in the extension trial. 
If a potential hypersensitivity reaction is observed, additional blood samples, as clinically 
indicated, may be required to further characterize the potential hypersensitivity reaction. If an 
anaphylactic shock is suspected, samples may be taken for the measurement of tryptase. In this 
case, a blood sample should be taken 3 to 4 hours after the event and again approximately 
1 to 2 weeks later to determine tryptase baseline levels. In addition, assessments for elevated 
histamine levels may be considered. 
The investigator must ensure that the worst-case severity and seriousness of an event is kept 
throughout the trial, from the start of trial product administration (i.e. the most severe of the 
applied severity/seriousness categories should be ascribed to the event). Accordingly, for AEs 
with onset after trial product administration, changes in the severity or seriousness of an event 
should not lead to reporting of separate AEs. In contrast, for AEs with onset before trial product 
administration, any worsening of severity/seriousness after trial product administration should be 
recorded as a separate AE, with onset date of the event corresponding to the date of the 
severity/seriousness upgrade. Similarly, AEs with onset during the blinded treatment that worsen 
after the switch to the second blinded treatment or to the unblinded treatment, should be recorded 
as separate AEs. 
If an AE is resolved and re-appears later then it should be reported as a new AE. 
Queries or follow-up requests must be responded within 14 calendar days from the date of 
receipt of the request, unless otherwise specified in the follow-up request. 
12.4. Precautions 
Normal precautions taken for a clinical trial, including the provision of emergency equipment, 
will be taken during this trial. Qualified and well-trained physicians and medical staff will 
instruct patients’ parent(s)/guardian. During a patient’s participation in the trial, the investigator 
should ensure that adequate medical care is provided to patients for any AEs, including clinically 
significant laboratory values related to the trial. The investigator should inform the patient’s 
parent(s)/guardian when medical care is needed for intercurrent illnesses of which the 
investigator becomes aware. 
For further information on safety precautions for dasiglucagon, refer to the current version of the 
IB. 
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12.5. Safety Committee 
An internal Zealand Safety Committee is constituted to perform ongoing safety surveillance of 
clinical trials with dasiglucagon, including this trial. 
If safety signals or concerns are observed, whether based on reported SAEs, review of all AEs 
and laboratory parameters reported, or any other notification of significant findings, the Safety 
Committee will respond appropriately to protect the safety of the patients. The Safety Committee 
meets quarterly and on an ad hoc basis as needed. 
12.6. Independent Data Monitoring Committee 
An independent data monitoring committee (DMC) will be established for this trial and follow 
the procedures outlined in the DMC Charter. 
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13. STATISTICS 
13.1. Statistical Hypotheses 
This section details the null hypotheses for this trial. They are presented in the form Hij, where 
i = trial part (i = 1, 2) and j = hypothesis number (j = 1, 2, 3, 4, 5). 
The hypothesis relates to the primary endpoint of mean IV GIR in the last 12 hours of each 
treatment period during Part 1. Formally, the hypothesis is: 
H11: Mean IV GIR dasiglucagon = Mean IV GIR placebo 
The hypotheses relating to the key secondary endpoints (based on the last 48 hours of each 
treatment period in Part 1) are: 
H12: Total amount (g) of carbohydrates administered (regardless of the route) per day 
dasiglucagon = total amount (g) of carbohydrates administered (regardless of the route) 
per day placebo 
A fixed-sequence statistical strategy will test first the primary (Section 7.2.1) and then the key 
secondary endpoint of Part 1 (Section 7.2.2), all at the same significance level (α = 0.05, 2-sided 
test), moving to the next hypothesis only after rejecting the previous null hypothesis. 
The test hierarchy is: 
Part 1 
H11: Mean IV GIR in the last 12 hours of each treatment period during Part 1 (primary 
endpoint) 
H12: Total amount (g) of carbohydrates administered (regardless of the route) per day 
(key secondary endpoint) 
13.2. Sample Size Determination 
A total of 12 patients is planned to be randomized and exposed to trial product in this crossover 
trial on the basis of the following considerations. 
The GIR results from 40 infants treated with IV glucagon for 24 hours published in the JIMD 
Research Report “The Effect of Continuous Intravenous Glucagon on Glucose Requirements in 
Infants with Congenital Hyperinsulinism.”14 
“Overall there was a statistically significant reduction in the median (IQR) GIR during the 24h 
following initiation of continuous glucagon infusion compared to 24 h before initiation 
(18.5 (12.9, 22.8) to 11 (6.6, 17.5) mg/kg/min…” 
This trial is powered to detect an effect in GIR for dasiglucagon after 48 hours compared to 
placebo of at least this effect size. Based on the longer infusion and titration of dasiglucagon in 
this trial, this is considered a conservative approach, allowing for some uncertainty when 
translating the published data into a clinical trial setting. Using unpublished individual patient 
data from the above-referenced study, the difference in GIR between the 2 treatment groups is 
assumed to follow a normal distribution. Assuming the true mean difference is 7.5 mg/kg/min 
with a standard deviation of differences of 7.36, the trial will have 89% power using a 1-sample 
t-test with 12 patients randomized to receive either placebo first and then dasiglucagon or vice 
versa. 
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13.3. Analysis Populations 
Three analysis populations have been defined for this trial: 
• The Safety Set: defined as all patients administered any randomized treatment. 
• The Full Analysis Set (FAS): defined as all patients in the Safety Set who have a valid 
baseline efficacy assessment. Patients will be analyzed according to randomized treatment 
(Part 1) or overall patients (otherwise). 
• Per protocol (PP) set: defined as all patients in the FAS without any major protocol 
deviations. Patients will be excluded from the PP set if they do not receive both treatments 
and/or do not have efficacy data available to evaluate the primary endpoint for both 
treatments. 
• Pharmacokinetic Set (PK): defined as all patients in the Safety Set who have at least 1 
measurement with quantifiable plasma concentration of dasiglucagon. 
The primary analyses of the primary and key secondary endpoints will be based on the FAS. 
Supportive analyses of the primary and key secondary endpoints will be based on the PP. All 
safety analyses will be based upon the safety analysis set. 
Inclusion in the analysis populations will be determined prior to database lock. 
For the primary endpoint, baseline is defined as the IV GIR rate obtained at the end of the run-in 
period which corresponds to the last value obtained before randomization. During the 24-hour 
run-in period, all non-nutritional carbohydrates and carbohydrate fortification of feeds are 
prohibited as this might impact the GIR level and result in many updates during the run-in 
period. Therefore the IV GIR rate obtained at the end of the run-in period will give a better 
estimate of the stabilized value of GIR. For the second period of the crossover (Part 1), the IV 
GIR is also started at the IV GIR obtained at the end of the run-in period.For the purpose of all 
other efficacy analyses where applicable, baseline is defined as the last measurement prior to the 
start of trial drug administration on Day 1. 
13.4. Statistical Analyses 
This section presents a summary of the planned statistical analyses. A statistical analysis plan 
(SAP) that describes the details of the analyses to be conducted will be finalized prior to database 
lock. 
Unless otherwise indicated, testing of statistical significance will be 2 sided with a significance 
level of α = 0.05. 
Continuous endpoints will be summarized with number (n), mean, standard deviation (SD), 
median, minimum, and maximum. In addition, change from baseline values will be calculated at 
each time point and summarized descriptively; the exception to this is the time of PG within 
prespecified ranges, which will not have a baseline value. For categorical endpoints, descriptive 
summaries will include counts and percentages. 
All data will be presented in the data listings. 
Immunogenicity data will be analyzed descriptively. No statistical tests are planned. Baseline 
ADA-positive patients will be calculated as a percentage of the total number of patients whose 
baseline samples were tested for ADA. Overall ADA incidence, the combined results of 
treatment-induced and treatment-boosted ADA-positive patients will be calculated as a 
percentage of the total number of evaluable patients, excluding baseline positive patients without 
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any samples available after drug administration. Titers will be reported as median and 
interquartile range. 
Graphical presentations of selected endpoints will be prepared and will be outlined in the SAP. 
13.4.1. Trial Patients and Demographics 
13.4.1.1. Disposition and Withdrawals 
The numbers of patients randomized, completing, and withdrawing, along with reasons for 
withdrawal, will be tabulated overall and by treatment sequence. The number of patients in each 
analysis population will be reported. 
13.4.1.2. Protocol Deviations 
Protocol deviations will be provided in a listing and summarized if appropriate. 
13.4.1.3. Demographics and Other Baseline Characteristics 
Demographic and baseline characteristics (including age, sex, race, ethnicity, weight, and length) 
at screening will be summarized using descriptive statistics. No formal statistical analyses will be 
performed. 
Prior and concomitant medications and procedures will be summarized by treatment sequence 
(prior medications and procedures) or treatment and part (concomitant medications and 
procedures), by the number and percentage of patients taking each medication, classified using 
World Health Organization Drug Dictionary Anatomical Therapeutic Chemical classes and 
preferred term (PT). 
13.4.2. Duration of Exposure and Compliance 
Trial drug administration (i.e., amount administered) will be summarized in terms of each 
patient’s mean, mode, and final dose, and in terms of duration of exposure. Descriptive statistics 
for these quantities, including the mean, median, SD, minimum, maximum, and quartiles, will be 
provided by treatment and part. 
13.4.3. Efficacy Analyses 
13.4.3.1. Primary Analysis 
The mean IV GIR in the last 12 hours of each treatment period during Part 1 will be analyzed for 
the FAS and PP populations. The hypothesis: 
H11: Reduction in weighted mean IV GIR dasiglucagon = Reduction in weighted mean 
IV GIR placebo 
will be based the last 12 hours of each treatment period, calculated as a weighted mean across the 
12 hours, taking the actual time periods between the measurements into account (corresponding 
to calculating the area under the curve [AUC] and dividing by the length of the time period, 
i.e., weighted mean IV GIR). The IV GIR endpoint is expressed as glucose in mg/kg/min, i.e., 
data reported from different concentrations of the glucose used for infusion will be transformed 
to this standardized unit prior to analysis. 
The primary analysis is defined by the estimand based on the treatment policy (de-facto) 
strategy, where the actual GIR measurement reported irrespective of adherence to treatment or 
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use of subsequent therapy is used. The reduction in weighted mean IV GIR between placebo and 
dasiglucagon will be estimated. 
The weighted mean IV GIR will be analyzed using a mixed-model regression approach, with 
treatment and period as fixed effects and patient as a random effect. The 2-sided 95% confidence 
interval (CI) for the treatment difference will be calculated from the mixed regression model. 
Missing data will be imputed using the following methodology: if the weighted mean IV GIR is 
missing for the placebo period, it will be imputed using the baseline weighted mean IV GIR; if 
the weighted mean IV GIR is missing for the dasiglucagon period, it will be imputed using the 
placebo-weighted mean IV GIR for that patient. As a sensitivity analysis, the primary endpoint 
will be re-analyzed as follows: 1) using only complete cases (i.e., weighted mean IV GIR is 
non-missing for both placebo and dasiglucagon) and 2) imputing missing weighted mean IV GIR 
using the baseline weighted mean IV GIR and 3) imputing missing dasiglucagon values during 
one period with the placebo value for that patient and imputing missing placebo values with the 
mean values of placebo patients for that period.. 
13.4.3.2. Key Secondary Analyses 
The hypothesis: 
H12: Total amount (g) of carbohydrates administered (regardless of the route) per day 
dasiglucagon = total amount (g) of carbohydrates administered (regardless of the route) 
per day placebo 
between the 2 treatment groups will be analyzed by using a mixed-model regression approach, 
with treatment and period as fixed effects and patient as a random effect. The total amount (g) of 
carbohydrates administered (regardless of the route) per day is the sum of the last 48 hours of 
each period in Part 1. 
For the key secondary endpoint, 2-sided 95% CIs for the treatment differences will be estimated 
from the mixed-model. Missing dasiglucagon values during one period will be imputed with the 
placebo value for that patient and missing placebo values will be imputed with the mean values 
of placebo patients for that period. In addition, a sensitivity analysis will be performed using 
complete cases. 
13.4.3.3. Secondary and Other Efficacy Analyses 
Part 1 
A mixed-model regression approach will be used to analyze the weighted mean IV GIR over 48-
hour treatment period during Part 1 (dasiglucagon or placebo administration) similar to the 
primary analysis for the primary endpoint. 
A generalized estimating equation (GEE) method with a logit link function will be used to 
analyze the weighted mean IV GIR below 10 mg/kg/min in the last 12 hours of each treatment 
period during Part 1 (yes/no) (dasiglucagon or placebo administration) to account for repeated 
observations in patients. In case of non-convergence, a Mc Nemar test will be used. 
No sensitivity analysis will be used on these endpoints. 
Part 2 
Due to the potential impact of pancreatectomy on the secondary endpoints during Part 2, any 
endpoint assessment after pancreatectomy will not be included in the primary analyses 
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(endpoints set to missing after pancreatectomy). Sensitivity analyses will be run on those 
endpoints including all assessments in the descriptive analyses. 
For Part 2 efficacy endpoints, continuous and categorical endpoints will be presented using 
summary statistics or frequencies, respectively; no formal testing will be performed. For the time 
to complete weaning off IV GIR, the time to actual hospital discharge and the time to pancreatic 
surgery, Kaplan-Meier curves will be produced. 
13.4.4. Safety and Tolerability Analyses 
Safety analyses will be conducted using data from the Safety Population (as defined in 
Section 13.3). Safety assessments will include the evaluation of AEs; clinical laboratory 
assessments (hematology, biochemistry, and ADAs); vital signs, physical examinations; ECGs, 
echocardiography, and local tolerability issues. No formal inferential analyses will be conducted 
for safety variables, unless otherwise noted. 
Baseline is defined as the last nonmissing assessment before the first exposure to trial drug in the 
trial. 
All safety analyses will be summarized by treatment received within treatment period and part 
and by trial visit, if applicable. 
13.4.4.1. Adverse Events 
Adverse events will be coded using the most current version of MedDRA. 
A treatment-emergent AE is defined as an AE with an onset at the time of or following the start 
of treatment with the trial drug through the Follow-up Visit or Early Termination Visit, 
whichever occurs first. 
The number and percentage of patients with AEs, as well as the number of AEs, will be 
displayed by system organ class, PT, and treatment group. The incidence of AEs will also be 
presented by severity and relationship to the trial drug. Serious AEs, AESIs and AEs resulting in 
discontinuation of trial drug will be summarized separately in a similar manner. Patient listings 
of AEs, SAEs, AESIs, and AEs causing discontinuation of trial drug and withdrawal from the 
trial will be produced. 
13.4.4.2. Clinical Laboratory Evaluations 
Descriptive summaries (mean, SD, median, minimum, and maximum) of actual (absolute) values 
and changes from baseline values will be presented for clinical laboratory values. 
The number of patients with clinical laboratory values categorized as below, within, or above 
normal ranges will be tabulated showing change from baseline (shift tables) for each clinical 
laboratory analyte. 
Laboratory values that are outside the normal range will also be flagged in the data listings, 
along with corresponding normal ranges. Any out-of-range values that are identified by the 
investigator as being clinically significant will also be shown in a data listing. 
13.4.4.3. Vital Signs 
Descriptive summaries (mean, SD, median, minimum, and maximum) of actual values and 
changes from baseline will be calculated for systolic blood pressure, diastolic blood pressure, 
heart rate, respiratory rate, and SpO2. 
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The number of patients with vital signs values categorized as Abnormal, Clinically Significant or 
Abnormal, Not Clinically Significant will be tabulated showing change from baseline (shift 
tables) for each parameter. 
13.4.4.4. Twelve-lead Electrocardiograms 
The number and percentage of patients with normal and abnormal ECG findings will be 
summarized. Abnormal results will be grouped as Abnormal, Clinically Significant or Abnormal, 
Not Clinically Significant. 
13.4.4.5. Echocardiograms 
The number and percentage of patients with normal and abnormal echocardiogram findings will 
be summarized. Abnormal results will be grouped as Abnormal, Clinically Significant or 
Abnormal, Not Clinically Significant. 
13.4.4.6. Physical Examination Findings 
The number and percentage of patients with normal and abnormal findings in the complete 
physical examination will be displayed. 
13.4.4.7. Local Tolerability 
The number and percentage of patients with local tolerability findings, collected separately from 
AEs, will be summarized. 
13.4.5. Interim Analysis 
No interim analysis is planned. 
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14. TRIAL CONDUCT 
The accuracy and reliability of data are ensured, among others, by the selection of qualified 
investigators and appropriate trial sites, review of protocol procedures with the investigator and 
associated personnel before the trial, periodic monitoring visits, and meticulous data 
management. 
14.1. Sponsor and Investigator Responsibilities 
14.1.1. Sponsor Responsibilities 
The sponsor is obligated to conduct the trial in accordance with strict ethical principles 
(Section 16). The sponsor reserves the right to terminate participation of a trial site at any time 
(Section 14.7), and/or to discontinue the trial (Section 14.6 for US studies and Section 14.6.2 for 
studies conducted outside of the US). 
The sponsor agrees to provide the investigator with sufficient material and support to permit the 
investigator to conduct the trial according to the trial protocol. 
14.1.2. Investigator Responsibilities 
By signing the Investigator’s Agreement (Section 18.2), the investigator indicates that he/she has 
carefully read the protocol, fully understands the requirements, and agrees to conduct the trial in 
accordance with the procedures and requirements described in this protocol. 
The investigator also agrees to conduct this trial in accordance with all laws, regulations, and 
guidelines of the pertinent regulatory authorities, including the November 2016 ICH Guidance 
for Industry E6(R2) GCP, and in agreement with the 2013 version of the Declaration of Helsinki. 
While delegation of certain aspects of the trial to subinvestigators and trial coordinators is 
appropriate, the investigator will remain personally accountable for closely overseeing the trial 
and for ensuring compliance with the protocol and all applicable regulations and guidelines. The 
investigator is responsible for maintaining a list of all persons that have been delegated 
trial-related responsibilities (e.g., subinvestigators and trial coordinators) and their specific 
trial-related duties. 
Investigators should ensure that all persons who have been delegated trial-related responsibilities 
are adequately qualified and trained in the protocol, trial drugs handling, and their specific duties 
within the context of the trial. Investigators are responsible for providing the sponsor with 
documentation of the qualifications, GCP training, and research experience for themselves and 
their staff as required by the sponsor and the relevant governing authorities. 
To ensure compliance with the guidelines, the trial may be audited by an independent person. 
The investigator agrees, by written consent to this protocol, to cooperate fully with compliance 
checks by allowing access to all trial documentation by authorized individuals. 
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14.2. Site Initiation 
Trial personnel may not screen or enroll patients into the trial until after receiving notification 
from the sponsor or its designee that the trial can be initiated at the trial site. The trial site will 
not be authorized for trial initiation until: 
1. The trial site has received the appropriate IRB/IEC approval for the protocol and the 
appropriate ICF. 
2. All regulatory documents have been submitted to and approved by the sponsor or its 
designee. 
3. The trial site has a Clinical Trial Agreement in place. 
4. Trial site personnel, including the investigator, have participated in a trial initiation meeting. 
The regulatory documents must be received from the investigator before the sponsor will 
authorize shipment of trial drug to the trial site, Regulatory Green Light. Copies of the 
investigator’s regulatory documents must be retained at the trial site in a secure location in the 
ISF. Additional documents, including a copy of the protocol and applicable amendment(s), the 
dasiglucagon IB, eCRF completion guidelines, copies of regulatory references, copies of 
IRB/IEC correspondence, and trial drug accountability records should also be retained in the ISF. 
It is the investigator’s responsibility to ensure that copies of all required regulatory documents 
are organized, current, and available for inspection. 
14.3. Screen Failures 
Patients who fail inclusion and/or exclusion criteria may be rescreened for the trial upon 
approval by the sponsor and medical monitor. Patients may only be rescreened once 30 days or 
more after the original Screening Visit. If a patient is eligible to enter the trial after having 
previously failed screening, the patient will be assigned a new patient identification number. 
14.4. Trial Documents 
All documentation and material provided by the sponsor for this trial are to be retained in a 
secure location and treated as confidential material. 
14.4.1. Investigator’s Regulatory Documents 
The regulatory documents will be maintained by the investigator in the ISF. 
14.4.2. Case Report Forms 
By signing the Investigator’s Agreement (Section 18.2), the investigator agrees to maintain 
accurate eCRFs and source documentation as part of the case histories for all patients who sign 
an ICF. 
Case report forms are considered confidential documents and should be handled and stored 
accordingly. The sponsor or its designee will provide the necessary training on the use of the 
specific eCRF system used during the trial to ensure that the trial information is captured 
accurately and appropriately. 
To ensure data accuracy, eCRF data for individual patient visits should be completed as soon as 
possible after the visit. All requested information must be entered in the EDC system according 
to the completion guidelines provided by the sponsor or its designee. 
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The eCRF must be signed by the investigator or a subinvestigator when all data are entered and 
cleaned. These signatures serve to attest that the information contained in the eCRF is accurate 
and true. 
14.4.3. Source Documents 
Information recorded in the eCRF should be supported by corresponding source documentation. 
Examples of acceptable source documentation include, but are not limited to, hospital records, 
clinic and office charts, laboratory notes, and recorded data from automated instruments, 
memoranda, and pharmacy dispensing records. 
Clinical laboratory data required by the protocol will be entered into the eCRF at the site. 
The investigator should permit trial-related monitoring, IEC review, regulatory inspections, and 
sponsor audit by providing direct access to source data and documents. 
14.5. Data Quality Control 
The sponsor and its designees will perform quality control checks on this clinical trial. 
14.5.1. Monitoring Procedures 
The sponsor and/or its designee will conduct site visits to monitor the trial and ensure (i) the 
safety and rights of the patients are respected, (ii) compliance with the protocol, GCP, and 
applicable regulations and guidelines, and (iii) that accurate, valid, and complete data are 
collected. The assigned CRA(s) will visit the investigator and trial site at periodic intervals and 
maintain periodic communication, this are described in detail in the Monitoring Plan. The 
investigator agrees to allow the CRA(s) and other authorized sponsor personnel access to ISF 
and source data (original documents, data, and records). The CRA(s) will maintain current 
personal knowledge of the trial through observation, review of trial records and source 
documentation, and discussion of the conduct of the trial with the investigator and staff. While 
on site, the CRA(s) will review: 
• regulatory documents 
• entries in the EDC system compared with the source documents 
• consents 
• adherence to the inclusion/exclusion criteria 
• AE records 
• storage and accountability of trial drug and trial materials 
• adherence to the protocol and ICH GCP 
The CRA(s) will ask for clarification and/or correction of any noted inconsistencies. Procedures 
for correcting eCRFs are described in the Trial Reference Manual. As representatives of the 
sponsor, CRAs are responsible for notifying project management of any noted protocol 
deviations. 
By signing the Investigator’s Agreement (Section 18.2), the investigator agrees to meet with the 
CRA(s) during trial site visits; to ensure that trial staff is available to the CRA(s) as needed; to 
provide the CRA(s) access to all trial documentation, to the clinical supplies dispensing and 
storage area; and to assist the monitors in their activities, if requested. Further, the investigator 
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agrees to allow the sponsor or designee auditors or inspectors from regulatory agencies to review 
records, and to assist the inspectors in their duties, if requested. 
14.5.2. Data Management 
The sponsor or designee will be responsible for activities associated with the data management 
of this trial. The standard procedures for handling and processing records will be followed per 
GCP and Premier standard operating procedures. A comprehensive data management plan will 
be developed, including a data management overview, description of database contents, 
annotated eCRF, pre-entry review list, self-evident correction conventions, query contacts, and 
consistency checks. 
Trial site personnel will be responsible for providing resolutions to all data queries. The 
investigator will be required to document electronic data review to ensure the accuracy of the 
corrected and/or clarified data. Procedures for soliciting and documenting resolution to data 
queries are described in the trial manual. 
14.5.3. Quality Assurance/Audit 
This trial will be subject to audit by the sponsor/its designee or national/international regulatory 
authorities. Audits may be performed to check compliance with GCP guidelines, and can 
include: 
• site audits 
• trial master file audits 
• database audits 
• document audits (e.g., protocol and/or the clinical trial report [CTR]) 
The sponsor or its designee may conduct additional audits on a selection of trial sites, requiring 
access to patient notes, trial documentation, and facilities or laboratories used for the trial. 
The trial site, facilities, all data (including source data), and documentation will be made 
available for audit by quality assurance auditors and for IRB/IEC or regulatory authorities 
according to GCP guidelines. The investigator agrees to cooperate with the auditor during the 
visit and will be available to supply the auditor with eCRFs or other files necessary to conduct 
that audit. Any findings will be strictly confidential. 
If a regulatory authority informs the investigator that it intends to conduct an inspection, the 
investigator shall notify the sponsor immediately. 
14.6. Trial Termination 
The trial may be terminated at the sponsor’s discretion at any time and for any reason. 
14.6.1. Regular Trial Termination 
The end of this trial is defined as the date of the last visit of the last patient (last patient out or 
last patient last visit) participating in the trial. Within 90 days of the end of the clinical trial, the 
sponsor or its designee and/or site will notify the IRBs and IECs and regulatory authorities on the 
regular termination of the trial as required according to national laws and regulations. 
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14.6.2. Premature Trial Termination 
The trial may be terminated prematurely for any reason and at any time by the sponsor, the 
IRBs/IECs, regulatory authorities, respective steering committees, or the coordinating 
investigator. A decision to terminate the trial prematurely is binding to all investigators at all trial 
sites. 
Within 15 days of premature termination of a clinical trial, the sponsor or its designee and/or site 
will notify the IRBs/IECs and regulatory authorities on the premature termination as required 
according to national laws and regulations. The sponsor or its designee must clearly explain the 
reasons for premature termination. 
If the trial is terminated prematurely, all investigators must inform their patients and take care of 
their appropriate follow-up and further treatment to ensure protection of their interests. Trial sites 
may be asked to have all patients currently participating in the trial complete all of the 
assessments for an Early Termination Visit. 
14.7. Trial Site Closure 
At the end of the trial, all trial sites will be closed. The sponsor may terminate participation of a 
trial site at any time. Examples of conditions that may require premature termination of a trial 
site include, but are not limited to, the following: 
• Noncompliance with the protocol and/or applicable regulations and guidelines 
• Inadequate patient enrollment 
14.7.1. Record Retention 
After trial completion at sites in the US, the investigator shall retain and preserve 1 copy of all 
data generated in the course of the trial, specifically including, but not limited to, those defined 
by GCP as essential until: 
• At least 2 years after the last marketing authorization for the trial drug has been approved or 
the sponsor has discontinued its research with the trial drug, or 
• At least 2 years have elapsed since the formal discontinuation of clinical development of the 
trial drug 
However, these documents should be retained for a longer period if required by the applicable 
regulatory requirement(s) or if needed by the sponsor. 
At the end of such period, the investigator shall notify the sponsor in writing of his or her intent 
to destroy all such material. The sponsor shall have 30 days to respond to the investigator’s 
notice, and the sponsor shall have a further opportunity to retain such materials at the sponsor’s 
expense. 
After trial completion at sites in Europe, the sponsor will receive a copy of their data in 
electronic format (e.g., CD) and retain them for at least 25 years. 
One copy will remain with the investigator. The investigator shall arrange for the retention of the 
patient identification codes, patient files, and other source data until at least 5 years after the last 
approval of a marketing application in an ICH region and until there are no pending or 
contemplated marketing applications in an ICH region, or until at least 2 years have elapsed 
since the formal discontinuation of the clinical development of the product. These documents 
need to be retained for a longer period of time if required by applicable regulatory authorities or 
by agreement with the sponsor. 
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The investigator shall keep copies of these trial records (and all trial-related documents, 
including source data) for the maximum period of time permitted by the hospital, institution, or 
private practice. 
14.7.2. Sample Retention 
Samples will only be used for purposes related to this trial. 
All blood samples will be destroyed upon completion of the CTR, except for residual ADA 
samples, which will be stored until approval of market authorization because further 
characterization of the antibody response may be requested by the health authorities. Identifiable 
samples can be destroyed at any time at the request of the patient. 
14.8. Changes to the Protocol 
This protocol cannot be altered or changed except through a formal protocol amendment, which 
requires the written approval of the sponsor. The protocol amendment must be signed by the 
investigator and approved by the IRB/IEC before it may be implemented. Protocol amendments 
will be filed with the appropriate regulatory agency(s) having jurisdiction over the conduct of the 
trial. 
14.9. Use of Information and Publication 
All information concerning dasiglucagon, the sponsor’s operations, patent applications, 
formulae, manufacturing processes, basic scientific data, and formulation information supplied 
by the sponsor or its designee to the investigator and not previously published, is considered 
confidential and remains the sole property of the sponsor. Case report forms also remain the 
property of the sponsor. The investigator agrees to use this information for purposes of trial 
execution through finalization and will not use it for other purposes without the written consent 
of the sponsor. 
The information developed in this trial will be used by the sponsor in connection with the 
continued development of dasiglucagon and thus may be disclosed as required to other clinical 
investigators or government regulatory agencies. 
The information generated by this trial is the property of the sponsor. Publication or other public 
presentation of dasiglucagon data resulting from this trial requires prior review and written 
approval of the sponsor. Abstracts, manuscripts, and presentation materials should be provided to 
the sponsor for review and approval at least 30 days prior to the relevant submission deadline. 
It is agreed that the results of the trial will not be submitted for presentation, abstract, poster 
exhibition or publication by the investigator until the sponsor has reviewed and commented on 
such a presentation or manuscript for publication. 
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15. FINAL CLINICAL TRIAL REPORT 
The sponsor will retain ownership of the data. 
The final CTR will be prepared and reviewed in cooperation with the signatory investigator. The 
coordinating investigator will be appointed by the sponsor to review and sign the CTR on behalf 
of all participating investigators. This report will include a summary of the trial results based on 
a statistical evaluation and clinical assessment of the protocol-defined endpoints. 
The final CTR may be submitted to the regulatory authorities. 
16. ETHICAL AND LEGAL CONSIDERATIONS 
16.1. Declaration of Helsinki and Good Clinical Practice 
This trial will be conducted in compliance with the November 2016 ICH Guidance for Industry 
E6(R2) GCP (including archiving of essential trial documents), the 2013 version of the 
Declaration of Helsinki, and the applicable regulations of the country(ies) in which the trial is 
conducted. 
See Appendix B for regulation and guidelines. 
16.2. Patient Information and Informed Consent 
According to the Declaration of Helsinki and ICH GCP, patients’ parent(s)/guardian must 
provide their written informed consent prior to enrollment in a clinical trial and before any 
protocol-specified procedures are performed. Patients’ parent(s)/guardian must declare their 
consent by personally signing and dating the ICF. The written ICF will embody the elements of 
informed consent as described in the Declaration of Helsinki and will also comply with local 
regulations. 
Each patient’s parent(s)/guardian should be made aware by the investigator of the nature of the 
trial (objectives, methods, and potential hazards and benefits) and the procedures involved using 
the information on the ICF. Information should be given in both oral and written form whenever 
possible and deemed appropriate by the IRB/IEC. Patients’ relatives, or, if necessary, legal 
representatives must be given ample opportunity to inquire about details of the trial. 
Patient information and the ICF must be in a language fully comprehensible to the prospective 
patient’s parent(s)/guardian. The written information must be provided to the patient’s 
parent(s)/guardian to give him or her sufficient time to understand the information and to prepare 
questions before being asked for his or her consent. The investigator must confirm that the text 
was understood by the patient’s parent(s)/guardian. The patient’s parent(s)/guardian will then 
sign and date the IRB/IEC-approved consent form indicating that he or she has given his or her 
consent for his or her child to participate in the trial. The signature confirms that the consent is 
based on information that has been understood. The form will also be signed by the investigator 
obtaining the consent and annotated with the trial patient number. Each signed patient 
parent(s)/guardian ICF must be kept on file by the investigator for possible inspection by 
regulatory authorities, the sponsor, and/or the sponsor’s designee. Collection of informed consent 
has to be documented on the eCRF. 
Furthermore, the patient’s parent(s)/guardian will be informed that if he or she wishes to 
drop-out or withdraw his or her child (see Section 9.2.3) at any time during the trial, this will not 
have any negative consequences. Patients may be withdrawn by the investigator if any change 
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related to safety or ethics precludes further participation in the trial. Patients’ parent(s)/guardian 
will be asked to agree to a final assessment in the event of an early termination of the trial. 
If information becomes available that may be relevant to the patient’s willingness to continue 
participating in the trial, the investigator must inform the patients’ parent(s)/guardian in a timely 
manner, and a revised written informed consent must be obtained. 
Patients’ parent(s)/guardian will be informed that data from their children’s case may be stored 
in a computer without inclusion of their name and that such data will not be revealed to any 
unauthorized third party. Data will be reviewed by the monitor, an independent auditor, and 
possibly by representatives of regulatory authorities and/or IRBs/IECs. The terms of the local 
data protection legislation will be applied as appropriate. 
16.3. Approval by Institutional Review Board and Independent Ethics Committee 
For Investigational New Drug studies, the minimum standards of conduct and requirements for 
informed consent are defined in the FDA regulations. 
A valid IRB/IEC must review and approve this protocol before trial initiation. Written 
notification of approval is to be provided by the investigator to the sponsor’s monitor and project 
manager before shipment of investigational drug supplies, and will include the date of the 
committee’s approval and the chairperson’s signature. This written approval must consist of a 
completed sponsor form, IRB/IEC Approval Form, or written documentation from the IRB/IEC 
containing the same information. 
Until written approval by the IRB/IEC has been received by the investigator, no patient may 
undergo any procedure not part of routine care for the patient’s condition. 
Protocol amendments must also be reviewed and approved by the IRB/IEC. Written approval 
from the IRB/IEC, or a designee, must be received by the sponsor before implementation. This 
written approval will consist of a completed IRB Approval Form or written documentation from 
the IRB/IEC containing the same information. 
16.4. Finance and Insurance 
Details on finance and insurance will be provided in a separate agreement between the 
investigator and the sponsor. 
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17. REFERENCES 
 
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Arnoux J-B, Verkarre V, Saint-Martin C, et al. Congenital hyperinsulinism: current trends in 
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De Leon DD, Stanley CA. Congenital hypoglycemia disorders: New aspects of etiology, 
diagnosis, treatment and outcomes. Pediatr Diabetes. 2016;1-7. 
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Lord K, Radcliffe J, Gallagher PR, et al. High risk of diabetes and neurobehavioral deficits 
in individuals with surgically treated hyperinsulinism. J Clin Endocrinol Metab. 
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Stanley CA. Perspective on the genetics and diagnosis of congenital hyperinsulinism 
disorders. J Clin Endocrinol Metab. 2016;101(3):815-826. 
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Mazor-Aronovitch K, Gillis D, Lobel D, et al. Long-term neurodevelopmental outcome in 
conservatively treated congenital hyperinsulinism. Eur J Endocrinol. 2007;157(4):491-497. 
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Welters A, Lerch C, Kummer S, et al. Long-term medical treatment in congenital 
hyperinsulinism: a descriptive analysis in a large cohort of patients from different clinical 
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Arya VB, Senniappan S, Demirbilek H, et al. Pancreatic endocrine and exocrine function in 
children following near-total pancreatectomy for diffuse congenital hyperinsulinism. PLoS 
ONE. 2014;9(5):e98054. https://doi.org/10.1371/journal.pone.0098054. 
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Cederblad F, Ewald U, Gustafsson J. Effect of glucagon on glucose production, lipolysis 
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Miralles RE, Lodha A, Perlman M, Moore AM. Experience with intravenous glucagon 
infusions as a treatment for resistant neonatal hypoglycemia. Arch Pediatr Adolesc Med. 
2002;156(10):999-1004. 
10. Lord K, Dzato E, Snider KE, Gallagher PR, De Leon DD. Clinical presentation and 
management of children with diffuse and focal hyperinsulinism: a review of 223 cases. 
J Clin Endocrinol Metab. 2013;98(11):E1786-E1789. 
11. Mohnike K, Blankenstein O, Pfuetzner A, et al. Long-term non-surgical therapy of severe 
persistent congenital hyperinsulinism with glucagon. Horm Res. 2008;70:59-64. 
12. Pedersen JS, Dikov D, Flink JL, Jhuler HA, Christiansen G, Otzen DE. The changing face 
of glucagon fibrillation: structural polymorphism and conformational imprinting. 
J Mol Biol. 2006;355(3):501-523. 
13. Rose SR, Chrousos G, Cornblath M, Sidbury J. Management of postoperative 
nesidioblastosis with zinc protamine glucagon and oral starch. J Pediatr. 
1986;108(1):97-100. 
14. Hawkes CP, Lado JJ, Givler S, De Leon DD. The Effect of Continuous Intravenous 
Glucagon on Glucose Requirements in Infants with Congenital Hyperinsulinism. JIMD Rep. 
2019;45:45-50. 
15. Chastain MA. The glucagonoma syndrome: A review of its features and discussion of new 
perspectives. Am J Med Sci. 2001;321(5):306–320. 
16. International Conference on Harmonisation, Guideline for Good Clinical Practice. Retrieved 
June 20, 2018, from http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/ 
Guidelines/Efficacy/E10/Step4/E10_Guideline.pdf 
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17. Zealand Pharma report. Population PK modeling and simulation of dasiglucagon in pediatric 
patients with type I diabetes mellitus. 2017. 
18. European Medicines Agency. ICH Topic E11: Clinical Investigation of Medicinal Products 
in the Paediatric Population. January 2001. 
19. Howie, S. Blood sample volumes in child health research: review of safe limits. Bull World 
Health Organ 2011; 89:46–53. 
20. Food and Drug Administration (FDA). Guidance for Industry on Bioanalytical Method 
Validation. Food and Drug Administration. 2001. 
21. Viswanathan CT, Bansal S, Booth B, et al. Quantitative bioanalytical methods validation 
and implementation: best practices for chromatographic and ligand binding assays. 
Pharm Res. 2007;24(10):1962-73. 
22. Shankar G, Devanarayan V, Amaravadi L, et al. Recommendations for the validation of 
immunoassays used for detection of host antibodies against biotechnology products. 
J Pharm Biomed Anal. 2008;48(5):1267-81. 
23. Zealand Pharma report SS. Commissioning and validation of a method for the validation of 
anti-ZP4207 antibodies in human serum. 2014. 
24. Food and Drug Administration (FDA). Guidance Industry. E14 Clinical Evaluation of 
QT/QTc Interval Prolongation and Proarrhythmic Potential for Non-antiarrhythmic Drugs. 
Food and Drug Administration. 2005. 
 
 
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18. ATTACHMENTS 
18.1. Schedule of Events 
Table 2 
Schedule of Events 
Period 
Screening 
Part 1 (2x48-hr period: double-blind, 
randomized, placebo-controlled) 
Part 2 (21-day Open-label Active) 
Follow-
upa 
Visit day 
  
1b 
2 
3 
4 
5 
6 
11c 
18c 
25 
Telephone 
Calld  
53 
Time window  
Day -28 to -1 
0 
0 
0 
0 
0 
0 
±2 
±2 
±3 
 
±3 
Visit # 
1 
2 
3 
4 
5 
6 
7 
 
8 
General assessments 
  
  
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/exclusion criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
Randomization exclusion criteria 
 
X 
 
 
 
 
 
 
 
 
 
 
Demography 
X 
 
 
 
 
 
 
 
 
 
 
 
Body weight and lengthe 
Xe 
X 
X  
X  
X  
X 
X 
X 
X 
Xe 
 
 
Medical history (including current 
illnessf) 
X 
 
 
 
 
 
 
 
 
 
 
 
Concomitant medication 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
Safety Assessment 
  
 
 
 
 
 
 
 
 
 
Electrocardiogram 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
Echocardiography 
Xg 
 
 
 
 
 
 
 
 
 
 
X 
Vital signs 
X 
Xh 
Xh 
Xh 
Xh 
Xh 
Xh 
X 
X 
X 
 
X 
Adverse events 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Local tolerabilty 
  
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Physical examination and 
neurological examination 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
Fluid balance assessmenti 
 
Continuous (when receiving IV Glucose) 
 
 
Laboratory 
  
 
 
 
 
 
 
 
 
 
Clinical laboratory testsj 
X 
 
 
 
 
X 
 
 
X 
 
X 
Anti-drug antibodies 
  
Xk 
 
 
 
 
 
 
 
X 
 
Xk 
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Period 
Screening 
Part 1 (2x48-hr period: double-blind, 
randomized, placebo-controlled) 
Part 2 (21-day Open-label Active) 
Follow-
upa 
Visit day 
  
1b 
2 
3 
4 
5 
6 
11c 
18c 
25 
Telephone 
Calld  
53 
Time window  
Day -28 to -1 
0 
0 
0 
0 
0 
0 
±2 
±2 
±3 
 
±3 
Visit # 
1 
2 
3 
4 
5 
6 
7 
 
8 
Pharmacokinetics/drug exposure 
 
 
 
 
 
Xl 
X 
 
 
X 
 
 
Efficacy 
  
  
 
 
 
 
 
 
 
 
Continuous glucose monitoring 
 X (for 24 hours 
prior to 
randomization) 
 
Continuous 
 
 
Self-monitoring plasma glucose 
 
X 
 
 
IV GIR adjustment 
  
Continuous (until weaned off) 
 
 
Trial Materials and Reminders 
 
 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
 
 
Dispense patient diary 
 
 
 
 
 
 
 
Upon dischargem  
 
 
Diary recording 
 
 
 
 
 
 
 
Continuous after 
discharge from hospital 
 
 
Dispensing of trial product 
 
X 
 
X 
 
X 
 
 
 
 
 
 
Drug accountability 
 
 
 
X 
 
X 
 
X 
X 
X 
 
 
Abbreviations: GIR = glucose infusion rate; IV = intravenous; SOC = standard of care; SpO2 = blood oxygen saturation level 
Note: Unscheduled visits can occur at any time if the investigator deems it necessary for patient safety. 
a 
The Follow-up Visit will only be performed for patients who will not enter the extension trial. 
b After screening, eligible patients will complete a minimum 24-hour run-in period to confirm the IV glucose randomization requirement (≥10 mg/kg/min). All non-nutritional 
carbohydrates and carbohydrate fortification of feeds are prohibited during this 24-hour run-in period. 
c 
Visits 5 (Day 11) and 6 (Day 18) can be converted to phone visits at the investigator’s discretion. 
d Patients who are discharged from the hospital before Day 25 will be contacted by the investigator by telephone the day after discharge. The investigator will ask the 
parent(s)/guardian if they have any questions about the trial procedures and if their child has experienced any AEs. 
e 
Body length will be measured at screening and at the End of Treatment Visit. 
f 
For CHI diagnosis: Data on biochemical parameters, genotyping results, and information about PET CT should be captured when available. 
g An echocardiogram performed within 1 month of screening can be used. 
h Vital signs should be measured at 6 ± 1, 12 ± 2, and 24 ± 4 hours after initiation of the trial drug and every 8 ± 2 hours hereafter. 
i 
Fluid balance assessments are to be performed and documented every 8 hours as long as the patient is receiving IV glucose. 
j 
Clinical laboratory tests include hematology and biochemistry. 
k Blood test for anti-drug antibodies to be performed prior to dosing. Any anti-dasiglucagon antibody-positive patient (treatment induced or treatment boosted) will be monitored 
at an additional Follow-up Visit preferably 16 weeks after last ADA-positive sample. Patients completing the trial before the ADA screening and confirmatory assays have 
been approved by the FDA and who do not continue treatment in the long-term extension trial will have this additional visit 16 weeks after the end of trial visit (visit 8). 
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l 
Sampling for drug exposure at Day 5 is only applicable for patients with a body weight of ≥4 kg. This sample should only be collected if it does not compromise the total 
amount of blood drawn according to Section 11.2.3.1. 
m The diary should be dispensed if a patient is discharged from the hospital during Part 2. At subsequent visits, the parent(s)/guardian will return the completed diary and obtain a 
new one. 
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18.2. Investigator’s Agreement 
PROTOCOL 
NUMBER: 
ZP4207-17103 
PROTOCOL TITLE: 
A Randomized Trial in 2 parts: Double-Blind, Placebo-Controlled, 
Crossover Part 1 and Open-label Part 2, Evaluating the Efficacy and 
Safety of Dasiglucagon for the Treatment of Children with Congenital 
Hyperinsulinism 
FINAL 
PROTOCOL: 
Version 13.0, 04-Jun-2021 
The undersigned acknowledges possession of and has read the product information (e.g., IB) on 
the trial drug and have discussed these data with the trial monitor. Having considered fully all the 
available information, the undersigned considers that it is ethically justifiable to give the trial 
drug to selected patients in his or her care, according to the trial protocol. 
• He or she agrees to use the trial material, including trial drug, only as specified in the 
protocol. He or she understands that changes cannot be made to the protocol without prior 
written approval of Zealand. 
• He or she understands that any deviation from the protocol may lead to early termination of 
the trial. 
• He or she agrees to report to Zealand within time any clinical AE or abnormal laboratory 
value that is serious, whether or not considered related to the administration of trial drug. 
• He or she agrees to comply with Zealand and regulatory requirements for the monitoring and 
auditing of this trial. 
In addition, he or she agrees that the trial will be carried out in accordance with the revised 
Declaration of Helsinki (2013) and the local laws and regulations relevant to the use of new 
therapeutic agents. 
I, the undersigned, have carefully read this protocol and agree that it contains all the necessary 
information required to conduct the trial. 
Principal Investigator: 
 
Printed Name: 
 
 
 
 
 
 
 
 
Signature: 
 
 
 
 
 
 
 
 
Date: 
 
 
 
 
Investigator’s name and address (stamp) 
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APPENDICES 
 
A. Address List 
B. Regulations and Good Clinical Practice Guidelines 
 
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A. Address List 
 
Name: 
 
Address: 
 
 
 
E-mail: 
 
Telephone: 
 
 
 
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B. Regulations and Good Clinical Practice Guidelines 
1. Regulations 
Refer to the following United States Code of Federal Regulations (CFR): 
• FDA Regulations 21 CFR, Parts 50.20 – 50.27 
Subpart B – Informed Consent of Human Subjects 
• FDA Regulations 21 CFR, Parts 56.107 – 56.115 
Part 56 – Institutional Review Boards 
Subpart B – Organization and Personnel 
Subpart C – IRB Functions and Operations 
Subpart D – Records and Reports 
• FDA Regulations 21 CFR, Parts 312.50 – 312.70 
Subpart D – Responsibilities of Sponsors and Investigators 
Refer to the following European Directives [and applicable regulations/guidances]: 
• European Directive 2001/20/EC and related guidance documents 
• European Directive 2005/28/EC and related guidance documents 
2. Good Clinical Practice Guidelines 
ICH GCP guidelines can be found at the following URL: 
http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/Efficacy/E6/E6_R2__
Step_4_2016_1109.pdf 
 
 
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