Prospective, Single Dose, Randomized, Open Label, Comparative, Cross-study to Establish Bioequivalence Between the New Formulation and the Approved Formulation for Levothyroxine (Eutirox® From Merck, S. A. de C. V.) Given as 3 Tablets of 200 μg p.o. in Healthy Volunteers
Phase: PHASE1
Conditions: Healthy
Sponsor: Merck Healthcare KGaA, Darmstadt, Germany, an affiliate of Merck KGaA, Darmstadt, Germany

 


3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/

3K
)D[


Page 1 of 54 
 
 
“Prospective, single dose, randomized, open label, comparative, cross-study to 
establish bioequivalence between the new formulation and the approved 
formulation for Levothyroxine (Eutirox® from Merck, S. A. de C. V.) given as 
3 tablets of 200 μg p.o. in healthy volunteers"   
 
International non-proprietary name: 
 
Levothyroxine 
 
Reference drug: 
 
Eutirox® from Merck, S. A. de C. V. (approved 
formulation) 
 
Test drug: 
 
Eutirox® from Merck, S. A. de C. V. (new formulation) 
 
Project's general characteristics: 
 
Study code 
Version 
Date 
/ 
MS200125-0008 
1.0 
18th / october / 2018 
 
Principal Investigator and protocol's 
author: 
 
 
 
Study Monitor: 
 
 
 
Sponsor: 
 
Merck, S. A. de C. V. 
 
Development phase: 
 
Phase I (Bioavailability) 
 
 
 
 
 
 
 
Ph. 
 
Clinical unit and accountable 
person: 
 
 
Analytical unit and accountable 
person: 
 
 
 
 
 
Ph. 
 
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 2 of 54 
 
 
 
Study investigators and other people involved 
The undersigned acknowledge to conduct this study according to the provisions set forth in this protocol.  
C l i n i c a l  U n i t  
 
Name: 
 
 
 
Signature:  
 
 
Title: 
 
Principal Investigator  
 
Date: 
 
 
 
 
Name: 
 
 
 
Signature:  
 
 
Title: 
 
Physician 
 
Date: 
 
 
 
 
Name: 
 
 
 
Signature:  
 
 
Title: 
 
Sanitary Officer 
 
Date: 
 
 
 
 
Name: 
 
 
 
Signature:  
 
 
Title: 
 
Quality Assurance Officer 
 
Date: 
 
 
 
 
Name: 
 
 
 
Signature:  
 
 
Title: 
 
Biostatistics Officer  
 
Date: 
 
 
 
Address: 
 
 
. 
 
Telephone: 
 
/Fax: 
 
 
A n a l y t i c a l  U n i t  
 
Name: 
 
  
 
Signature:  
 
 
Title: 
 
Sanitary Officer 
 
Date: 
 
 
 
 
Name: 
 
 
 
Signature:  
 
 
Title: 
 
Investigator  
 
Date: 
 
 
 
 
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 3 of 54 
 
 
 
 
Name: 
 
 
 
Signature:  
 
 
Title: 
 
Quality Assurance Officer 
 
Date: 
 
 
 
Address: 
 
 
 
 
Telephone: 
 
 
 
S p o n s o r  
 
Name: 
 
 
 
Signature:  
 
 
Title: 
 
Accountable for the Study  
 
Date: 
 
 
 
C o m m i t t e e s  
 
 
 
Dr. 
 
Chairwoman 
Ph. 
 Ext. 
 
 filing number: 
  
Ethics and Investigation 
Committee: 
 
 
 
 
Dr. 
 
Chairman 
Ph. 
 Ext. 
 
 filing number: 
 
Investigational Committee: 
 
 
 
C l i n i c a l  L a b o r a t o r y   
 
 
 
 
 
 
 
Ph. 
 
Clinical Laboratory and 
Sanitary Officer: 
 
 
PPD
PPD
PPD
PPD
PP
D
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PP
D
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 4 of 54 
 
 
Table of contents 
Study investigators and other people involved ------------------------------------------------------------------------------- 2 
Table of contents --------------------------------------------------------------------------------------------------------------------- 4 
Glossary and abbreviations -------------------------------------------------------------------------------------------------------- 7 
Glossary 
--------------------------------------------------------------------------------------------------------------------------- 7 
Abbreviations ------------------------------------------------------------------------------------------------------------------------- 8 
1. 
Introduction ----------------------------------------------------------------------------------------------------------------- 10 
1.1. 
Study Ethical Conduct -------------------------------------------------------------------------------------------- 10 
1.2. 
Levothyroxine Pharmacology ---------------------------------------------------------------------------------- 10 
1.2.1. 
Levothyroxine's chemical structure --------------------------------------------------------------------------- 10 
1.2.2. 
Levothyroxine pharmacokinetic parameters --------------------------------------------------------------- 11 
1.2.2.1. 
Absorption ---------------------------------------------------------------------------------------------------------- 11 
1.2.2.2. 
Distribution --------------------------------------------------------------------------------------------------------- 11 
1.2.2.3. 
Metabolism --------------------------------------------------------------------------------------------------------- 11 
1.2.2.4. 
Excretion ------------------------------------------------------------------------------------------------------------ 11 
1.2.3. 
Pharmacodynamics (mechanism of action)----------------------------------------------------------------- 12 
1.2.4. 
Pharmacological properties ------------------------------------------------------------------------------------ 12 
1.2.5. 
Adverse reactions ------------------------------------------------------------------------------------------------- 12 
1.2.6. 
Precautions with regards to carcinogenicity, mutagenicity, teratogenicity and fertility -------- 13 
1.3. 
Problem statement ----------------------------------------------------------------------------------------------- 13 
2. 
Primary Objective---------------------------------------------------------------------------------------------------------- 15 
2.1. 
Secondary objectives --------------------------------------------------------------------------------------------- 15 
3. 
Statistical hypothesis ----------------------------------------------------------------------------------------------------- 16 
4. 
Investigational plan ------------------------------------------------------------------------------------------------------- 16 
4.1. 
Experimental design and study plan -------------------------------------------------------------------------- 16 
4.2. 
Study Population Screening (30 to 2 days before start of period 1) ---------------------------------- 17 
4.2.1. 
Inclusion Criteria--------------------------------------------------------------------------------------------------- 17 
4.2.2. 
Exclusion Criteria -------------------------------------------------------------------------------------------------- 18 
4.3. 
Study Early Termination ----------------------------------------------------------------------------------------- 19 
4.4. 
Study Procedures -------------------------------------------------------------------------------------------------- 20 
4.4.1. 
Subjects Screening ------------------------------------------------------------------------------------------------ 20 
4.4.2. 
Study Periods ------------------------------------------------------------------------------------------------------- 20 
4.4.2.1. 
Drugs to be given -------------------------------------------------------------------------------------------------- 21 
4.4.2.2. 
First Treatment Period ------------------------------------------------------------------------------------------- 22 
4.4.2.3. 
Wash-out Period--------------------------------------------------------------------------------------------------- 22 
4.4.2.4. 
Second Treatment Period --------------------------------------------------------------------------------------- 23 
4.4.2.5. 
Clinical Follow-up -------------------------------------------------------------------------------------------------- 23 
4.4.2.6. Final visit ------------------------------------------------------------------------------------------------------------------- 24 
4.4.2. 7. End of the study--------------------------------------------------------------------------------------------------------- 24 
4.4.3. 
Blood sampling schedule ---------------------------------------------------------------------------------------- 25 
4.4.4. 
Schedule ------------------------------------------------------------------------------------------------------------- 26 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 5 of 54 
 
 
4.4.5. 
Investigational Product Identity ------------------------------------------------------------------------------- 27 
4.4.5.1. 
Packaging and labelling ------------------------------------------------------------------------------------------ 27 
4.4.5.2. 
Storage --------------------------------------------------------------------------------------------------------------- 27 
4.4.5.3. 
Supply ---------------------------------------------------------------------------------------------------------------- 27 
4.4.5.4. 
Accountability ------------------------------------------------------------------------------------------------------ 28 
4.4.5.5. 
Retention samples ------------------------------------------------------------------------------------------------ 28 
4.4.5.6. 
Final Disposition --------------------------------------------------------------------------------------------------- 28 
4.4.6. 
Subjects Assignment Method to the Treatment Sequence --------------------------------------------- 29 
4.4.7. 
Dose Selection in the Study ------------------------------------------------------------------------------------- 29 
4.4.8. 
Selection and Timing of Dosing for Each Subject ---------------------------------------------------------- 29 
4.4.9. 
Blinding -------------------------------------------------------------------------------------------------------------- 29 
4.4.10. 
Previous and Concomitant Therapy -------------------------------------------------------------------------- 30 
4.4.11. 
Therapy Compliance ---------------------------------------------------------------------------------------------- 31 
4.5. 
Study Variables ---------------------------------------------------------------------------------------------------- 31 
4.5.1. 
Demographic Variables ------------------------------------------------------------------------------------------ 31 
4.5.2. 
Pharmacokinetic Variables -------------------------------------------------------------------------------------- 31 
4.5.3. 
Safety Variables ---------------------------------------------------------------------------------------------------- 32 
4.5.4. 
Biosafety Variables ------------------------------------------------------------------------------------------------ 32 
4.5.5. 
Variable Assessment Periods ----------------------------------------------------------------------------------- 32 
4.5.6. 
Control of Drugs and Liquid Intake---------------------------------------------------------------------------- 33 
4.5.7. 
Pre-analytical control for biological samples --------------------------------------------------------------- 33 
4.5.7.1. 
Biological Fluids for the Study ---------------------------------------------------------------------------------- 34 
4.5.7.1.1. 
Blood Samples ----------------------------------------------------------------------------------------------------- 34 
4.5.7.1.2. 
Samples shipment ------------------------------------------------------------------------------------------------- 34 
4.5.7.1.3. 
Receipt, Inspection and Storage of Samples at the Analytical Unit ----------------------------------- 35 
4.5.7.1.4. 
Biological samples handling by the Analytical Unit ------------------------------------------------------- 35 
4.5.7.1.5. 
Disposal of biological samples --------------------------------------------------------------------------------- 35 
4.5.7.1.6. 
Labelling of the deep-frozen samples ------------------------------------------------------------------------ 35 
4.6. 
Quality Management --------------------------------------------------------------------------------------------- 36 
4.7. 
Documentation ---------------------------------------------------------------------------------------------------- 36 
4.8. 
Direct Access to the Source Data ------------------------------------------------------------------------------ 36 
4.9. 
Agreement with an Ambulance and Hospital Service for Emergencies ------------------------------ 36 
5. 
Ethical and Legal Aspects ------------------------------------------------------------------------------------------------ 36 
5.1. 
Ethics and Investigation Committee and Investigation Committee ---------------------------------- 36 
5.2. 
Ethical and Regulatory Compliance --------------------------------------------------------------------------- 37 
5.3. 
Approval by Regulatory Authorities -------------------------------------------------------------------------- 37 
5.4. 
Informed Consent Form and Non-Pregnancy Commitment Letter ----------------------------------- 37 
5.5. 
Confidentiality, responsibility and compensation --------------------------------------------------------- 37 
6. 
Samples Chemical Analysis ---------------------------------------------------------------------------------------------- 38 
7. 
Sample Size Determination, Pharmacokinetic and Statistical Analysis --------------------------------------- 38 
7.1. 
Sample Size Determination ------------------------------------------------------------------------------------- 38 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 6 of 54 
 
 
7.2. 
Pharmacokinetic Analysis --------------------------------------------------------------------------------------- 39 
7.3. 
Statistical Analysis ------------------------------------------------------------------------------------------------- 39 
7.3.1. 
Descriptive Statistics---------------------------------------------------------------------------------------------- 39 
7.3.2. 
Statistical Analysis for Bioequivalence ----------------------------------------------------------------------- 40 
7.3.2.1. 
Variance Analysis (ANADEVA) ---------------------------------------------------------------------------------- 40 
7.3.2.2. 
Hypothesis Statement for the double, one-sided Schuirmann's t test, ------------------------------ 40 
7.3.2.3. 
Determination of the Classical 90 % confidence Interval------------------------------------------------ 41 
7.3.3. 
Outliers -------------------------------------------------------------------------------------------------------------- 41 
7.3.4. 
Deviation to the Statistical Plan ------------------------------------------------------------------------------- 42 
7.4. 
Biowaiver of bioequivalence test for other strengths ---------------------------------------------------- 42 
8. 
Adverse Events ------------------------------------------------------------------------------------------------------------- 43 
8.1. 
Warnings ------------------------------------------------------------------------------------------------------------ 43 
8.2. 
Adverse Events Monitoring ------------------------------------------------------------------------------------- 43 
8.3. 
Observation Period for Adverse Events ---------------------------------------------------------------------- 43 
8.4. 
Adverse Events Definitions ------------------------------------------------------------------------------------- 43 
8.4.1. 
Adverse Event ------------------------------------------------------------------------------------------------------ 43 
8.4.2. 
Serious Adverse Event ------------------------------------------------------------------------------------------- 44 
8.4.3. 
Unexpected Adverse Reaction --------------------------------------------------------------------------------- 44 
8.4.4. 
Exposure during pregnancy ------------------------------------------------------------------------------------- 45 
8.5. 
Causality of the Adverse Event with the Investigational Product ------------------------------------- 45 
8.6. 
Adverse Event Severity ------------------------------------------------------------------------------------------ 46 
8.7. 
Adverse Events Documentation and Report---------------------------------------------------------------- 46 
9. 
Data Use and Publication ------------------------------------------------------------------------------------------------ 47 
10. 
Management of Concurrent Events (Administrative and Medical) ------------------------------------------- 47 
10.1. 
Research Protocol Amendments ------------------------------------------------------------------------------ 47 
10.2. 
Deviations to the Protocol -------------------------------------------------------------------------------------- 47 
11. 
References ------------------------------------------------------------------------------------------------------------------ 48 
12. 
APPENDIXES ----------------------------------------------------------------------------------------------------------------- 50 
12.1. 
Schedule of Assessments ---------------------------------------------------------------------------------------- 50 
12.2. 
Sampling Schedule ------------------------------------------------------------------------------------------------ 51 
12.3. 
Summary ------------------------------------------------------------------------------------------------------------ 53 
12.4. 
Diet ------------------------------------------------------------------------------------------------------------------- 54 
12.5. 
Drugs Classification According to their Risk for Pregnancy and Breastfeeding (FDA) ------------ 54 
 
 
 
 
 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 7 of 54 
 
 
 
Glossary and abbreviations 
Glossary 
Bioavailability 
Part of the drug absorbed in the blood stream following the dosing and time needed for this 
purpose (Mexican Official Standard [NOM, for its abbreviation in Spanish] NOM-177-SSA1-
2013). 
Bioequivalence 
Ratio between 2 drugs and equivalent dosage forms available to achieve similar 
bioavailability when given under the same conditions (NOM-177-SSA1-2013). 
Pharmacokinetics Branch of pharmacology studying the process of a drug in the body. It is intended to 
elucidate the drug's effect from its dosing until it has been fully cleared from the body 
(Goodman & Gilman, 12th Edition).  
Pharmacology 
Science 
studying 
the 
origin 
and 
physicochemical 
properties, 
dosage 
form, 
pharmacodynamics (biochemical and physiological effects, and mechanism of action), 
pharmacokinetics (absorption, distribution, biotransformation and excretion), as well as the 
therapeutic effect of the chemical substance interacting with living organisms. In the strict 
sense of the word, pharmacology is considered as the drugs study; and whether they are 
beneficial or toxic (Goodman & Gilman, 12th Edition). 
Drug 
Any substance or mix of substances of natural or synthetic origin which have therapeutic, 
prophylactic or rehabilitation effect, and a dosage form identified as such by its 
pharmacological activity, and physicochemical and biological characteristics (NOM-073-
SSA1-2005). 
 
 
 
 
 
 
 
 
 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 8 of 54 
 
 
Abbreviations 
A 
Absorption 
AE 
Adverse Event 
AUC 
Area under the curve of serum concentration  
AUC0-t 
Area under the curve of serum concentration from time 0 until the last sampling time 
AUC0-t(aj) 
Area under the curve of serum concentration from time 0 until the last sampling time in pre 
dose corrected data 
BC 
Blood chemistry  
BMI 
Body Mass Index 
°C 
Celsius degrees 
CBC 
Complete blood count 
CI 
Confidence Interval 
Cmax (aj) 
Maximum serum concentration in pre dose corrected data 
Cmax 
Maximum serum concentration  
CNFV 
National Center of Pharmacovigilance 
COFEPRIS 
Federal Commission for the Protection against Sanitary Risks 
CRF 
Case Report Form 
DBP 
Diastolic Blood Pressure 
dL 
Deciliter 
E 
Elimination 
EIC 
Ethics and Investigation Committee  
FDA 
Food and Drug Administration  
g 
Gravity or grams (depending on the context) 
h 
Hour 
HIV 
Human immunodeficiency virus 
IC 
Investigation Committee  
ICF 
Informed Consent Form 
IUPAC 
International Union of Pure and Applied Chemistry  
Kel 
Elimination constant 
kg 
Kilogram 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 9 of 54 
 
 
μg 
Micrograms 
m2  
Square meter 
mg 
Milligrams 
min 
Minute 
mL 
Milliliter 
mmHg 
Millimeters of mercury  
PLM 
Dictionary of Pharmaceutical Specialties 
(SOP - Standard Operating Procedure) 
SAE 
Serious Adverse Event 
SBP  
Systolic Blood Pressure 
SC 
Serum concentration 
TSH 
Thyroid stimulating hormone 
T3 
Triiodothyronine 
T4 
Thyroxine 
t 
Time 
t½ 
Elimination half-time  
tmax 
Time to reach the maximum serum concentration  
UA 
Urinalysis  
VDRL 
Venereal Disease Research Laboratory (serological screening test for syphilis) 
 
PPD
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 10 of 54 
 
 
1. Introduction 
As per the pharmacokinetic characteristics, variable drugs' bioavailability, influence of the different techniques 
and pharmaceutical processes, including the possible differences in the quality and type of the formulation's 
ingredients, it is essential to perform comparative studies for new formulations. Therefore, it is important to 
assess the products under development by providing evidence about their appropriate and equivalent 
absorption and bioavailability with regards to the reference product; to ensure that the change of formulation 
will not be to the detriment of the subject's subsequent therapy, in addition to fulfill the legal requirements 
established by the health authorities.  
1.1.
Study Ethical Conduct 
This protocol is compliant with the current regulation on clinical research, including the Good Clinical Practice 
(GCP), the ethical principles of medical research in human beings from the Declaration of Helsinki issued by the 
64th General Assembly of the World Medical Association, Fortaleza, Brazil, October 2013, and the General Health 
Act and the Regulations of the General Health Act in the Field of Health Research, as well as with the International 
Ethical Guidelines for Health-related Research Involving Humans, Prepared by the Council for International 
Organizations of Medical Sciences (CIOMS) in collaboration with the World Health Organization (WHO), Geneva 
2016.   
According to the provisions of the Regulations of the General Health Act in the Field of Health Research, second 
title, chapter I, section 17, part III issued in the Official Gazette of April 2nd, 2014, this study is considered as a 
study with risk higher than minimum.   
1.2.
Levothyroxine Pharmacology 
1.2.1. Levothyroxine's chemical structure 
Levothyroxine systematic name is (PubChem CID 23666112- Levothyroxine Sodium):  
(2S)- 2-amine-3-[4-(4-hydroxy-3,5-diiodophenoxy)-3,5-diiodophenyl] sodium propanoate 
Levothyroxine's molecular formula is: C15H10I4NNaO4. Its molecular weight is 798.856 g/mol and its structural 
formula is (PubChem CID 23666112- Levothyroxine Sodium): 
 
Figure 1.- Levothyroxine 

PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 11 of 54 
 
 
1.2.2. Levothyroxine pharmacokinetic parameters  
TABLE No. 1 
No. 
DOSES 
Cmax  
tmax (h) 
t½ (h) 
AUC0-∞ 
Reference 
1) 
600 μg* 
11.58 (2.10) μg/dL 
2.50 (4.50) 
403.84 
(16850.26) 
14447.11 
(36474.98) μg·h/dL 
Abib et al., (2010) 
2) 
600 μg** 
11.53 (2.40) μg/dL 
2.00 (23.02) 
348.30 
(6309.87) 
10679.17 
(17326.22) μg·h/dL 
Abib et al., (2010) 
3) 
600 μg* 
112.0 ± 17.3 ng/ml 
3.9 ± 1.6 
ND 
◊ 4359.3 ± 619.3  
ng h/ml 
Koytchev & 
Lauschner, (2004) 
4) 
600 μg** 
113.4 ± 18.5 ng/ml 
4.6 ± 2.0 
ND 
◊ 4463.8 ± 694.7  
ng h/ml 
Koytchev & 
Lauschner, (2004) 
1) and 2) Data reported as mean (standard deviation); 3) and 4) Data reported as mean ± standard deviation; * Test drug; ** Reference 
drug; ◊ AUC0-48h; NA, not available. 
1.2.2.1.
Absorption 
Levothyroxine is synthetically produced, but it is identical to the T4 secreted by the thyroid. Levothyroxine's 
gastrointestinal absorption is approximately 80 % and does not change in hypothyroid or euthyroid state. 
Absorption takes place throughout the human small bowel but decreases distally. Following levothyroxine's 
intake, T4 serum levels reach its peak within 2 to 4 hours and remain above the baseline level for 6 h. Increase 
of T3 serum levels following levothyroxine's administration is slow due to the time required for the T4 conversion 
into T3 (Koytchev & Lauschner, 2004). 
1.2.2.2.
Distribution 
Levothyroxine has a limited volume of distribution of 11.6 L in healthy volunteers. Both T4 and T3 bind in a higher 
ratio of 99.8 % of plasma protein, mainly the thyroxine binding globulin (TBG), and in a lesser degree to the 
thyroxine binding pre-albumin and to the albumin (Guidance to Establish the Interchangeability of Oral Solid 
Drugs Containing Levothyroxine Sodium, COFEPRIS, 2017).  
1.2.2.3.
Metabolism 
T4 metabolism is carried out by means of de-iodination sequential reactions. Approximately 80 % of the T4 daily 
dose is transformed into T3 which is the active hormone and into reverse T3 (rT3), in an approximate ratio of 
50 % for each of them. In turn, T3 hormone is metabolized into diiodothyrosine (T2) and iodotironamine (T1) 
(Guidance to Establish the Interchangeability of Oral Solid Drugs Containing Levothyroxine Sodium, COFEPRIS, 
2017).       
1.2.2.4.
Excretion  
Levothyroxine's elimination is produced by conjugation with glucuronic and sulfuric acid, and excretion in the 
bile. Thyroid hormones release by means of bacterial hydrolysis in the bowel and partial re-absorption lead to 
enterohepatic circulation. Approximately 20 - 40 % of thyroxine is cleared in the feces (Koytchev & Lauschner, 
2004).  
 
 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 12 of 54 
 
 
 
T4 elimination half-life is approximately 6.2 days in healthy volunteers, meanwhile T3 half-life is of approximately 
1 day (Guidance to Establish the Interchangeability of Oral Solid Drugs Containing Levothyroxine Sodium, 
COFEPRIS, 2017).  
1.2.3. Pharmacodynamics (mechanism of action) 
Levothyroxine Sodium is a levothyroxine sodium salt, a synthetic levoisomer of thyroxine (T4), similar to the 
endogenous hormone produced by the thyroid gland. Thyroxine is de-iodinated by 5' de-iodinase to 
form triiodothyronine (T3) in the peripheral tissues. T3 enters the cell and binds to nuclear thyroid hormone 
receptors, and the hormone-receptor complex in turn triggers gene expression and produces proteins required 
in the regulation of cellular respiration, thermogenesis, cellular growth and differentiation, and metabolism of 
proteins, carbohydrates and lipids. T3 also possesses cardiac stimulatory effect. (PubChem CID 23666112- 
Levothyroxine Sodium). 
1.2.4. Pharmacological properties 
Hypothyroidism: Levothyroxine is indicated in replacement therapy in congenital or acquired hypothyroidism, of 
any etiology. Specific indications include: Primary hypothyroidism (thyroid), secondary (pituitary) or tertiary 
(hypothalamic) and subclinical hypothyroidism. Pituitary suppression of TSH: in the treatment or prevention of 
various types of euthyroid goiters, including thyroid nodules, chronic or subacute lymphocytic thyroiditis 
(Hashimoto's thyroiditis), multinodular goiter and as adjuvant to radioiodine or surgical therapy for cancer 
management well-differentiated thyroid-dependent thyrotropin (PLM, 2016 - Eutirox®). 
1.2.5. Adverse reactions 
Side effects described for levothyroxine therapy based on its frequency are the following (Drugs & Medications 
– Levothyroxine Sodium): 
 
 Common: in women difficulty to get pregnant. 
 Uncommon: poor calcification and bone density, hypertension and weight loss.  
 Rare: abnormal heart rhythm, abnormal liver function tests, angina, cardiac arrest, tachycardia, heart 
failure or heart attack, hives, allergic dermatitis, mood swings, pseudotumor cerebri, seizures, rash, lack 
of breath, pulse changes, chronic sleep difficulty, diarrhea, irritability, excessive sweating, anxiety, fever, 
hair loss, headache, palpitations, appetite increase, involuntary tremors, irregular menstruation, low 
energy, muscular weakness, nervousness, abdominal cramps, temporary redness of the face and neck, 
vomiting.  
 
The CIOMS classification (Council for International Organizations of Medical Sciences in collaboration with the 
World Health Organization [WHO]) for drug's adverse reactions based on their frequency are the following:  
 
 Very frequent or very common: they occur with a frequency ≥ 1 case for each 10 patients who receive the 
drug. It is expressed as ≥ 1/10. 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 13 of 54 
 
 
 Frequent or common: they occur with a frequency ≥ 1 case for each 100 patients who receive the drug, but 
less than 1/10. It is expressed as ≥ 1/100 and < 1/10. 
 Infrequent or uncommon: they occur with a frequency ≥ 1 case for each 1,000 patients who receive the 
drug, but less than 1/100. It is expressed as ≥ 1/1,000 and < 1/100. 
 Rare: they occur with a frequency ≥ 1 case for each 10,000 patients who receive the drug, but less than 
1/1,000. It is expressed as ≥ 1/10,000 and < 1/1,000. 
 Very rare: they occur with a frequency less than 1 case for each 10,000 patients who receive the drug. It is 
expressed ad < 1/10,000. 
1.2.6. Precautions with regards to carcinogenicity, mutagenicity, teratogenicity and fertility  
Thyroid hormones do not cross the placental barrier. Based on clinical experience, levothyroxine does not cause 
fetal abnormalities when given during pregnancy. No conclusive studies to determine mutagenicity and 
carcinogenicity have been conducted; and despite the apparent relationship between prolonged thyroid 
hormones therapy and breast cancer, a true validation for such statement does not exist (PLM, 2016 - Eutirox®). 
Levothyroxine belongs to the FDA's category A for the risk classification during pregnancy and breastfeeding 
(Drugs.com - Levothyroxine Pregnancy and Breastfeeding Warnings) (See Appendix 12.4). 
1.3.
Problem statement 
Study rationale  
Congenital hypothyroidism is the most frequent cause of preventable intellectual disability. Incidence in Mexico 
is of 1:2,729 newborns. More than 90 % of congenital hypothyroidism are of primary origin and its treatment 
consists of thyroid hormone deficiency replacement by adjusting the dose according to patient's age and clinical 
and biochemical conditions (Rojas et al., 2009). 
Currently, the optimal therapy for hypothyroidism requires the thyroid hormone deficiency replacement with 
synthetic levothyroxine. The drug is used as interventional therapy to suppress the secretion of the thyroid 
stimulating hormone (TSH) in patients with nodular thyroid disease or thyroid cancer. As the evident 
hypothyroidism incidence occurs in 1.5 % to 2 % of women and in 0.2 % of men, and its incidence increases with 
age to 6 % and 2.5 % in women and men older than 60 years old respectively, levothyroxine is one of the most 
prescribed drugs in the United States (Koytchev & Lauschner, 2004). 
Under the concept that the biological effect of a drug depends on the concentration reached in the effector 
organ, and based on its steadiness in the blood concentration, it is accepted that the pharmacokinetic 
equivalence between two drugs is evidence that the same efficacy and clinical safety will be achieved. Therefore, 
bioavailability studies should be subject to a clinical research protocol where confounding variables affecting the 
study basic characteristics such as oral dosing formulation: rate and extent of absorption are controlled by an 
experimental design. This absorption process characteristics are measured by the pharmacokinetic parameters 
of tmax and Cmax for the rate and the AUC0-t for the extent. 
 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 14 of 54 
 
 
As the goal is to prove the lack of significant differences in the pharmacokinetic parameters where each subject 
is his/her own control, the chosen experimental design is one of those suggested by the NOM-177-SSA1-2013, 
crossed, open label, two sequences and two periods of treatment (scheme A - B and B - A), and single dose. 
Section 8.4.8.1 of this Standard states that drugs with a long half-life, crossed or parallel designs should include 
a limited sampling for at least 72 hours. However, prior studies showed that sampling times longer than 48 hours 
do not allow to characterize differences between exogenous and endogenous levothyroxine concentrations with 
certainty. Therefore, bioequivalence studies for this drug should be truncated up to 48 hours (Guidance to 
Establish the Interchangeability of Oral Solid Drugs Containing Levothyroxine Sodium, COFEPRIS, 2017). According 
to the, a 48-h sampling time, which is compliant with the Mexican health authorities' requirement, is proposed. 
In addition, it allows to characterize at least the 80 % of the AUC, by having 26 total samples and a wash-out 
period of 35 days between the two study periods. 
Besides the inclusion and exclusion criteria, confounding variables to be controlled are: fasting state (at least 
10 hours before the drug intake); morning time for the administration; volume and type of liquid for the drug 
intake; timing, type and quantity of food; liquid intake prior to the breakfast; restricted physical activity for a 
minimum that does not alter the heart rate; orthostatic or seated position till reaching the stated time for tmax; 
abstinence of caffeine or theophylline containing products; controlled access to restrooms until the tmax is 
reached. Additionally, concomitant drugs are not allowed, except for the medical prescription for to adverse 
events. The occasional use of acetaminophen (maximum of 1000 mg per day, for three days) is allowed. While 
complying with the permitted dose, the use of paracetamol will not be reason for exclusion of the subject, nor 
for the study or pharmacokinetic analysis. 
Literature information states that the systemic levels of levothyroxine (T4) show a better correlation with the T4 
levels in the triiodothyroxine (TE) or thyroid stimulating hormone (TSH) site of action. Therefore, it is the most 
appropriate to establish the drug's efficacy and safety. Despite the TSH sensitivity to changes in the level of 
thyroid hormone, the TSH is not appropriate to establish the bioequivalence between formulations since there 
is a significant delay between the exogenous levothyroxine dosing and the observed changes in the TSH levels 
(Guidance to Establish the Interchangeability of Oral Solid Drugs Containing Levothyroxine Sodium, COFEPRIS, 
2017).      
Since levothyroxine is and endogenous compound, a high relation of exogenous levothyroxine concentrations 
with regards to the baseline concentrations of endogenous levothyroxine should be guaranteed to distinguish 
the real differences between the formulations. Therefore, over-therapeutic doses of levothyroxine are 
encouraged, as well as the pre-dosing study drug sampling to determine the baseline values of the endogenous 
levothyroxine (Guidance to Establish the Interchangeability of Oral Solid Drugs Containing Levothyroxine Sodium, 
COFEPRIS, 2017). According to the aforementioned, the dose to be used in the study is the recommended one, 
which is equivalent to 600 μg of levothyroxine. Three pre-dose drug samples will be taken to determine the 
baseline levels of endogenous levothyroxine. Levothyroxine (T4) serum concentrations measurement will be 
carried out. Cmax and AUC0-t parameters will be used for the statistical analysis of bioequivalence, by means of 90 
% confidence intervals construction for geometric means of these pharmacokinetic parameters. The statistical 
analysis will be made using the corrected values only. In both pharmacokinetic parameters, equivalence margins 
will be of 80 % to 125 % according to the Guidance to Establish the Interchangeability of Oral Solid Drugs 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 15 of 54 
 
 
Containing Levothyroxine Sodium, (COFEPRIS, 2017). There are no data on variation of serum levels of 
levothyroxine due to gender; therefore, this study will be carried out in male and female healthy volunteers.  
2. Primary Objective 
To establish the bioequivalence between the new and approved levothyroxine's formulation in tablets of 200 μg 
(Eutirox® from Merck, S. A. de C. V.) in healthy volunteers for the marketing approval of the new formulation in 
all its strength. The lower strengths will be justified with the biowaiver criteria described in NOM-177-SSA1-2013. 
 
2.1.
Secondary objectives 
To assess the pharmacokinetics parameters of levothyroxine at a total dose of 600 μg (3 x 200 μg) of the test and 
reference drugs. 
To assess the safety and tolerability of levothyroxine at a dose of 600 μg (3 x 200 μg) of the test and reference 
drugs. 
The study objectives and endpoints are described in Table 2. 
 
TABLE No. 2 Study Objectives and endpoints 
Primary Objective 
Endpoints 
x To establish the bioequivalence between the new and 
approved levothyroxine's formulation in tablets of 200 μg 
(Eutirox® from Merck, S. A. de C. V.) in healthy volunteers 
for the marketing approval of the new formulation in all 
its strength. The lower strengths will be justified with the 
biowaiver criteria described in NOM-177-SSA1-2013 
x Primary endpoints are baseline-adjusted Cmax(aj) and 
AUC0-t (aj)of levothyroxine (T4) in serum after dosing 
of 600 μg levothyroxine with either the test product 
or the reference product 
Secondary objectives 
Endpoints 
x To assess pharmacokinetic parameters of levothyroxine 
 
x To assess the safety and tolerability of levothyroxine 
200μg for both test and reference products. 
x Levothyroxine (T4): tmax, t1/2, AUC0-t and Cmax. 
x Safety assessments:  
x Physical examination 
x Vital signs (body temperature, blood pressure, 
Breathing frequency and pulse rate) 
x Complete blood count; 4-panel chemistry; 
urinalysis; liver function tests; HIV, hepatitis B and C, 
and VDRL test; and qualitative urine test for illicit 
drugs, and pregnancy test for women. Thyroid 
profile.  
x Electrocardiogram (ECG) 
x Recording of Adverse Events (AEs) 
 
 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 16 of 54 
 
 
3. Statistical hypothesis 
 
H0: Drug A and drug B are not bioequivalent. 
 
H1: Drug A and drug B are bioequivalent. 
 
4. Investigational plan 
4.1.
Experimental design and study plan 
Single dose design will be used with 44 subjects in fasting state, two periods, two sequences, open-label, crossed 
in scheme blocks A-B and B-A, randomized, longitudinal, comparative and prospective, with a 35-day wash-out 
period between the two study periods. Treatment groups will be balanced, with the same number of subjects 
who will be randomly assigned to the study drug sequences of administration.   
All data from participant subjects should be analyzed and included in the statistical analysis, if the fulfill with the 
established criteria.  
 
NOM-177-SSA1-2013 
 
 
Selection period 
(Screening) 
Clinical phase 
Period 1 
Washout 
Period 2 
Clinical 
monitoring 
End of Study 
30 to 2 days 
before the start 
of Period 1 
From approx.12 
hours pre-dose 
until 48 h 
sampling post-
dose 
At least 35 
days 
From approx. 12 
hours pre-dose 
until 48 h 
sampling post-
dose 
 
At least 14 days 
after the dose in 
period 2 
Subjects will be randomized to one of the 2 sequences by a randomization plan completed before first dosing 
 
SECUENCIA 1
REFERENCIA
PRUEBA
SECUENCIA 2
PRUEBA
REFERENCIA
II
PERIODO
DISEÑO CRUZADO  2 x 2
A
L
E
A
T
O
R
I
Z
A
C
I
Ó
N
SUJETOS
L
A
V
A
D
O
I
&5266(''(6,*1î
3(5,2'
68%-(&76
6(48(1&(
6(48(1&(
5()(5(1&(
7(67
7(67
5()(5(1&(
:$6+287
5$1'20,=$7,21
Screening period 
End of Study 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 17 of 54 
 
 
4.2.
Study Population Screening (30 to 2 days before start of period 1) 
 Invitation-made recruitment by open call. 
 Inclusion of 44 subjects in the study according to the protocol's criteria. 
4.2.1. Inclusion Criteria 
All the following criteria should be met to be included in the study: 
 Subjects who have provided their written consent prior to any study-related activity.  
 Male and female (non-pregnant women) healthy volunteers, Mexican (NOM-177-SSA1-2013). 
 From 18 to 55 years old (NOM-177-SSA1-2013). 
 Body mass index from 18 to 27 kg/m2 (NOM-177-SSA1-2013). 

Normal vital signs (the measurement will be made according to the instructive 
 
): 
9 Heart rate between 50 and 100 beats per minute. 
9 Respiratory rate between 12 and 20 per minute. 
9 Systolic blood pressure between 80 and 129 mmHg 
9 Diastolic blood pressure between 50 and 80 mmHg 
9 Temperature between 36.0 °C and 37.0 °C. 
 Normal electrocardiogram [ECG]. No abnormalities are allowed, even though they are not relevant (PR, QRS, 
QT, QTcF should be within normal range; no conduction abnormalities are allowed, etc.)  

All values in blood and urine tests should be within the normal range or showing no clinically relevant 
deviation as judged by the Investigator, in the following:  
9 Complete blood count (CBC): hematocrit and hemoglobin mandatorily above the lower level. 
9 Liver function tests, including: total bilirubin, direct bilirubin, indirect bilirubin, glutamic oxaloacetic 
transaminase, pyruvic glutamic transaminase, total protein, albumin, globulin and albumin-globulin 
ratio. 
9 Chemistry (C) including at least: glucose, urea, creatinine and uric acid. 
9 Lipid panel, including total cholesterol and triglycerides. 
9 Urinalysis (UA).  
9 Subjects with isolated data, reported as out of range and not related each other, can be included in the 
study after documenting that signs and symptoms are not related each other at the screening and who 
do not have personal history of any related disease.  
 Subjects with thyroid panel results within normal range (T3 and T4 total and free, as well as TSH should be 
within the normal range).  
 Non-smoker at least in the last 3 months. 
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 18 of 54 
 
 
 All child-bearing potential women who are not pregnant or who are breastfeeding, and who are using any 
highly effective contraceptive method (defined as those which alone or combined, which failure rate is low; 
i.e., less than 1 % a year if used continuously and correctly) for at least the first dose and after the last one, 
can take part in in the study. Barrier methods and intrauterine device are considered as standard 
contraceptive methods. Women using hormonal methods will not be included. Post-menopausal women 
can be included (i.e., those amenorrhoeic for at least 12 consecutive months following their last cycle) or 
those who are surgically sterile or who have undergone hysterectomy at least 6 months prior to their 
participation in their study.   
 
4.2.2. Exclusion Criteria 
Subjects will not be eligible for the study if meet one or more of the following exclusion criteria: 
 Participation in the clinical study within 90 days prior to the first dose of the study drug.  
 Subjects with history of hypersensitivity or allergy to the study drug or its excipients; history or current 
asthma or any severe allergy (which requires hospitalization or prolonged therapy), allergy or intolerance to 
any food that, in the opinion of the investigator, poses a safety risk (allergy to iodine, etc.)  
 Subjects with history of cardiovascular, renal, liver, metabolic, gastrointestinal, neurological, endocrine, 
hematopoietic (any type of anemia) conditions, mental disorder or organic abnormalities that may affect 
the pharmacokinetic study of the study drug.    
 Any medical or surgical condition, including findings in the medical history or clinical assessment prior to the 
study, that in the opinion of the investigator poses a risk or contraindication for the subject's participation 
in the study and may affect the study objectives, conduct or analysis.  
 History or presence of alcohol abuse (average daily intake not higher than 3 units or weekly intake not higher 
than 21 units; 1 unit is equivalent to 340 mL of beer, 115 mL of wine or 43 mL of prepared drinks), 
psychoactive substances or chronic use of drugs.  
 Subjects who have been exposed to agents knows by inducing or inhibiting the liver enzymatic systems or 
who have taken potentially toxic drugs within the last 30 days to the study start-up. 
 Subjects who take drugs affecting the metabolism of the thyroid hormone, such as: oral contraceptives, 
hormonal implants, parenteral hormones, steroids, anabolic drugs, androgens, etc., or any drug affecting 
the levothyroxine's bioavailability such as the proton pump inhibitors or multivitamins, nutritional 
supplements or herbal products that may affect the study, except for the occasional use of paracetamol.     
 Subjects who have been hospitalized for any reason within the 60 days prior to the study start-up or who 
have been severely ill within the last 30 days prior to the study start-up.  
 Subjects who have donated or lost 450 mL of blood within the last 60 days prior to the study start-up.  
 Subjects non- smokers, who have smoked tobacco, cigarettes or consumed coffee, snuff or drinks containing 
xanthines such as caffeine, (tea, cocoa, chocolate, matte, cola, etc.) theobromine, theophylline, among 
others, affecting the pharmacokinetics of the drug in assessment, drinking alcohol, or charcoal-grilled foods 
consumed within twenty-four hours prior to administration the dose of medication. 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 19 of 54 
 
 
 Screening biosafety positive tests for the human immunodeficiency virus (HIV), hepatitis B virus (HBV), 
hepatitis C virus (HCV) and syphilis (VDRL). 
 Positive result in the abuse drugs screening tests, such as: amphetamines, benzodiazepines, cocaine, 
methamphetamines, morphine and tetrahydrocannabinoids. 
 Presence of alcohol in breath test. 
 Women pregnancy postivie tests (qualitative and quantitative) at the screening and inclusion in each period. 
 Consumption of grapefruit, oranges, cranberries, or their juices within 48 hours prior to the study drug 
dosing, until the last sampling in each period.  
 Breastfeeding women.  
 Abnormal findings in the medical history that, as per the investigator's judgment, poses a risk or 
contraindication for the study subject's participation; or that might interfere with the study objectives, 
conduct or analysis. 
 Any case where the Principal Investigator thinks that the lack of compliance to the protocol may the study 
results questionable (serious adverse reaction or serious adverse event, subject's indiscipline, lack to 
compliance to the diet, emesis within the established time for the tmax).  
 Difficulties to follow the protocol's requirements, instructions or study-related restrictions; e.g., 
uncooperative behavior, impossibility to return for the visits and likelihood of not completing the study.  
 Impossibility to communicate or cooperate with the Investigator (language issues, illiterate subjects, poor 
mental capacity) or to follow the study requirements, including diet restrictions.  
 If the subject is the Principal Investigator or any Sub-Investigator, assistant, coordinator, or relative to any 
of the team members directly involved in the study conduct.  
 
Additionally, participant subjects in the study are free to abandon the study at any time and they will only be 
requested to inform the reason of their withdrawal.  
 
4.3.
Study Early Termination 
 This study can be temporally or definitively terminated based on the Sponsor, Principal Investigator or Ethics 
and Investigation Committee or Investigation Committee's decision, according the Ministry of Health 
guidelines.  
 Causes may be different, among others the frequency and type of adverse events which make a considerable 
number of subjects to take the decision of terminating the study; new drug's information which states that 
the subjects' safety or study conduct might be affected; or by reasoned decision by the Ethics and 
Investigation Committee, Investigation Committee and the Ministry of Health.  
 In the event of temporary or early termination, study subjects will be immediately informed and an 
appointment will be scheduled to inform them about the final decision about the study course. For definitive 
termination, the Principal Investigator will inform this decision to the study subjects and will perform the 
termination procedures.   
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 20 of 54 
 
 
 If the decision is taken by the Sponsor or the Principal Investigator, they should document the decision and 
inform in writing, with a detailed explanation about the temporary or definitive termination, to the Ethics 
and Investigation Committee, to the Investigation Committee and to the Ministry of Health.    
 Study drugs will be kept safely and will be disposed (return or storage) as agreed with the Sponsor.  
4.4.
Study Procedures 
4.4.1. Subjects Screening  
Once the informed consent form is signed, subjects' eligibility will be checked according to the inclusion and 
exclusion criteria. Confirmation of the medical chart and its update will be made according to the standard 
operating procedure, code: 
, at the 
 If the subject already has a medical chart, 
the medical history will only be updated. 
Subjects should have:  
 Laboratory tests within 30 days prior to the study start-up. 
 Electrocardiogram within 30 days prior to the study start-up.  
 
4.4.2. Study Periods 
To confirm that the subject is still a suitable candidate for the study at the entrance of each period, a clinical 
assessment consisting of interrogation by apparatus and systems with a physical exam and an electrocardiogram 
will be carried out. Urine samples will be taken for abuse drugs screening; for women, a blood sample will be 
taken for the pregnancy tests. In addition, a breath alcohol test will be done.    
At the end of each period, a clinical assessment consisting of an interrogation, physical exam, vital signs 
measurement and adverse events follow-up will be done.  
Subjects should inform to the medical staff in charge of the study conduct about any symptom they have. 
Likewise, the medical staff will enquire in each period to the subjects about symptoms since the first period and 
following the dosing. Should they report any, the medical staff should provide treatment to the subject and notes 
to the appropriate documents will be made.      
Prior to the dosing, blood pressure (seated position), pulse, respiratory frequency and temperature will be 
measured to each subject. These values should be within the normal ranges (SBP between 80 and 129 mmHg 
and DBP between 50 and 80 mmHg) in order the subjects keep on participating in the study. Same measurements 
will be taken in every shift following the dosing in each phase. Vital signs will be taken as shown in Table No. 3. 
 
 
 
PPD
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 21 of 54 
 
 
TABLE No. 3 
Vital Signs Record 
First Period 
Second Period 
Admission 
Admission 
Pre-dose 
Pre-dose 
Morning shift (2 to 3 h after 
administration) 
Morning shift (2 to 3 h after 
administration) 
Evening shift (6 to 8 h after 
administration) 
Evening shift (6 to 8 h after 
administration)  
Night shift (11 to 13 h after 
administration) 
Night shift (11 to 13 h after 
administration) 
Discharge (23 to 24 h after 
administration) 
Discharge (23 to 24 h after 
administration) 
Ambulatory sample (36 and 48 
hours) 
Ambulatory sample (36 and 48 
hours) 
If any subject has clinically significant changes, out of the normal ranges, in his/her blood pressure and pulse 
during post-dose confinement, he/she will be closely checked by the medical staff and appropriate supporting 
measures will be taken according to the his/her condition until resolution. Should these changes persist, his/her 
participation in the study will be checked by the Principal Investigator.    
Due to operations issues, the Principal Investigator may change the study start-up (from the study drug intake) 
in 1 hour, if it does not affect the study result. 
4.4.2.1.
Drugs to be given 
Drugs to be given to the subjects in each of the study visits will be given by the study Sponsor.  
 International non-proprietary name: Levothyroxine Sodium. 
 Reference drug: Eutirox® (approved formulation). 
o Dosage form: tablets. 
o Qualitative-quantitative formula: each tablet contains levothyroxine sodium 200 μg. 
o
Expiry date: The expiry date must not be before the end of the study. 
o
Sanitary approval number: 297M89, SSA IV. 
o Manufacturer: Merck, S. A. de C. V. 
o Distributor: Merck, S.A. de C.V. 
o Marketing Authorization Holder: Merck, S.A. de C.V. 
 Test drug: Eutirox® (new formulation). 
o Dosage form: tablets. 
o Qualitative-quantitative formula: each tablet contains levothyroxine sodium 200 μg. 
o Expiry date: The expiry date must not be before the end of the study. 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 22 of 54 
 
 
o Manufacturer: Merck, S. A. de C. V. 
o Distributor: Merck, S. A. de C. V. 
 Dose to be given: 600 μg (3 tablets of 200 μg), orally. 
4.4.2.2.
First Treatment Period 
 Admission in the afternoon of the day before dosing (approximately at 3pm). 
 Dinner at least 10 hours before the dosing. 
 Catheter insertion (as chosen). 
First Day: 
 At 06:00 h, grooming and intake of 250 mL of water. 
 Between 06:30 and 07:30 h, catheter insertion. 
 As per 07:30 h, first pre-dose sample (- 0.50 h); as per 07:45 h, second pre-dose sample (-0.25 h); and as per 
07:55 h, third pre-dose sample (0 h). 
 As per 08:00 h, study drug or reference drug dosing with 250 mL of room temperature water, according to 
the standard operating procedure, code: 
 
 
 
 
 
 
    
 From 08:30 to 20:00 h, sampling according to the schedule. 
 As per 12:00 h, breakfast. 
 As per 16:00 h, lunch. 
 As per 21:00 h, dinner. 
Second Day: 
 At 08:00 horas, 24.0 h sampling. 
 Approximately at 10:00 h, discharge from the clinic. 
 At 20:00 h, 36.0 h ambulatory sampling. 
Third Day: 
 At 08:00 h, 48.0 h ambulatory sampling. 
 Approximately at 10:00 h, temporary discharge with open appointment. 
 
4.4.2.3.
Wash-out Period 
Wash-out period length is of 35 days starting at the drug's dosing in the previous period. It is intended to remove 
the previous dose before giving the next one and fulfills the criterion of the NOM-177-SSA1-2013 of at least 
7 half-lives for the study drug.   
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 23 of 54 
 
 
4.4.2.4.
Second Treatment Period 
 Admission the afternoon of the day before dosing (approximately at 3pm). 
 Dinner at least 10 h before the dosing. 
 Catheter insertion (as chosen). 
First day: 
 At 06:00 h, grooming and intake of 250 mL of water. 
 Between 06:30 and 07:30 h, catheter insertion. 
 As per 07:30 h, first pre-dose sample (- 0.50 h); as per 07:45 h, second pre-dose sample (-0.25 h); and as per 
07:55 h, third pre-dose sample (0 h). 
 As per 08:00 h, study drug or reference drug dosing with 250 mL of room temperature water, according to 
the standard operating procedure, code: 
 
 
 
 
 
 
 
 From 08:30 to 20:00 h, sampling according to the schedule. 
 As per 12:00 h, breakfast. 
 As per 16:00 h, lunch. 
 As per 21:00 h, dinner. 
Second Day: 
 At 08:00 horas, 24.0 h sampling. 
 Approximately at 10:00 h, discharge from the clinic. 
 At 20:00 h, 36.0 h ambulatory sampling. 
Third Day: 
 At 08:00 h, 48.0 h ambulatory sampling. 
 Approximately at 10:00 h, temporary discharge with open appointment. 
4.4.2.5.
Clinical Follow-up 
All study subjects will be followed-up in an outpatient basis, as per the last drug's dosing, with open appointment 
or telephone contact as per the Investigator's opinion, for 14 days after last administration. 
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 24 of 54 
 
 
4.4.2.6. Final visit 
14 days after the last administration, the subjects will be cited for their final visit in which the following 
evaluations will be made: 
- Sampling for clinical laboratory: equal to the tests carried out in the screening. 
- Control electrocardiogram. 
- Medical review: will include directed interrogation (including AEs) and physical examination. 
4.4.2. 7. End of the study 
Any clinically relevant deviation from the initial findings for all subjects should be monitored until they have 
returned to normal, are no longer considered clinically relevant or can be explained. 
Adverse events that were presented during the follow-up period and continued unresolved in the final visit, 
should be followed until resolved, are no longer considered clinically relevant or can be explained. 
The study will end when the last subject has been subjected to the activities described in the final visit and the 
laboratory or cabinet findings or adverse events, if detected, have been explained and closed by the investigator. 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 25 of 54 
 
 
4.4.3. Blood sampling schedule 
Clinical Stage 
NUMBER OF SUBJECTS: 
44 
 
SEX: 
Male or female 
BIOLOGICAL MATRIX: 
 Serum 
 
DOSAGE FORM: 
Tablets 
PHARMACEUTICAL FORM: 
Levothyroxine sodium 
200 μg 
 
DOSES AND NO. OF UNITS: 
200 μg (3 tablets) 
WASH-OUT PERIOD: 
35 days 
 
ANTICOAGULANT: 
Does not apply  
BLOOD VOLUME EXTRACTED 
PER SAMPLE: 
10 mL 
 
TOTAL OF SAMPLES PER SUBJECT 
IN EACH PERIOD: 
26 
 
Sampling time interval 
Stage 
Sample 
Time 
Unit 
 
Total number of samples 
Pre-dose 
01 
- 0.50 
h 
 
No. of 
cases 
Samples 
Periods 
Total 
Pre-dose 
02 
- 0.25 
h 
 
44 
26 
2 
2,288 
Pre-dose 
03 
0.00 
h 
 
 
A 
04 
0.50 
h 
 
Diet 
A 
05 
1.00 
h 
 
Standardized by the clinical unit
A 
06 
1.50 
h 
 
 
A 
07 
2.00 
h 
 
 
A 
08 
2.50 
h 
 
 
~ Cmax 
09 
3.00 
h 
 
 
~ Cmax 
10 
3.25 
h 
 
 
~ Cmax 
11 
3.50 
h 
 
 
~ Cmax 
12 
3.75 
h 
 
 
~ Cmax 
13 
4.00 
h 
 
 
~ Cmax 
14 
4.25 
h 
 
 
~ Cmax 
15 
4.50 
h 
 
 
~ Cmax 
16 
4.75 
h 
 
 
~ Cmax 
17 
5.00 
h 
 
 
E 
18 
5.50 
h 
 
 
E 
19 
6.00 
h 
 
 
E 
20 
6.50 
h 
 
 
E 
21 
8.00 
h 
 
 
E 
22 
10.00 
h 
 
 
E 
23 
12.00 
h 
 
 
E 
24 
24.00 
h 
 
 
E 
25 
36.00 
h 
 
 
E 
26 
48.00 
h 
 
 
Each subject will have a participation of 64 hours approximately (approximately 43 hours confined with 
outpatient follow-up for the 36 and 48-h samples) for each of the periods, with a wash-out period of 35 days, 
starting as per the drug's intake in the 1st period, according to the following schedule:   
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 26 of 54 
 
 
4.4.4. Schedule 
Pre-clinical Stage 
Clinical Stage 
Post-Clinical Stage 
Activity form day -120 to 0 
Day 
Time 
Activity 
Activity as per day 38  
 Protocol's elaboration. 
 Preparation of the non-
pregnancy letter, 
summary, schedule, 
ICF, and CRF. 
 Protocol's approval. 
 Approval by the Ethics 
and Investigation 
Committee and 
Investigation 
Committee. 
 Filing at the COFEPRIS. 
 COFEPRIS approval. 
 Drug's receipt. 
 Planning. 
 Subjects screening. 
 
0 
As per 15:00 h 
Admission. 
 Subjects' clinical follow-
up. 
 CRF close-out. 
 Delivery to the 
Analytical Unit. 
 Clinical Report 
elaboration. 
 Analytical stage. 
 Final report. 
 Study close-out. 
 Approval request for 
the biological samples 
disposal. 
VISIT 1 
01 
06:00 h 
Intake of 250 mL of water. 
06:30 h 
Catheter insertion. 
07:30 - 07:55 h 
Pre-dose sampling. 
08:00 h 
Drug intake. 
08:30 h 
Start of sampling (post-dose) 
02 
08:00 h 
24.0-h sampling 
Approximately at 
10:00 h 
Discharge from the Clinical Unit 
20:00 h 
36.0-h ambulatory sampling 
03 
08:00 h 
48.0-h ambulatory sampling 
Approximately 
10:00 h 
Temporal discharge, open 
appointment 
Wash-out Period – 35 days 
35 
As per 15:00 h 
Admission 
VISIT 2 
36 
06:00 h 
Intake of 250 mL of water 
06:30 h 
Catheter insertion 
07:30 – 07:55 h 
Pre-dose sampling 
08:00 h 
Drug intake 
08:30 h 
Sampling start (post-dose) 
37 
08:00 h 
24.0-h sampling 
Approximately at 
10:00 h 
Discharge from the Clinical Unit 
20:00 h 
36.0-h ambulatory sampling 
38 
08:00 h 
48.0-h ambulatory sampling 
Approximately at 
10:00 h 
Definitive discharge, open 
appointment. 
 
 
 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 27 of 54 
 
 
4.4.5. Investigational Product Identity 
4.4.5.1.
Packaging and labelling 
Reference Eutirox® (approved formulation) from Merck, S.A. de C.V. 
The reference drug will be supplied by Merck, S. A. de C. V. in its commercial presentation (original primary and 
secondary packaging).  
The drug will be kept in an identified closed package with an external label containing the study code and, if 
applicable, an internal label stating as minimum the study code, batch number and expiry date. The drug will be 
stored according the product's requirements.  
The reference drug will be given orally at a dose of 600 μg (3 tablets of 200 μg) of levothyroxine sodium, with 
250 mL of water. Single dose. 
Test Eutirox® (new formulation) from Merck, S.A. de C.V. 
Test drug will be supplied by Merck, S. A. de C. V. in its commercial presentation (original or prototype primary 
and secondary packaging). 
The drug will be kept in an identified closed package with an external label stating the study code and, if 
applicable, an internal label stating as minimum the study code, batch number and expiry date. The drug will be 
stored according to the product's requirements.  
The test drug will be given orally at a dose of 600 μg (3 tablets of 200 μg) of levothyroxine sodium, with 250 mL 
of water. Single dose. 
4.4.5.2.
Storage 
The drug should be kept safely, in a dry place, locked, at a temperature not higher than 25 °C, according to the 
label information.  
4.4.5.3.
Supply 
Test and reference drugs will be received at the
 
. by the person in charge of the pharmacy or designated personnel according to the standard 
operating procedures, code: 
 
Once the drugs have been identified, they will be kept by the Clinical Unit until its dosing to the subjects.   
Acceptance criteria for the test and reference drugs. 
 Complete documentation: 
9 Copy of the certificate of analysis for the test and reference drugs, endorsed by the Sponsor's Sanitary 
Officer, including the following tests: 
o Dose uniformity per content uniformity. 
o Evaluation.  
o Dissolution (if applicable). 
PPD
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 28 of 54 
 
 
9 Letter issued by the Sponsor stating that the test and reference drug's batch fulfill with the current NOM-
059-SSA1, endorsed by the Sanitary Officer. 
9 Under oath letter, endorsed by the Sponsor's Sanitary Officer, stating that the test batch for 
interchangeability test corresponds to the qualitative-quantitative formula for which the marketing 
approval will be applied for.  
 Test drug with a label which fulfills with the minimum required by the current NOM-072-SSA1Labelling of 
Drugs and Herbal Remedies. 
 Enough quantity of the test and reference drug.  
 Valid expiry date during study. 
 Test and reference drug in good physical conditions. 
Rejection criteria for test and reference drugs: 
 
 For blisters, that have been modified. 
 If drug is receipt out of the storage or transportation conditions. 
 If the primary packaging is damaged. 
 If difference in review between of the test and reference drugs is > 5 %.  
4.4.5.4.
Accountability 
The Sponsor will send enough quantity of the tests and reference drug to the 
 
, so the study can be conducted and keep another complete set of reference 
and test drug as «retention samples». The person in charge of the pharmacy at the 
 
 or designated personnel will be in charge of dispensing the 
required doses of this on the study days and to keep an inventory of the used and stored doses as retention 
samples, according to the standard operating procedure, code: 
 
    
4.4.5.5.
Retention samples 
The unused drug will be kept at the retention samples warehouse, in its primary and secondary package, and 
locked for a 1 year period as per the study completion or until the expiry date (if it is earlier). The person in charge 
of the pharmacy o designated personnel, the 
 
 will be in charge of the custody of the retention samples.   
4.4.5.6.
Final Disposition 
Following one year of the study completion or once the expiry date of the drugs is reached, these can be returned 
to the study Sponsor or will be made available for destruction by an authorized company, according to the 
standard operating procedure, code: 
 
  
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 29 of 54 
 
 
4.4.6. Subjects Assignment Method to the Treatment Sequence 
Once the inclusion criteria have been confirmed, a consecutive number will be assigned in ascending order from 
number 1 to the last case (44). A sequence A-B or B-A will correspond to each of these numbers from a 
randomization list previously produced by means of the software www.randomization.com and according to the 
standard 
operating 
procedure, 
code: 
 
 
 
 
 
   
4.4.7. Dose Selection in the Study 
Since levothyroxine is an endogenous compound, a high ratio of the exogenous levothyroxine concentrations 
with regards to the baseline concentrations of the endogenous levothyroxine should be ensured to differentiate 
the real differences between the formulations. Therefore, use of doses over the therapeutic doses of 
levothyroxine is recommended. Recommended dose is equivalent to 600 μg and, therefore, it will be the dose 
used in this study. Three tablets of 200 μg, single dose will be given from test (B) and reference (A) product as 
corresponds to the period.        
4.4.8. Selection and Timing of Dosing for Each Subject 
Following the standardized fasting period, the drug will be given to all subjects from 08:00 to 08:08 h, in 4 groups 
of 9 subjects and 1 group of 8, with a 2-minute gap between each other for the dosing and each one of the 
activities. Groups distribution can be changed due to operation issues, if there is no impact in the study results.    
The distribution of groups, subjects and timings of doses is shown in Table No. 4. 
TABLE No. 4  
Drug Dosing Schedule 
Group 
No. of Subjects 
Dosing Time 
A 
1 - 9 
08:00 h 
B 
10 - 18 
08:02 h 
C 
19 - 27 
08:04 h 
D 
28 - 36 
08:06 h 
E 
37 - 44 
08:08 h 
4.4.9. Blinding 
Randomization codes to the dosing sequence will be kept by the Principal Investigator. The Analytical Unit, the 
person in charge of the biological samples processing will be blinded during the samples analysis according to 
the standard operating procedures.  
 
 
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 30 of 54 
 
 
4.4.10.Previous and Concomitant Therapy 
Soya products can reduce the intestinal absorption of levothyroxine, so it should be avoided. 
Occasional use of paracetamol will be permitted within the screening period. The investigator may allow the 
subject to take paracetamol in case of pain during the trial, but the dose should not exceed 1000 mg/day for a 
maximum of three consecutive days. The amount of paracetamol administered must be recorded in the Case 
Report Format. Any additional concomitant therapy that becomes necessary during the trial from the date of 
signature of informed consent and any change to concomitant drugs must be recorded in the corresponding 
section of Case Report Format and in that case, the permanence of the subject in the study will be evaluated by 
the principal investigator.  
The following are known interactions of levothyroxine, for the purposes of this clinical study, the use of 
concomitant medications (except paracetamol) is not permitted. 
• 
Digitalis preparations: If levothyroxine therapy is initiated in digitalised patients, the dose of digitalis may 
require adjustment. Hyperthyroid patients may need their digoxin dosage gradually increased as treatment 
proceeds because initially patients are relatively sensitive to digoxin. 
• 
Sympathomimetic agents: The effects of sympathomimetic agents (e.g. adrenaline) are enhanced. 
• 
Protease inhibitors: Levothyroxine has been reported to lose its therapeutic effect when co administered 
with lopinavir/ritonavir. 
• 
Antidiabetic agents: Levothyroxine may reduce the antihyperglycaemic effect of antidiabetics. 
• 
Coumarin derivatives: Levothyroxine may potentiate the effect of coumarin derivatives due to plasma 
protein binding displacement. 
• 
Ion exchange resins: Ion exchange resins, such as cholestyramine, colestipol, calcium salts and sodium salts 
of polystyrene sulphonic acid, inhibit the absorption of levothyroxine and should therefore not be administered 
within 4 to 5 hours of taking Levothyroxine sodium. 
• 
Gastric acid binding agents containing aluminum, medications containing iron, calcium carbonate: 
Absorption of levothyroxine can be reduced by concomitant intake of gastric acid binding agents containing 
aluminum (antacids, sucralfate), medications containing iron and calcium carbonate. Levothyroxine sodium 
should therefore be taken at least two hours before these medications. 
• 
Propylthiouracil, glucocorticoids and beta receptor blockers: These substances inhibit conversion of T4 to T3. 
• 
Amiodarone inhibits the peripheral conversion of T4 to T3. Due to its high iodine content amiodarone can 
trigger hyperthyroidism as well as hypothyroidism. Particular caution is advised in the case of nodular goitre with 
possibly unrecognized autonomy. 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 31 of 54 
 
 
• 
Salicylates, dicoumarol, furosemide, clofibrate, phenytoin: Levothyroxine may be displaced from plasma 
protein binding by salicylates, dicumarol, high doses (250 mg) of furosemide, clofibrate, phenytoin and other 
substances 
• 
Oestrogen based contraceptives, medications used in postmenopausal hormone replacement: 
Levothyroxine requirements may increase during intake of oestrogen based contraceptives or during 
postmenopausal hormone replacement therapy 
• 
Sertraline, chloroquine/proguanil: These substances reduce the efficacy of levothyroxine and increase the 
serum TSH level 
• 
Tricyclic antidepressants Levothyroxine increases receptor sensitivity to catecholamines thus accelerating 
the response to tricyclic antidepressants (e.g. amitriptyline, imipramine) 
4.4.11.Therapy Compliance 
Throughout the period of administration of the dose, the complete taking of IMP will be checked and the intake 
time will be registered in the appropriate forms for this purpose.  
A subject is compliant with the therapy if completes the two study periods.  
4.5.
Study Variables 
Study variables will be divided in the following groups: 
 Demography 
 Pharmacokinetic  
 Safety  
 Biosafety; and  
 Biological samples control. 
4.5.1. Demographic Variables  
 Age 
 Sex 
 Weight 
 Height 
 Body Mass Index 
4.5.2. Pharmacokinetic Variables 
To determine the SC panel versus time and the pharmacokinetic variables: AUC0-t and Cmax, 26 samples will be 
taken per period and approximately 10 mL of venous blood via catheter in the following times: -0.50, -0.25, 0.00 
pre-dose and at 0.5, 1.0, 1.5, 2.0, 2.5, 3.0, 3.25, 3.5, 3.75, 4.0, 4.25, 4.5, 4.75, 5.0, 5.5, 6.0, 6.5, 8.0, 10.0, 12.0, 
24.0 36.0 and 48.0 hours following the treatment and levothyroxine serum concentration will be determined. 
 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 32 of 54 
 
 
 
Serum from these subjects will be collected as described in section 4.5.7.1.1. Dosing sequence and blood samples 
among subjects should be kept so that timing of these activities is the same among the subjects. Sampling exact 
time should be recorded in the appropriate forms. 
Once each blood sample is taken, these will be sent to the samples processing area and serum will be obtained 
by centrifuging (between 30 and 60 minutes after sample collection). Serum samples should be frozen and kept 
at a temperature ≤ -40 °C until their shipment to the Analytical Unit and until analysis. 
4.5.3. Safety Variables 
Safety variables to be collected from subjects include: 
Complete medical history, including drugs and use of tobacco and alcohol.  
Clinical laboratory tests profile and thyroid profile. 
Electrocardiogram (in the selection and in the admission to each period). 
Vital signs. 
Adverse events. 
Abuse drug screening tests (at screening and each admission of the two periods). 
Pregnancy test (qualitative and quantitative) at screening and each admission. 
4.5.4. Biosafety Variables 
Safety for the personnel who handles the biological samples at the Clinical Unit and at the Analytical Unit. 
 Screening for Hepatitis B Virus, Hepatitis C Virus, VDRL test (syphilis) and HIV (AIDS) at Screening only. 
4.5.5. Variable Assessment Periods 
For the study conduct the following periods have been planned: 
 Screening: within the 30 days prior to the dosing.  
 First period of the study: from the 16.00 hours prior to the first dose and at least 48.00 hours post-dose. 
 Wash-out period: 35 days between each dose. 
 Second period of the study: from the 16.00 hours prior to the second dose and at least 48.00 hours post-
dose. 
 Study withdrawal: following the 48.00-hour sampling in the second period. 
 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 33 of 54 
 
 
 Follow-up of adverse events: adverse events occurring in a 14-day period following the dosing in the second 
period will be reported. Adverse events that were presented during the follow-up period and continued 
unresolved in the final visit, should be followed until resolved are no longer considered as clinically relevant 
or can be explained. 
 Final Visit: 14 days after last administration of the study product. 
 End of study: The study will end when the last subject has been subjected to the activities described in the 
final visit (section 4.4.2.6.) and the laboratory or cabinet findings or adverse events, if detected, have been 
explained and closed by the investigator. 
For the wash-out period - drug's elimination - time when the subjects are out of the clinic, general directions will 
be given to each subject. They include specific information about feeding, restriction of drugs and overall care.  
4.5.6. Control of Drugs and Liquid Intake 
During the study conduct subjects should fast for at least 10 hours before the dosing and at least 4 hours 
following the dosing. Water is allowed ad libitum, except for the period between 1-hour pre-dose and the first 
meal (4 h after dose).  
During confinement period, food will be provided as stated in Table No. 5. Forty-five minutes will be granted as 
maximum to have food; water intake is not subject to this period. 
TABLE No. 5 
Schedule of Feeding 
FOOD 
DAYS 0 and 35 
DAYS 1 and 36 
Breakfast 
----- 
As per 12:00 h 
Lunch 
----- 
As per 16:00 h 
Dinner 
21:00 h 
As per 21:00 h 
 
There will be a 2-minute gap between groups (following the dose) for the food delivery according to the order 
and interval of the dosing.  
4.5.7. Pre-analytical control for biological samples 
To determine serum drug's concentrations, 26 samples of 10 mL approximately of venous blood will be taken 
per period by using catheter or venipuncture: -0.50, -0.25, 0.00 pre-dose and at 0.5, 1.0, 1.5, 2.0, 2.5, 3.0, 3.25, 
3.5, 3.75, 4.0, 4.25, 4.5, 4.75, 5.0, 5.5, 6.0, 6.5, 8.0, 10.0, 12.0, 24.0 36.0 and 48.0 hours following the treatment. 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 34 of 54 
 
 
4.5.7.1.
Biological Fluids for the Study 
4.5.7.1.1.
Blood Samples  
 According to the scheduled times, 26 blood samples will be taken by period, in test tubes specifically 
designed for venipuncture. 
 During the clinical phase each sample volume will be of 10 mL. Blood withdrawn to clean the catheter should 
be discarded before the blood sampling (purge). Volume to be withdrawn by visit will be of 260 mL 
approximately, 520 mL of blood in total at the end of the study. This amount can slightly more due to the 
blood withdrawn for purging (approximately 0.5 to 1 mL) which may change. In addition to this amount of 
blood, approximately 20 ml of blood and approximately 20 ml of urine (laboratory test) are required for the 
selection. In women, consider 3 ml more for the pregnancy test. For the examination at the final visit 
consider the same amount. 
 Real time of each sampling will be recorded.  
 Each blood sample collected for pharmacokinetic analysis should be stored at room temperature for 30 - 60 
minutes to allow for coagulation to occur, following this time period samples will be centrifuged at 2500 x g 
for 5 minutes at 4 °C (± 2 °C) to produce serum samples (If blood samples are not processed within 60 
minutes of sample collection, the blood samples should be stored refrigerated prior to processing).  
 Resulting serum samples will be deposited into 3 cryotubes containing approximately 1.5 - 2 mL of serum 
per tube. 
 Serum tubes will be properly identified by the study number (##), case number (C##), sample number (S##), 
and visit number (V#), according to the standard operating procedures, code: 
 
 
; and they will be kept frozen at a temperature 
≤ -40 °C until their delivery to the analytical unit.   
4.5.7.1.2.
Samples shipment 
To ensure that the shipping conditions from the laboratory where the biological samples were processed for 
their freezing and storage to the analytical unit do not affect the samples stability, it will be essential to fulfill the 
following guidelines:   
 The Principal Investigator or designated personnel will define the date and time of shipping in agreement 
with the analytical unit, as well as the transportation to be used and the approximate time for the 
transportation.  
 Mechanism of control and security for the sample shipment will be defined by the person in charge of the 
shipment in agreement with the Principal Investigator or designated personnel.  
 The person in charge of the samples processing will sign the material list attached, with a detailed 
description of the number of tubes and codes for each subject.  
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 35 of 54 
 
 
 An internal temperature reading system should be available in the container. A reading with its appropriate 
record will be made at least every 15 minutes.  
 Additionally, the reading at the moment the material is leaving the samples processing area will be recorded, 
as well as at the moment it is received at the analytical unit.  
 Samples transportation is the responsibility of the Clinical Unit where they were collected and processed.  
 A member of the clinical unit will make the delivery. 
 Samples must be frozen when delivered (-20 °C as maximum) when the container bags are checked.  
4.5.7.1.3.
Receipt, Inspection and Storage of Samples at the Analytical Unit 

The study responsible or the designated personnel at the analytical unit will receive the samples (with their 
documentation) and will review 100 % with the assistance of analysts and Quality Assurance, and will make 
notes in the appropriate form. Once the inspection is finished, the study responsible or designated 
personnel will store the samples in a deep freezer, and will document it on the equipment log.  

Quality Assurance will check the accuracy and reliability of the operations. 
Samples failing the acceptance criteria will be rejected. In addition, those samples which do not have the 
appropriate documentation will be reported to the Clinical Unit stating the reason why those samples were 
rejected. Rejected biological samples will be kept at the Analytical Unit meanwhile their disposition is determined 
by agreement with the Analytical Unit and the Clinical Unit.    
4.5.7.1.4.
Biological samples handling by the Analytical Unit 
Biological samples will be handled and processed as described in the appropriate analytical technique and 
according to the standard operating procedure, code: 
 
4.5.7.1.5.
Disposal of biological samples 
Following 30 calendar days to the final report issue, samples will be kept on the deep freezer and stored deep 
frozen, until they are recollected for their final disposition by an authorized company for that purpose.  
4.5.7.1.6.
Labelling of the deep-frozen samples  
Cryotubes will be identified with labels according to the standard operating procedure, code: 
 
. Each cryotube will show the 
study number, subject's number, period, and sample number specified in the protocol. Labels will be digitally 
designed and printed with a thermal printer. Type of label and printing will guarantee that the printing and 
adhesiveness resist several freezing and thawing cycles.      
PPD
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 36 of 54 
 
 
4.6.
Quality Management 
The quality assurance will be made by following the standard operating procedures, codes: 
 
 
 
      
The Quality Assurance Area follows up the study conduct process by means of quality control monitoring to check 
the compliance with the clinical protocol, internal standard operating procedures and the applicable guidelines 
of the Good Clinical Practice (ICH E6R1). Lack of compliance findings or opportunities for improvement as per the 
guidelines for the standard operating procedures, code: 
 
will be followed-up. All information collected will be 
analyzed for the Quality Assurance report elaboration and issue.    
4.7.
Documentation 
Case Report Forms will be completed by the authorized medical personnel according to the standard operating 
procedure, code: 
, with legible letter and without 
amendments.   
4.8.
Direct Access to the Source Data 
As part of the Sponsor's responsibilities, the study can be monitored in the analytical and clinical aspects to 
ensure data accuracy and understandability by accessing to the source documents to verify the Case Report 
Forms.    
4.9.
Agreement with an Ambulance and Hospital Service for Emergencies 
For adverse events, the medical staff will provide the immediate medical assistance required according to the 
adverse event occurred. In case of a serious event which requires hospital assistance, the Principal Investigator 
or medical staff on duty will indicate the transfer of the subject to the agreed hospital and will request the 
external ambulance service.   
5. Ethical and Legal Aspects 
5.1.
Ethics and Investigation Committee and Investigation Committee 
Before the start of the study, written approval from the Ethics and Investigation Committee and from the 
Investigation Committee, which should provide a list of their members, as per request of the study Sponsor or 
Principal Investigator. In the same way, is necessary the written authorization of the health authority in Mexico 
through the COFEPRIS before starting with any procedure of the study. If necessary due to modifications to the 
clinical protocol, case report form or informed consent form, a new approval from both committees and 
COFEPRIS will be obtained.     
PPD
PPD
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 37 of 54 
 
 
5.2.
Ethical and Regulatory Compliance 
This protocol fulfills with the current regulations on clinical research, including: the Guidelines of the Good 
Clinical Practice (GCP), Ethical Principles for Medical research in human beings from the Declaration of Helsinki 
issued by the 64th General Assembly of the World Health Organization, Fortaleza, Brazil, October 2013; the 
General Health Act and the Regulations of the General Health Act in the Field of Health Research, as well as the 
International Ethical Guidelines for Health-related Research Involving Humans, Prepared by the Council for 
International Organizations of Medical Sciences (CIOMS) in collaboration with the World Health Organization 
(WHO), Geneva 2016.   
5.3.
Approval by Regulatory Authorities 
This study will be carried out according to the provisions of the regulations set forth in the NOM-177-SSA1-2013 
which states the tests and procedures for proving that a drug is interchangeable and the requirements which 
third parties performing interchangeability tests should fulfill; the requirements for conducting biocomparability 
studies; requirements for authorized third parties, research centers or hospital institutions conducting 
biocomparability tests, as well as the NOM-012-SSA3-2012 which states the criteria for conducting research 
project for human beings health.  
5.4.
Informed Consent Form and Non-Pregnancy Commitment Letter 
The Principal Investigator or designated person, will inform the subjects about the appropriate aspects of his/her 
participation in this study. The process for the informed consent obtainment form the subject will be conducted 
according to all applicable regulatory requirements. The person obtaining the consent, witnesses and the subject 
should sign and date the informed consent form before performing any study related procedures. Decision 
regarding the subject's participation in the study, is absolutely free. The Principal Investigator or the person who 
gets the consent should stress to the subject that his/her consent regarding his/her participation in the study, 
can be withdrawn at any time without any prejudice or loss of benefits which he/she is entitled anyway.     
Child-bearing potential women will have to sign and date a Non-Pregnancy Commitment Letter where they state 
that they are not pregnant or have any delay in their cycle, that they will avoid getting pregnant by means of 
barrier or non-hormonal contraceptive methods throughout the study.   
If the informed consent form or the Non-Pregnancy Commitment Letter are modified during the study, the 
Principal Investigator should fulfill all the applicable regulatory requirements necessary for the approval of the 
informed consent form amendment by the Ethics and Investigation Committee and the Investigation Committee 
and use the amended form in the study.     
5.5.
Confidentiality, responsibility and compensation  
Information collected in this study will be exchanges exclusively between Merck, S.A. de C.V. and the 
 
 and will be treated as confidential. 
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 38 of 54 
 
 
Subjects will sign a consent specifying that they will receive an economical compensation for their participation 
in the study. The Sponsor will pay (o compensate, if applicable) the resulting injuries or diseases caused by the 
subjects' participation in the study until their resolution according to the medical opinion. The Sponsor will not 
pay if this is due to the subject's negligence, irresponsible conduct or medical conditions no related to the study. 
The Ministry of Health, the Ethics and Investigation Committee and the Investigation Committee will be the only 
authorized bodies for reviewing the study documents (including the participant subjects' identity data) and the 
documents considered confidential by the 
 
 and Merck, S. A. de C. V.  
Study participant subjects' personal data will be confidential and will be protected by the Federal Law on the 
Protection of Personal Data held by Private Parties, which is stated in our PRIVACY NOTICE and can be checked 
in our website www.cecype.com. 
6. Samples Chemical Analysis 
Levothyroxine (T4) serum concentrations will be determined by liquid chromatography coupled in a mass 
detector/mass according to the physicochemical properties and reported in the international scientific literature 
(LC MS/MS), which will be validated prior to the start of the study according to the applicable guidelines and the 
study working plan, as well as to the applicable analytical technique, in compliance with the applicable Analytical 
Unit and Quality Assurance procedures, and according to the NOM-177-SSA1-2013 and the Good Laboratory 
Practice. The analytical method details will be described in the validation protocol.  
7. Sample Size Determination, Pharmacokinetic and Statistical Analysis 
The pharmacokinetic and statistical analysis for the levothyroxine serum concentrations will be carried at the 
 as per its standard operating procedures 
and in compliance with the NOM-177-SSA1-2013. 
7.1.
Sample Size Determination 
The sample size determination was based on the variability seen in the most recent study conducted by the study 
Sponsor EMR200125-001 (comparative study of the levothyroxine formulations for approval in Europe) where 
the intrasubject variability for AUC0-72h was 23.7 % and the Cmax was 17.7 %. Using the most variable parameter 
AUC0-72h, a difference of 5 %, a power of 90 % and applying the accepted bioequivalence range of 80 % to 125 %.       
By using the Chow & Wang equation, and substituting the aforementioned values, a sample size of 34 subjects 
was obtained. If a drop rate of 20 % is considered, the sample size should be of 44 subjects. 

PPD
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 39 of 54 
 
 
7.2.
Pharmacokinetic Analysis 
The pharmacokinetic analysis will be obtained by using a non-compartmental analysis with the use of the current 
versions of the Phoenix® WinNonlin® software. 
The following parameters will be determined. They will be calculated with the uncorrected data of the baseline 
levels (raw values), as well as the corrected values by baseline levels (adjusted values). The mean of the pre-dose 
levothyroxine levels should be used for the baseline adjustment of the post-dose levels. Any negative values 
obtained from baseline correction should be designated as zero (0):   
Cmax: maximum serum concentration observed directly from the concentration-time curve.  
Cmax(aj): maximum serum concentration in pre dose corrected data.  
tmax: time when the maximum serum concentration was obtained. 
AUC0-t: area under the curve of the serum concentration as a function of time, from time 0 until the last sampling 
time by means of the trapezoidal rule.  
AUC0-t (aj): area under the curve of the serum concentration as function of time, from time 0 until the last 
sampling, by means of the trapezoidal rule in pre dose corrected data. 
AUC0-∞ (aj) = AUC0-t (aj) + Ct (aj) /Kel 
Kel: elimination constant, calculated from the semi-logarithmic graphic of the serum concentration as function 
of time. It is estimated by means of a simple linear regression analysis from at least the last three serum 
concentrations different to zero.    
t1/2: time of the half-life or elimination half-life calculated as Ln (2)/Kel 
7.3.
Statistical Analysis  
7.3.1. Descriptive Statistics 
Adjusted concentrations will be tabulated by treatment and by time of all subjects, stating the drug or 
formulation, the arithmetic mean, standard deviation and variation coefficient.  
A descriptive statistic will be presented by the adjusted serum concentrations, by treatment globally (arithmetic 
mean, minimum value, maximum value, standard deviation and coefficient of variation).  
The descriptive statistic will be determined from the individual adjusted pharmacokinetic parameters, by 
treatment, stating the period, sequence, quotient of the reference test, as well as its logarithm for the 
pharmacokinetic parameters used to determine the bioequivalence (geometric means, arithmetic mean, 
median, minimum value, maximum value, standard deviation and variation coefficient).  This will only apply for 
evaluable subjects. 
An evaluable subject will be one who has completed both periods of the study and has at least 60% of their 
samples with measurable concentrations, who has not presented vomiting or diarrhea before 2 times the median 
of the tmax or 2 times the value of tmax and who has not presented any situation that could modify the result of 
the study due to uncontrolled variables. 
A graphic of the adjusted serum concentration against individual and average time in the arithmetic and semi-
logarithmic scale.    
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 40 of 54 
 
 
7.3.2. Statistical Analysis for Bioequivalence 
7.3.2.1.
Variance Analysis (ANADEVA) 
The general linear model of the analysis of variance that represents the experimental design for the analysis of 
data of the adjusted pharmacokinetic variables will be used, considering the following sources of variation in an 
additive way: 
 Dosing sequence. 
 Nested subjects in the dosing sequence call inter-subject variability or inter-subject residual variability. 
 Dosing period. 
 Therapy or formulation. 
 Experimental error, called intra-subject variability or intra-subject residual variability. 
This general lineal model, applied to the crossed designs to determine bioequivalence is the following: 
Yijk = μ + Gk + Sjk + Pj + F(j,k) + eijk  (Chow & Liu, 2009) 
Where: 
μ = general mean. 
Gk = fixed effect of kth sequence. 
Sjk = randomized effect of the ith subject in the kth sequence, where i = 1, 2, ..., nk and k = 1, 2, ...K 
Pj = fixed effect of the jth period, where j = 1, 2, …, J y Σj Pj = 0 
F(j,k) = direct fixed effect of the formulation in the kth sequence, which is given in the jth period and Σ F(j,k) = 0 
eijk = randomized error (intra-subject) in the observation Yijk     
The sequence effect should be assessed using the square means of the nested subject in the sequence as a term 
of error. All other main effects should be assessed against the residual error (error square mean) and F values 
reported as appropriate. Additionally, it should be stated if the source of variation is significant when p is < 0.05 
(p < 0.05).    
In the event of a significant effect in the variability factors for the sequence or period, actions will be taken in 
accordance with the NOM-177-SSA1-2013. 
7.3.2.2.
Hypothesis Statement for the double, one-sided Schuirmann's t test,  
The double, one-sided t test (Schuirmann) will be done with the obtained data from the logarithmic 
transformation for the AUC0-t (aj) and Cmax (aj), by means of the 90 % CI construction for the quotient between the 
average pharmacokinetic parameters logarithmically transformed from the test and reference drugs. 
H0: μp / μr ≤ Li or μp / μr t Ls 
H1: Li< μp / μr < Ls 
Null hypothesis for bioequivalence is rejected if Schuirmann's P probability P(t) for the lower limit (Li = 0.8) and 
upper (Ls = 1.25) is P < 0.05. 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 41 of 54 
 
 
7.3.2.3.
Determination of the Classical 90 % confidence Interval 
Compliance with the Guide to Establish Interchangeability of Oral Solid Drugs containing Levothyroxine Sodium 
(COFEPRIS, 2017). The pharmacokinetic parameters that will be used for the statistical analysis of bioequivalence 
are Cmax (aj) and AUC0-t (aj) of levothyroxine (T4), by means of 90 % confidence intervals for the geometric means of 
these pharmacokinetic parameters to check their bioequivalence. The classical 90 % confidence interval will be 
calculated by means of the following equation for the lower and upper limit, respectively.   
 
Where: 
YT = population media for the assessed pharmacokinetic parameter of the test drug.   
YR = population media of the assessed pharmacokinetic parameters of the reference drug. 
Vw = square root of the square mean for the error of the assessed pharmacokinetic parameter. 
t(1-α,N-2) = distribution of the Student's t with an α probability of 0.05 and N-2 degrees of freedom (df) = N – 2 
with an α probability = 0.1 
n1 = number of volunteers in the sequence 1. 
n2 = number of volunteers in the sequence 2. 
 
The statistical analysis to show interchangeability will be done using only the corrected values of the parameters 
for Cmax (aj) and AUC0-t (aj), equivalence margins will be considered as 80 % - 125 %. 
 
7.3.3. Outliers 
An analysis to identify the outliers (extreme values) based on the estimation of the Student intra-subject residual 
values will be done using Excel software. By means of the determination of the residual value obtained with the 
model using the following equation: 
 
݁పఫ௞
ෞൌܻ௜௝௞ିܻ෠௜௝௞ 
Where: 
ܻ௜௝௞ is the observed response. 
ܻ෠௜௝௞ is the estimated value with the model. 
This residual value should be in the Student fashion by using the following equation:   
݁ఫ௞௟௦௧ௗൌ
݁పఫ௞
ෞ
ටቀܵെͳ
ʹ כ ܵכ ܥܯ݁ݎݎ݋ݎቁ
෣
 
Where: 
݁పఫ௞
ෞ is the residual value previously determined. 
S is the number of subjects considered for the assessment 
CMerror, value of the mean square value of error, corresponding to each of the assessed pharmacokinetic 
parameters.  
Determination of outliers will be done for the pharmacokinetic parameters of Cmax, and AUC0-t for both analytes. 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 42 of 54 
 
 
Criterion: data which extent is higher than ± 2 intra-subject standardized residual values will be considered 
outlier (extreme). 
7.3.4. Deviation to the Statistical Plan 
The study statistical plan will correspond to what is specified in the section 7.3 of this protocol with regards to 
the methods and criteria for the statistical tests thus established to compare the bioavailability of the study drug.   
All deviations should be justified by statistical or scientific evidence and any change should be reported in the 
original statistical plan, in the study master file and in the statistical pharmacokinetic report and study final 
report.   
Subject data will not be replaced and any missing data will be considered as non-existent data. Likewise, data 
cannot be removed from the statistical analysis, except for the following cases:   
 Elimination of date due to vomiting and diarrhea. 
Data from the research subjects who suffer from vomiting and diarrhea during the bioequivalence study for 
immediate release products can be removed from the statistical analysis if vomiting or diarrhea occurs before 
twice the median for tmax or twice the value for tmax from the research subject in a given period.   
 Research subject with very low serum concentrations for the study drugs. 
As established by the NOM-177-SSA1-2013, also the research subjects who do not provide evaluable data in a 
crossed design, both for the test drug and for the reference drug, o who do not provide evaluable data in the 
single period of a parallel design, should not be included in the statistical analysis.   
A research subject is considered to have very low concentrations, if the AUC (aj) is < 5 % for the geometric mean 
for the AUC of the reference drug (it should be calculated without including outliers). Exclusion of data for this 
reason, will only be accepted under scientific rationale and previous review of the case by the COFEPRIS.  
 Finally, all data which do not show significant outliers will be considered according to the criteria for outliers 
in the section 7.3.3 of this protocol. Outliers exclusion should be supported by scientific evidence.  
7.4.
Biowaiver of bioequivalence test for other strengths  
According to the official Mexican norm (NOM-177-SSA1-2013) if a product has more than one strength, in the 
same pharmaceutical form and shows acceptable in vitro dissolution testing of all strengths, a biowaiver is 
possible if the following requirements are met: 
The proportionality (constant relationship) in the content of drug (s) and additive (s) in the qualitative-
quantitative formula with respect to the drug was found. Proportionality must meet the following criteria (NOM-
177-SSA1-2013): 
 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 43 of 54 
 
 
x
The drug (s) or additive (s) are in the same proportion between the different concentrations. 
x
The drug (s) or additive (s) are not exactly in the same proportion between the different doses, but 
the ratio of active ingredients relative to the total weight of the dosage form can vary up to 10% 
without any impact on the dissolution rate of the drug. 
x
For potency drugs, where the amount thereof in the dosage form is very low (less than 10 mg per 
tablet), and the total weight of the dosage form is equal at all doses, they could be proportionality if 
don´t vary by more than 10% of the total weight of the dosage form. 
x
For immediate release, the coated components, colorings, flavorings and capsule shell should not be 
considered in the calculations to establish the proportionality of the formulas. 
x
The dissolution profile is similar between the bioequivalent strength of the test drug and the test 
drug with the strengths to exempt, which must be performed by an authorized third party. 
x
Sufficient scientific evidence is submitted to demonstrate that the drug exhibits linear 
pharmacokinetics in the range of concentrations applied. 
x
Manufacturing processes are validated. 
8. Adverse Events 
8.1.
Warnings 
Prior to the study drug's administration, information of the prescribing information related to the study side 
effects (approved by the Ministry of Health) should be considered. The Principal Investigator and the involved 
physicians in the study should know in advance the prescribing information.  
8.2.
Adverse Events Monitoring 
Subjects should be carefully monitored with regards to the presence of adverse events. Adverse events should 
be established in terms of their seriousness, severity and causality with the study drug. 
8.3.
Observation Period for Adverse Events 
Adverse events occurring from the signature of the informed consent form and until 14 days following the dosing 
in the second period of the study will be reported. 
8.4.
Adverse Events Definitions 
8.4.1. Adverse Event 
Any untoward medical event which might occur in a research subject during the clinical investigation stage of a 
drug or vaccine, but that not necessarily has a causality with it (NOM-220-SSA1-2016). 
 
 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 44 of 54 
 
 
 
Adverse events related to the use of drugs in humans, whether related with it or not, include the following: 
 An adverse occurring during the use of a drug in a professional setting.  
 An adverse event occurring due to the abuse of drugs or illicit drugs. 
 An adverse event occurring following the drug's intake stop.  
 An adverse event where there is a reasonable possibility that the event occurred only as a result of the 
subject's participation in the study (e.g., serious or non-serious adverse event due to the antihypertensive 
drugs discontinuation during the wash-out phase) should be reported as an adverse event even if it is not 
related with the investigational product.   
 Clinical onset of any failure of the expected pharmacological action. 
If the event fulfills with the "serious" adverse event criteria should be recorded and reported as such. 
8.4.2. Serious Adverse Event 
A serious adverse event is any clinical onset occurring following the dosing of any drug, including vaccines, and 
that (NOM-220-SSA1-2016): 
 Causes the subject's death. 
 Is life-threatening for the subject when occurring.  
 It is necessary to admit the subject at the hospital or extend his/her stay at the hospital. 
 Causes permanent or significant inability or disability. 
 Causes abnormalities or malformations in the newborn. 
 Are considered medically important. 
Some important medical events, even though they not produce death or are life-threatening, or require 
hospitalization, can be considered serious adverse events based on the appropriate medical opinion; or those 
which pose a risk for the subject, leading to medical or surgical intervention to avoid them. Example of those 
medical events include allergic bronchospasm which requires intensive treatment at the emergency room or at 
home; blood dyscrasias or seizures which do not lead the hospital admission or drug dependence or abuse.     
Life-threatening means that the subject was, at the investigator's opinion, at immediate risk of death by the 
reaction when it occurred.   
Disability means an important disorder in the person's ability to perform his/her daily activities.  
8.4.3. Unexpected Adverse Reaction 
An unexpected adverse reaction is an adverse reaction which nature or severity is not described in the product's 
prescribing information, nor in the documentation submitted for the marketing approval (NOM-220-SSA1-2016). 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 45 of 54 
 
 
8.4.4. Exposure during pregnancy 
If a female subject becomes pregnant during their participation in the study, the corresponding notification will 
be made as a serious adverse event. Follow-up will be mandatory throughout the pregnancy and until at least 
the first 6 months of life of the newborn (NOM-220-SSA1-2016). 
Based on the subject's preference, follow-up can be done through telephone contact or medical consultation in 
the clinical unit, at least every two months during pregnancy and up to 6 months of life of the newborn or until 
the pregnancy is resolved (in case an abortion happens). 
8.5.
Causality of the Adverse Event with the Investigational Product 
Establishment of the causality of the adverse events with the administered study drug is a clinical decision based 
on the available information when the adverse event occurred.  
According to the causality assessment provided by the World Health Organization and the Uppsala's Monitoring 
Center, probabilistic characteristics are the following (NOM-220-SSA1-2016): 
 Certain: clinical event, including laboratory tests abnormalities, which occur with a plausible temporary 
sequence with regards to the drug's dosing, and which cannot be explained by the concurrent disease, 
or by other drugs or substances. Drug's dechallenge response (withdrawal) should be clinically plausible. 
The event should be definitive from the pharmacological or phenomenological point of view, using, if 
necessary, the conclusive rechallenging procedure.    
 Probable: clinical event, including laboratory tests abnormalities, which occur with a reasonable 
temporary sequence with regards to the drug's dosing and it is unlikely that it is attributed to the 
concurrent disease, or other drugs or substances; and that shows a clinically reasonable response to the 
drug's dechallenge. It is not necessary to have information about rechallenge to assign this definition.    
 Possible: clinical event, including laboratory tests abnormalities, which occur with a reasonable 
temporary sequence with regards to the drug's dosing, but that can be explained by the concurrent 
disease, or by other drugs or substances. Information regarding the drug's dechallenge may be missing 
or unclear.   
 Unlikely: clinical event, including laboratory tests abnormalities, which occur with an unlikely temporary 
sequence with regards to the drug's dosing which can be explained in a more plausible way by the 
concurrent disease, or by other drugs or substances.   
 Conditional or not classified: clinical event, including laboratory tests abnormalities, reported as an 
adverse reaction, for which it is essential to get more data to make an appropriate assessment or which 
data are being analyzed.  
 Not evaluable or unclassifiable: a report that suggests an adverse reaction which cannot be assessed 
due to insufficient or contradictory information and which data cannot be checked or completed. 
 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 46 of 54 
 
 
8.6.
Adverse Event Severity 
Adverse events severity or seriousness should be classified as follows: 
 Mild: occur with signs and symptoms easily tolerated that do not require treatment; they do not require 
hospitalization or its extension, and do not require that the causative drug is stopped.   
 Moderate: interfere with daily activities (may cause work or school absence), without threatening the 
subject's life directly. They require pharmacological therapy and may not require that the causative drug 
is stopped.   
 Severe: interfere with daily activities (may cause work or school absence). Require pharmacological 
therapy and the discontinuation of the causative drug. 
8.7.
Adverse Events Documentation and Report  
Any adverse event occurring during the study period should be fully recorded both in the subject's medical chart 
and in the Case Report Form. 
Documentation should be supported by a record in the subject's medical chart. Laboratory tests abnormalities 
considered as clinically relevant, for instance, which cause the subject's withdrawal from the study and require 
therapy or cause apparent clinical signs in the subject, or that are considered relevant by the investigator, should 
be reported as an adverse event. All adverse events should be described in detail, including the subject's identity 
(name, age and sex), adverse event, suspected drug, reporter data, onset date and event's term and therapy, 
generic and distinctive name, dosage, route of administration, reason of prescription, event's consequence and 
important data in the medical history.  
The report of adverse events will be the responsibility of the 
 
 and will be made according to the standard operating procedure, code: 
 
 and the Mexican Official Standard for the Pharmacovigilance Setting Up and Operations in Mexico, 
NOM-220-SSA1-2016. Therefore, reports from institutions or establishment which intend to or conduct research 
in human beings should be coded with reported clinical onset using the current MedDRA term. Timelines for 
reports submission to the National Center of Pharmacovigilance (CNFV) from the Federal Commission for the 
Protection against Sanitary Risks (COFEPRIS) in the country and to the Sponsor are as follows:       
 Serious adverse event: up to 7 calendar days. 
 Non-serious adverse event: report at the end of the study. 
 Two or more serious events, similar in the same location, with the same drug and batch number: 
immediately, no later than 48 hours. 
Report to the CNFV should be made by the Pharmacovigilance Officer at the 
 
 in compliance with the NOM-220-SSA1-2016. 
The ways to make the report to the Sponsor are the following: 
 
 
PPD
PPD
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 47 of 54 
 
 
Telephone: 
 
Mobile: 
 
E-mail:  
 
 
 
According to the local law and regulations, adverse events should be reported to the appropriate Ethics and 
Investigation Committee, Investigation Committee and regulatory authorities. 
9. Data Use and Publication 
All data and results, and all rights and intellectual property for the data and results from this study will be 
property of Merck, S. A. de C. V. that can use the data in several ways, such as submitting them to government 
regulatory authorities or sending them to other investigators.  
Although the Investigator is free to use the data obtained in the study for scientific purposes, he/she should 
discuss any publication with Merck, S. A. de C. V. in advance, and he/she should obtain the written consent from 
the Sponsor for the intended publication.  
The Sponsor acknowledges the Investigator's right to publish the results once the study is completed. Anyway, 
the Investigator should send the paper's draft to be published or its summary to Merck, S. A. de C. V., 30 days in 
advance to the submission of the final version for publication. 
This will be reviewed soon and approval will not be unnecessarily delayed. In case of disagreement between the 
Sponsor and the Investigators, publication content will be discussed to find an appropriate solution for both 
parties.   
10. Management of Concurrent Events (Administrative and Medical) 
10.1. Research Protocol Amendments  
Research protocol amendments may be issued by the Principal Investigator in agreement with the Sponsor and 
vice versa, and should be approved by the Ethics and Investigation Committee and by the Investigation 
Committee. Administrative changes which do not affect the study design should be agreed and approved by the 
Sponsor, the Analytical Unit and the Principal Investigator. They should be submitted to the Ethics and 
Investigation Committee and to the Investigation Committee.  
10.2. Deviations to the Protocol 
Deviations to the research protocol occurring during the study conduct should be reported to the Principal 
Investigator, Study Sponsor, to the Ethics and Investigation Committee and to the Investigation Committee.  
Whenever a deviation to the protocol occurs during the clinical stage conduct, it should be assessed by the 
Principal Investigator. If considering that the subject's continuation in the study may affect the study's results, 
the Sponsor will be informed; and jointly they will decide the continued subject's participation in the study.  
PPD
PPD
PPD
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 48 of 54 
 
 
11. References 
 Abib E., Pedrazzoli J., Duarte I., Marques P., Levothyroxine Bioequivalence Study: Determination in 
Healthy Volunteers by Microparticle Enzyme Immunoassay. Global Journal of Medical Research, Vol. 10 
Issue 2(Ver 1.0); 58-63. October 2010. 
 Drugs & Medications – Levothyroxine Sodium. Checked on January 9th, 2018. Available on the website: 
https://www.webmd.com/drugs/2/drug-1433/levothyroxine-oral/details/list-sideeffects 
 Drugs.com - Levothyroxine Pregnancy and Breastfeeding Warnings. Checked on January 11th, 2018. 
Available on the website: https://www.drugs.com/pregnancy/levothyroxine.html 
 Fuhr U. (Nov 1998). Tobacco smoking, alcohol, and special diet in drug trials: exclusion criteria or target 
of specific investigations? International Journal of Clinical Pharmacology and Therapeutics, 36 (11), 604 
- 606. 
 Guidance to Establish the Interchangeability of Oral Solid Drugs Containing Levothyroxine Sodium, 
COFEPRIS, 
2017. 
Checked 
on 
January 
11th, 
2018. 
Available 
on 
the 
website: 
https://www.gob.mx/cms/uploads/attachment/file/224149/Gu_a_intercamb_de_med_s_lidos_orales
_con_Levotiroxina_s_dica..pdf 
 International Conference on Harmonization of Technical Requirements for Registration of 
Pharmaceuticals for Human Use - ICH Harmonized Tripartite Guideline - Guideline for Good Clinical 
Practice E6(R1), June 10th, 1996. 
 Koytchev R. & Lauschner R., Bioequivalence Study of Levothyroxine Tablets Compared to Reference 
Tablets and an Oral Solution. Arzneim. Forsch/Drug Res. 54, No. 10, 680−684 (2004). 
 General Health Act, Federal Official Gazette, December 16th, 2016. 
 Mexican Official Standard, Good Manufacturing Practice for Drugs (NOM-059-SSA1-2015), Federal 
Official Gazette, February 5th, 2016. 
 Mexican Official Standard, Drug Substances and Drug's Stability (NOM-073-SSA1-2015). Federal Official 
Gazette, June 7th, 2016. 
 Mexican Official Standard, Drugs and Herbal Remedies Labelling (NOM-072-SSA1-2012), Federal Official 
Gazette, November 21st, 2012. 
 Mexican Official Standard, Pharmacovigilance Set-up and Operations (NOM-220-SSA1-2016), Federal 
Official Gazette, July 19th, 2017. 
 Mexican Official Standard which establishes the tests and procedures to prove that a drug is 
interchangeable. Requirements which authorized third parties performing interchangeability tests 
should fulfill. Requirements to conduct biocomparability studies. Requirements which third parties, 
investigational centers or hospital institutions performing interchangeability tests should fulfill. (NOM-
177-SSA1-2013), Federal Official Gazette, September 20th, 2013. 
 Mexican Official Standard which establishes the criteria to conduct research projects for health in human 
beings (NOM-012-SSA3-2012), Federal Official Gazette, January 4th, 2013. 
 Olagnier V., Sibille M, Vital Durand D, Deigat N, Baltassat P, Levrat R. (1993 Nov-Dec). Critical value of 
bilirubin in the selection of healthy volunteers in for phase I. Therapie, 48(6), 617-622. 
 International Ethical Guidelines for Health-related Research Involving Humans, Prepared by the Council 
for International Organizations of Medical Sciences (CIOMS) in collaboration with the World Health 
Organization (WHO), Geneva 2016.   
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 49 of 54 
 
 
 PLM, 
2016 
- 
Eutirox®, 
checked 
on 
January 
11th, 
2018, 
available 
on 
the 
website: 
http://www.medicamentosplm.com/Home/productos/eutirox_tabletas/115/101/7592/210 
 Ethical Principles for Medical Research in Human Beings from the Declaration of Helsinki, issued by the 
64th General Assembly of the World Medical Association, Fortaleza, Brazil; October 2013.  
 PubChem CID 23666112- Levothyroxine Sodium; checked on January 9th, 2017. Available on the website: 
https://pubchem.ncbi.nlm.nih.gov/compound/23666112#section=Top 
 Regulations of the General Health Act in the Field of Health Research, Federal Official Gazette, April 2nd, 
2014. 
 Rojas A., Garrido E., Nishimura E., Manejo del hipotiroidismo congénito con dosis diarias no equitativas 
de levotiroxina. Revista de Endocrinología y Nutrición Vol. 17, No. 2, Abril-Junio 2009 pp 66-70. 
 Sibille M., Deigat N., Durieu I., Guillaumont M., Morel D., Bienvenu J., Massignon D., Vital Durand D. 
(1999). Laboratory data in healthy volunteers: reference values, reference changes, screening and 
laboratory adverse event limits in Phase I clinical trials. Eur J Clin Pharmacol, 55, 13 - 19. 
 WinNonlin Pro, Ver. 5.3 Pharsight Corporation, Mountain view California 94040. 2011. 
 
 
 
 
 
 
 
 
 
 
 
 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 50 of 54 
 
 
12. APPENDIXES 
12.1. Schedule of Assessments 
 
 
 
 
 
 
$'0,6
6,21
3HULRG
7'Ǧ
7'
7'
ZDVKRXW
3HULRG
7'
7'
7'
(27
7LPH3RVWGRVHK
























7'
,QIRUPHG&RQVHQW
;
+RVSLWDOL]DWLRQ
$PEXODWRU\9LVLWV
;
;
,QFO([FO&ULWHULD²
;
;
0HGLFDO+LVWRU\
;
%RG\ZHLJKWKHLJKW
;
9LUXVVHURORJ\+&9+%9
+,9DQG9'5/
;
8ULQHGUXJVRIDEXVH	
DOFRKROVFUHHQV
;
;
6HUXP3UHJQDQF\7HVWLQJ
:2&%3
;
;
3K\VLFDOH[DPLQDWLRQ
;
;
9LWDO6LJQV
;
;
;
;
;
(&*OHDG
;
;
;
6DIHW\/DERUDWRU\
+HPDWRORJ\&OLQLFDO
&KHPLVWU\8ULQDO\VLV
;
;
5DQGRPL]DWLRQ
;
,03DGPLQLVWUDWLRQ
;
3.
;
;
;
;
;
;
;
;
;
;
;
;
;
;
;
;
;
;
;
;
;
;
;
;
;
;
$GYHUVH(YHQWV
;
;
;
;
&RQFRPLWDQWPHGLFDWLRQ
;
;
;
(QGRI&OLQLFDOPRQLWRULQ
FDOO
;
)RRWQRWHV












 %ORRGVDPSOHFROOHFWLRQIRUVDIHW\ODERUDWRU\DVVHVVPHQWVZLOOEHSHUIRUPHGDIWHUDIDVWRIDWOHDVWKRXUV
+RVSLWDOL]DWLRQ)URP7'±XQWLOWKHKRXUVSRVWGRVHIRUHDFKSHULRG
6XEMHFWHOLJLELOLW\PXVWEHFKHFNHGDJDLQRQ7'SULRUWRUDQGRPL]DWLRQDQG7'SULRUVHFRQGDGPLQLVWUDWLRQ
+HLJKW>FP@VFUHHQLQJDQGZHLJKW>NJ@VFUHHQLQJ
6XEMHFWVZLOOEHDVNHGDWVHOHFWLRQDWDGPLVVLRQLQERWKSHULRGDQGZKHQWKHVXEMHFWFRPSOHWHWKHFOLQLFDOPRQLWRULQJ
)RUIHPDOHVXEMHFWVZKRDUHSRVWPHQRSDXVDOIRUOHVVWKDQ\HDUVSRVWPHQRSDXVDOVWDWXVZLOOEHFRQILUPHGE\)6+OHYHOGHWHUPLQDWLRQDWVFUHHQLQJRQO\UHVXOWVPXVWEHZLWKLQWKHODERUDWRU\SRVWPHQRSDXVDO
UDQJH
6SRQWDQHRXV$(VZLOOEHFRQWLQRXVO\UHSRUWHGVLQFHWKHVXEMHFWVVLJQWKHLQIRUPHGFRQVHQWXQWLOFRPSOHWHWKHFOLQLFDOPRQLWRULQJVXEMHFWVZLOOEHDVNHGVSHFLILFDOO\DWDGPLVVLRQLQERWKSHULRGSUHGRVHDIWHUHDFK
DGPLQLVWUDWLRQGXULQJWKHKRVSLWDOL]DWLRQDQGZKHQVXEMHFWVDWWHQGWRWKHFOLQLFIRUWKHEORRGVDPSOLQJ
7'
7'
7'7'
“A prospective, single dose, randomized, open, crossover, comparative study to establish bioequivalence in healthy subjects between the new formulation vs. the currently approved formulation of 
levothyroxine 3 tablets of 200 μg  Eutirox® Merck, S.A. C.V.”
7ULDO'D\
6&5
3UHGRVH

6DIHW\
6XEMHFWVZLOOUHFHLYH,03DIWHUDQRYHUQLJKWIDVWRIDWOHDVWKRXUV7KH,03ZLOOEHDGPLQLVWHUHGDWPRUQLQJμJVLQJOHGRVHZLWKP/RIZDWHULQFRPSOLDQFHZLWKWKH12066$1RIRRGZLOOEH
DOORZHGIRUWKHQH[WKRXUVXQWLODVWDQGDUGL]HGOXQFKZLOOEHVHUYHG
5DQGRPL]DWLRQZLOORFFXURQFHDOOVFUHHQLQJDFWLYLWLHVKDYHEHHQFRPSOHWHGDQGWKHVXEMHFWLVGHHPHGHOLJLEOH
8ULQHVFUHHQIRUGUXJVRIDEXVHDPSKHWDPLQHVEHQ]RGLD]HSLQHVFRFDLQHPHWKDPSKHWDPLQHVPRUSKLQHDQGWHWUDK\GUR±FDQQDELQRLGVDQGDOFRKRO7KHWHVWVFDQEHUHSHDWHGDWDQ\WLPHDWWKHGLVFUHWLRQRIWKH
LQYHVWLJDWRU
&RPSOHWHSK\VLFDOH[DPLQDWLRQVZLOOEHFRQGXFWHGDWVFUHHQLQJDQGDEEUHYLDWHGH[DPLQDWLRQVDWWKHRWKHUWLPHSRLQWVLQGLFDWHG$EEUHYLDWHGH[DPLQDWLRQVZLOOLQFOXGHRUDOLQVSHFWLRQSOXVKHDUWOXQJVDEGRPHQDQG
IXUWKHURUJDQVLIUHTXLUHGGXHWRV\PSWRPV
9LWDOVLJQVLQFOXGHV\VWROLFDQGGLDVWROLFEORRGSUHVVXUHSXOVHUDWHDQGERG\WHPSHUDWXUH7KH7'DQG7'WKHYLWDOVLJQVZLOOEHWDNHQSUHGRVHDQGWKHQDWHDFKWXUQ
)RUYLWDOVLJQVDQG(&*DVVHVVPHQWWKHVXEMHFWVVKRXOGEHDWUHVWDQGVHPLVXSLQHIRUDWOHDVWPLQXWHVEHIRUHUHFRUGLQJDQGVKRXOGUHPDLQUHVWLQJDQGVXSLQHGXULQJUHFRUGLQJV
3.
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 51 of 54 
 
 
12.2. Sampling Schedule 
)LUVW9LVLW
'D\
$FWLYLW\
6FKHGXOHGWLPH
6FKHGXOHG
WLPH
'D\
$'0,66,21


',11(5


)$67,1*67$57$1'5(67


'D\
*5220,1*$1',17$.(2)
0/2):$7(5


%/22'6$03/(
3UHGRVH


%/22'6$03/(
3UHGRVH


%/22'6$03/(
3UHGRVH


'58*
6'26,1*


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%5($.)$67


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


/81&+


%/22'6$03/(


%/22'6$03/(


',11(5


'D\
%/22'6$03/(


%/22'6$03/(


'D\
%/22'6$03/(


PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 52 of 54 
 
 
6HFRQG9LVLW
'D\
$FWLYLW\
6FKHGXOHGWLPH
6FKHGXOHG
WLPH
'D\
$'0,66,21


',11(5


)$67,1*67$57$1'5(67


'D\
*5220,1*$1',17$.(2)
0/2):$7(5


%/22'6$03/(
3UHGRVH


%/22'6$03/(
3UHGRVH


%/22'6$03/(
3UHGRVH


'58*
6'26,1*


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%5($.)$67


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


%/22'6$03/(


/81&+


%/22'6$03/(


%/22'6$03/(


',11(5


'D\
%/22'6$03/(


%/22'6$03/(


'D\
%/22'6$03/(


 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 53 of 54 
 
 
12.3. Summary 
STUDY TITLE 
“Prospective, single dose, randomized, open label, comparative, cross-study to establish bioequivalence 
between the new formulation and the approved formulation for Levothyroxine (Eutirox® from Merck, S. A. 
de C. V.) given as 3 tablets of 200 μg p.o. in healthy volunteers" 
STUDY OBJECTIVE 
To establish the bioequivalence between the new and approved levothyroxine's formulation in tablets of 
200 μg (Eutirox® from Merck, S. A. de C. V.) in healthy volunteers for the marketing approval of the new 
formulation in all its strength. The lower strengths will be justified with the biowaiver criteria described in 
NOM-177-SSA1-2013.. 
STUDY DESIGN 
Experimental design, longitudinal, comparative, open-label, randomized, crossed in blocks, scheme A-B and 
B-A. 
RATIONALE FOR THE 
STUDY DESIGN 
As the goal is to prove the lack of significant differences in the pharmacokinetic parameters where each 
subject is his/her own control, the chosen experimental design is one of those suggested by the NOM-177-
SSA1-2013, crossed, open label, two sequences and two periods of treatment (scheme A - B and B - A), and 
single dose. Section 8.4.8.1 of this Standard states that drugs with a long half-life, crossed or parallel designs 
should include a limited sampling for at least 72 hours. However, prior studies showed that sampling times 
longer than 48 hours do not allow to characterize differences between exogenous and endogenous 
levothyroxine concentrations with certainty. Therefore, bioequivalence studies for this drug should be 
truncated up to 48 hours (Guidance to Establish the Interchangeability of Oral Solid Drugs Containing 
Levothyroxine Sodium, COFEPRIS, 2017). According to the aforementioned, a 48-h sampling time, which is 
compliant with the Mexican health authorities' requirement, is proposed. In addition, it allows to 
characterize at least the 80 % of the AUC, by having 26 total samples and a wash-out period of 35 days 
between the two study periods. 
POPULATION 
44 male and female healthy subjects. 
RATIONALE FOR THE 
SAMPLE SIZE 
The sample size determination was based on the variability seen in the most recent study conducted by the 
study Sponsor EMR200125-001 (comparative study of the levothyroxine formulations for approval in 
Europe) where the intrasubject variability for AUC0-72h was 23.7 % and the Cmax was 17.7 %. Using the most 
variable parameter AUC0-72h, a difference of 5 %, a power of 90 % and applying the accepted bioequivalence 
range of 80 % to 125 %, a sample size of 34 subjects was obtained. If a drop rate of 20 % is considered, the 
sample size should be of 44 subjects. 
DOSAGE FORM 
Tablets 200 μg. 
DOSE 
600 μg (3 tablets of 200 μg), orally, with a 10-h fasting state. 
PRE-TREATMENT 
Not required. 
WASH-OUT TIME 
35 days. 
CLINICAL LABORATORY 
TESTS 
Complete blood count; 4-panel chemistry; urinalysis; liver function tests; HIV, hepatitis B and C, and VDRL 
test; and qualitative urine test for illicit drugs, and pregnancy test for women. Thyroid profile.  
REFERENCE PRODUCT 
Eutirox® from Merck, S. A. de C. V. (approved formulation). 
TEST DRUG 
Eutirox® from Merck, S.A. de C.V. (new formulation) 
ENDPOINTS 
48.00-h follow-up to collect 26 blood samples to determine levothyroxine (T4) in serum and to calculate the 
AUC0-t and Cmax corrected values. 
SAMPLING TIMES 
-0.50, -0.25, 0.00 pre-dose and at 0.5, 1.0, 1.5, 2.0, 2.5, 3.0, 3.25, 3.5, 3.75, 4.0, 4.25, 4.5, 4.75, 5.0, 5.5, 6.0, 
6.5, 8.0, 10.0, 12.0, 24.0 36.0 and 48.0 h post-dose. 
SPECIAL REMARKS 
Pre-dose sampling will be carried out. 
Statistical analysis to prove interchangeability will only be made using the corrected values for the 
parameters Cmax and AUC0-t. Equivalence margins will be considered as 80 % - 125 %. 
 
PPD
PPD
PPD

/ MS200125-0008 
 
Version No. 1.0 of october 18th, 2018 
 
 
 
3$57,$/25)8//5(352'8&7,21,6)25%,''(1:,7+287$33529$/ 
Page 54 of 54 
 
 
12.4. Diet 
Diet will be provided to the subjects following the dose in each period. It will be the same in quantity and content 
as that provided in the previous period. 
Energetic Distribution 
Group 
% 
gr. 
Kcal. 
Carbohydrates 
55 
275 
1100 
Proteins 
15 
75 
300 
Lipids 
30 
67 
600 
Total Kcal 
---- 
---- 
2000 
12.5. Drugs Classification According to their Risk for Pregnancy and Breastfeeding 
(FDA) 
A 
Without apparent 
risks 
Controlled studies in women do not show risk for the fetus during the first 
quarter and the likelihood of fetal injuries seems remote. They can be used.  
B 
With apparent risks 
Animal studies do not show risk for the fetus, and there are no controlled 
studies in humans, or the animal studies do show an adverse effect for the 
fetus, but in well controlled studies in pregnant women they have not showed 
fetal risk. Probably safe.  
C 
Undetectable risk 
Animal studies have shown that the drug has teratogenic or embryocidal 
effects, but there are not controlled studies in women, or there are not studies 
in animals or women. Avoid them if there is any other choice.   
D 
Proven risk 
There is positive evidence of fetal risks in humans, but, in some cases (e.g., in 
life-threatening situations or in serious diseases where safer drugs cannot be 
used, or those which can be used are inefficient), benefits may turn the drug 
acceptable despite its risks. Avoid them if there is any other choice.   
X 
Contraindicated 
Studies in animals or in human beings have shown fetal abnormalities; or there 
is fetal risk based on the experience in human beings; or are applicable to both 
cases. Risks clearly overcome the possible benefit. Contraindicated.    
 
 
 
This material is property of the 
 
 This information is confidential and will only be 
used jointly with the authorized entities; and any partial information will be 
distributed to other parties without prior written approval from the 
 
 
Confidentiality: 
 
 
PPD
PPD
PPD
PPD
PPD