A Phase I/II Multicenter Open-label Dose Escalation Study of HGT-1110 Administered Intrathecally in Children With Metachromatic Leukodystrophy
Phase: PHASE1
Conditions: Metachromatic Leukodystrophy (MLD)
Sponsor: Shire

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PPD
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HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
Shire
Confidential
2
SYNOPSIS 
Sponsor:
Shire Human Genetic Therapies, Inc. (Shire)
Name of Finished Product:
HGT-1110 (recombinant human arylsulfatase A, rhASA)
Name of Active Ingredient:
Recombinant human arylsulfatase A (rhASA)
Name of Devices:
•
SOPH-A-PORT® Mini S, Implantable Access Port, Spinal, Mini Unattached, with 
Guidewire (SOPH-A-PORT Mini S)
•
PORT-A-CATH® II Low Profile™ Intrathecal Implantable Access System 
(PORT-A-CATH)
Study Title:
A Phase I/II Multicenter Open-label Dose Escalation Study of HGT-1110 Administered 
Intrathecally in Children with Metachromatic Leukodystrophy
Study Number:
HGT-MLD-070
Study Phase:  I/II
Investigational Drug Product, Dose, and Mode of Administration:  
Patients in Cohorts 1-3 received intrathecal (IT) injections at 1 of 3 dose levels (10, 30, or 
100 mg) of HGT-1110 every other week (EOW) (±3 days). Patients in Cohorts 4 will 
receive 100 mg of HGT-1110 EOW (±3 days).
Device, Intended Use:
The SOPH-A-PORT Mini S is a system intended for implantation by physicians. The 
SOPH-A-PORT Mini S, once implanted, allows healthcare personnel to administer 
HGT-1110 indicated for IT delivery intermittently over a long period of time.
Primary Objective:  
•
Cohorts 1-3: The primary objective is to determine the safety of ascending doses 
of HGT-1110 administered by IT injection for 38 weeks in children with 
metachromatic leukodystrophy (MLD).
•
Cohort 4: The primary objective is to determine the safety of HGT-1110 
produced with a revised drug substance manufacturing process administered by IT 
injection for 38 weeks in children with MLD.
Secondary Objectives:
•
To evaluate the effects of IT administration of HGT-1110 on gross motor 
function
•
To evaluate the effects of IT administration of HGT-1110 on the ability to 
swallow

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
Shire
Confidential
3
•
To evaluate the effects of IT administration of HGT-1110 on nerve conduction 
capabilities
•
To evaluate the effects of IT administration of HGT-1110 on adaptive behavior
•
To evaluate the effects of IT administration of HGT-1110 on health status and the 
ability to carry out activities of daily life
•
To assess single and repeated-dose pharmacokinetics (PK) of HGT-1110 in serum 
•
To assess concentrations of HGT-1110 in cerebrospinal fluid (CSF)
Study Endpoints: 
Safety will be measured by the following endpoints:
•
Reporting of treatment-emergent adverse events (TEAE)
•
Change from baseline in clinical laboratory testing (serum chemistry including 
liver function tests, hematology, and urinalysis)  
•
Change from baseline in 12-lead electrocardiograms (ECGs), vital signs, physical 
examinations, and CSF chemistry (including cell counts, glucose, and protein)
•
Determination of the presence of anti-HGT-1110 antibodies in CSF and/or serum 
The secondary endpoints of this study are the following:
•
Change from baseline in motor function using the Gross Motor Function 
Measure-88 (GMFM-88) total score (percent)
•
Change from baseline in the ability to swallow as measured by the Functional 
Endoscopic Evaluation of Swallowing (FEES) 
•
Change from baseline in nerve conduction as measured by the electroneurography 
(ENG) assessments of nerve conduction velocity (NCV), compound motor action 
potential (CMAP), amplitude (AMP), and distal latency (DL)
•
Change from baseline in the adaptive behavior composite standard score as 
measured by the Vineland Adaptive Behavior Scales, Second Edition (VABS-II)
•
Change from baseline in the domain specific Caregiver Observed MLD 
Functioning and Outcomes Reporting Tool (COMFORT) scores
•
Single and repeated-dose PK parameter estimates for HGT-1110 in serum
•
Concentrations of HGT-1110 in CSF at selected time points after single and 
repeated investigational drug product administration
Study Population:  
Approximately 24 male or female patients with a confirmed diagnosis of MLD are 
planned.

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
Shire
Confidential
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Study Design:
This is a multicenter open-label dose-escalation study designed to evaluate the safety of 
HGT-1110 in 4 cohorts. In Cohorts 1-3, three dose levels (10, 30, or 100 mg) of 
HGT-1110 were administered. In Cohort 4, patients will be administered 100 mg of HGT-
1110. HGT-1110 is administered via an intrathecal drug delivery device (IDDD) every 
other week (EOW) for a total of 38 weeks (20 IT injections, Weeks 0 to 38) to children 
with MLD. The study also includes the assessment of HGT-1110 drug product produced
with a revised drug substance manufacturing process (referred to as Process B) in a fourth 
cohort (Cohort 4).  
For Cohorts 1-3, 18 patients were enrolled, 6 in each of the 3 dose level cohorts. The dose 
level cohorts were sequentially enrolled starting with the 10 mg dose as follows: 
•
Cohort 1:  HGT-1110 by IT injection 10 mg EOW for a total of 38 weeks 
(6 patients)
•
Cohort 2:  HGT-1110 by IT injection 30 mg EOW for a total of 38 weeks 
(6 patients)
•
Cohort 3:  HGT-1110 by IT injection 100 mg EOW for a total of 38 weeks 
(6 patients)
Cohorts 1-3 received HGT-1110 drug product manufactured using Process A.
Patient enrollment was staggered in this study to facilitate adequate safety evaluation per 
cohort.
Dose escalation of HGT-1110 for Cohorts 2 and 3 was contingent on review of safety data 
by the Data Safety Monitoring Board (DSMB). Following enrollment of Cohort 1, the 
decision to escalate to the next higher dose level (Cohort 2) was based on a review of the 
safety data obtained in Cohort 1 (after all treated patients in the cohort have each received 
a minimum of 2 IT doses) by an independent DSMB and representatives from the 
Sponsor. The decision to escalate to the next higher dose level (Cohort 3) followed the 
same safety review process as that used for Cohort 2. A DSMB meeting will be held after 
completion of Cohorts 1-3.
Cohort 4 will be enrolled following Cohort 3, after DSMB review of Cohorts 1-3 and drug 
product manufactured with Process B becomes available. Approximately 6 patients who 
undergo device implant surgery or receive at least 1 dose of study drug will be included in 
Cohort 4, which will receive 100 mg HGT-1110 EOW for a total of 38 weeks. .
During the course of their participation in the study, a patient may request a transfer to a 
different qualified site, if agreed by both the sites and the Sponsor.
This study will have the following 5 phases:  
Cohorts 1-3: Phases 1-3
Phase 1:  Screening:  Day -40 through Day -11
Upon obtaining informed consent, the procedures and assessments required for the 
determination of the patient’s eligibility will be completed at the clinical site within 
40 days of the baseline visit (Week 0). Sample collection for diagnostic testing should 
take place between Day -40 and Day -29 to ensure diagnostic results are received prior 

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
Shire
Confidential
5
to IDDD implantation in Phase 2 of the study.
Sites will be allowed one opportunity to re-screen any patient who fails initial 
screening or withdraws consent prior to device implantation. If the patient 
subsequently screen fails, the patient will no longer be considered for inclusion in the 
study.
Phase 2:  Surgical Implantation of the IDDD:  Day -10 to Day -1
Patients will undergo surgical implantation of an IDDD and a post-surgical 
assessment.
Phase 3:  Baseline and Treatment Week 0 to Week 38 (±3 days for injection of 
HGT-1110)  
Upon confirmation of study eligibility, baseline assessments (ie, those scheduled for 
Week 0) may be performed at any time prior to dosing, including the Phase 2 period of 
the study, but baseline assessments should be performed as close to dosing as possible. 
Patients will undergo pre-dose baseline assessments at Week 0, which will include a 
standard battery of clinical laboratory tests (serum chemistry, hematology, and 
urinalysis), serum assessments of anti-HGT-1110 antibodies and CSF assessments 
(cell counts, protein, glucose, albumin, anti-HGT-1110 antibodies, and HGT-1110 
levels) as well as safety assessments (ie, vital signs, physical examination, routine CSF 
analysis, pregnancy testing [if applicable], AEs, and concomitant 
medication/therapies/procedures assessments).
Baseline efficacy outcome assessments including the GMFM-88, FEES, ENG studies, 
VABS-II, COMFORT questionnaire, and brain MRI and MRS will be performed as 
well as sample collection for CSF, serum, and urine biomarker assessments. 
Patients will receive their first dose (Week 0) and begin the HGT-1110 EOW dosing 
period (through Week 38). At Week 0, blood will also be drawn for a PK assessment 
at the time points specified in the Schedule of Events. 
During the EOW treatment period (Weeks 2 through 38), all assessments will be 
performed prior to IT injection of HGT-1110 unless otherwise indicated. Safety 
assessments (ie, vital signs, physical examination, routine CSF analysis, pregnancy 
testing [if applicable], AEs, and concomitant medication/therapies/procedures 
assessments) will be performed. Patients will remain under observation in the hospital 
setting for at least 36 hours following dosing and will be discharged when deemed 
clinically stable by the Investigator. Additionally, anti-HGT-1110 antibody sampling, 
the standard battery of clinical laboratory tests (serum chemistry, hematology, and 
urinalysis) and sample collection for analysis of CSF concentration of HGT-1110, and 
CSF, serum, and urine biomarkers will be performed every 4 weeks. 
In addition to the scheduled assessments performed Weeks 2 through 38, 
Weeks 16 and 28 will also include the efficacy outcome assessments of the 
GMFM-88, FEES, ENG studies, VABS-II, COMFORT questionnaire, and brain MRI 
and MRS. For Weeks 16 and 28, the window for assessments will be -5 days. In 

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
Shire
Confidential
6
addition, at Week 38 blood will be drawn for a PK assessment at the time points 
specified in the Schedule of Events.
It is anticipated that the IDDD will be used to obtain CSF samples and to deliver all 
20 IT injections of HGT-1110. If the IT space is not accessible via the IDDD, 
investigational drug product may be administered by LP. Should the IDDD become 
clogged, undergo mechanical complications or otherwise not be accessible, the CSF 
sample may also be obtained by LP. Anesthesia may be required for injections of 
investigational drug product and some evaluations, and can be used at the discretion of 
the Investigator. The IDDD Manual provides details on the investigation and 
management of any IDDD-related issues. 
Cohort 4: Phases 1-3
Note:  Enrollment may occur prior to IDDD implantation or the first dose (baseline); 
however, implantation of the device should occur within 28 days of the first dose.
Phase 1:  Screening:  Day-40 through Day -1
Upon obtaining informed consent, the procedures and assessments required for the 
determination of the patient’s eligibility, including GMFM-88, will be completed at 
the clinical site within 40 days prior to the baseline visit (Week 0). Sample collection 
for central diagnostic testing should take place at the screening visit to ensure 
diagnostic results are received promptly. Local laboratory results confirming the MLD 
diagnosis (analysis of urine sulfatide, ASA activity in leukocytes) will be accepted to 
confirm the MLD diagnosis enrollment criteria while waiting for the central laboratory 
results so that dosing of the study medication can occur as soon as possible.
Sites will be allowed one opportunity to re-screen any patient who fails initial 
screening or withdraws consent prior to device implantation or dose administration (if 
administration to be initiated by LP prior to device implantation). If the patient 
subsequently screen fails, the patient will no longer be considered for inclusion in the 
study.
Phase 2:  Surgical Implantation of the IDDD:  Day -10 to Day +28
To confirm the patient meets eligibility criteria at baseline, specifically the baseline 
GMFM-88 assessment will be performed as close as possible to, but before device 
implantation or prior to first dose administration, whichever occurs first. Patients who 
do not continue to meet eligibility criteria will be discontinued from the study prior to 
device implantation and/or initial dosing. If device implantation and/or initial dosing 
occur within 7 days of the screening GMFM-88 assessment, the baseline GMFM-88 
assessment will not be required. However, if more than 7 days has passed since the 
screening GMFM-88 assessment, the baseline GMFM-88 assessment will need to be 
completed prior to IDDD implantation or first dose, and prior to any other baseline 
assessments in order to confirm eligibility for enrollment (per inclusion criterion 3.1).
Upon confirmation of eligibility, patients will undergo surgical implantation of an 
IDDD and a post-surgical assessment. The patient may receive study drug by LP until 

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
Shire
Confidential
7
the device is implanted. Device implantation should be scheduled within 28 days of 
enrollment unless a delay is required due to clinical judgment for medical reasons (eg, 
infection).
Phase 3:  Baseline and Treatment Week 0 to Week 38 (±3 days for injection of 
HGT-1110)  
Upon confirmation of study eligibility, baseline assessments (ie, those scheduled for 
Week 0) may be performed at any time prior to dosing, including the Phase 2 period of 
the study, but baseline assessments should be performed as close to dosing as possible. 
Patients will undergo pre-dose baseline assessments at Week 0, which will include a 
standard battery of clinical laboratory tests (serum chemistry, hematology, and 
urinalysis), serum assessments of anti-HGT-1110 antibodies and CSF assessments 
(cell counts, protein, glucose, albumin, anti-HGT-1110 antibodies, and HGT-1110 
levels) as well as safety assessments (ie, vital signs, physical examination, routine CSF 
analysis, pregnancy testing [if applicable], AEs, and concomitant 
medication/therapies/procedures assessments).
Baseline efficacy outcome assessments including the GMFM-88, FEES, ENG studies, 
VABS-II, COMFORT questionnaire, and brain MRI and MRS will be performed as 
well as sample collection for CSF, serum, and urine biomarker assessments. If device 
implantation and/or initial dosing occur within 7 days of the screening GMFM-88 
assessment, the baseline GMFM-88 assessment will not be required.
Patients will receive their first dose (Week 0) and begin the HGT-1110 EOW dosing 
period (through Week 38). At Week 0, blood will also be drawn for a PK assessment 
at the time points specified in the Schedule of Events. 
During the EOW treatment period (Weeks 2 through 38), all assessments will be 
performed prior to IT injection of HGT-1110 unless otherwise indicated. Safety 
assessments (ie, vital signs, physical examination, routine CSF analysis, pregnancy 
testing [if applicable], AEs, and concomitant medication/therapies/procedures 
assessments) will be performed. Patients will remain under observation in the hospital 
setting for at least 36 hours following dosing and will be discharged when deemed 
clinically stable by the Investigator. Additionally, anti-HGT-1110 antibody sampling, 
the standard battery of clinical laboratory tests (serum chemistry, hematology, and 
urinalysis) and sample collection for analysis of CSF concentration of HGT-1110, and 
CSF, serum, and urine biomarkers will be performed every 4 weeks. 
In addition to the scheduled assessments performed Weeks 2 through 38, 
Weeks 16 and 28 will also include the efficacy outcome assessments of the 
GMFM-88, FEES, ENG studies, VABS-II, COMFORT questionnaire, and brain MRI 
and MRS. For Weeks 16 and 28, the window for assessments will be -5 days. In 
addition, at Week 38 blood will be drawn for a PK assessment at the time points 
specified in the Schedule of Events.
It is anticipated that the IDDD will be used to obtain CSF samples and to deliver all 
20 IT injections of HGT-1110. If eligibility has been confirmed, and IDDD 

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
Shire
Confidential
8
implantation cannot be scheduled to occur within the Phase 2 window, or it is desired 
to shorten the screening period to promptly initiate first dose administration, 
investigational drug product may be administered by means of an LP. 
If the IT space is not accessible via the IDDD, investigational drug product may be 
administered by LP. Should the IDDD become clogged, undergo mechanical 
complications or otherwise not be accessible, the CSF sample may also be obtained by 
LP until the device is repaired or replaced. Anesthesia may be required for injections 
of investigational drug product and some evaluations, and can be used at the discretion 
of the Investigator. The IDDD Manual provides details on the investigation and 
management of any IDDD-related issues. 
All Cohorts (1-4): Phases 4 and 5
Phase 4:  End of Study:  Week 40 (-5, +3 days)
The assessments scheduled at Week 40, 2 weeks after the last HGT-1110 dose, will be 
the same as those at Weeks 16 and 28 with the addition of a 12-lead ECG and an 
X-ray (to confirm that the IDDD remains positioned correctly). Patients who 
discontinue early will have an end-of-study (EOS) visit 2 weeks (-5, +3 days) after the 
last IT injection of HGT-1110. All EOS assessments should be performed. For 
Week 40, assessments may be performed as early as 5 days prior to the scheduled visit 
date.
Patients will have the IDDD removed when they discontinue from or complete the 
study, unless the patient is continuing to receive treatment through another mechanism 
(eg, a different study or commercially available).
Phase 5:  Safety Follow-up:  Week 42 (±3 days) 
The Safety Follow-up visit will be conducted at Week 42 or 4 weeks (±3 days) after 
the last injection of HGT-1110 or 2 weeks after the removal of the IDDD, whichever 
occurs later, for patients who discontinue. The follow-up safety assessments (AEs and 
concomitant medications/therapies/procedures) may be performed via telephone from 
the clinical site.
Patients who complete all requirements in Study HGT-MLD-070 through Week 40 may 
be eligible to participate in an extension study. However, patients are not obligated to 
participate in any additional studies, and the Sponsor cannot guarantee that such studies 
will occur. Anesthesia may be required for injections of investigational drug product and 
some evaluations, and can be used at the discretion of the Investigator. 
If patients in the study require revision and/or replacement of the PORT-A-CATH IDDD, 
it will be removed and replaced with the SOPH-A-PORT Mini S device at a time judged 
appropriate by the Investigator.
Study Duration:  
The duration for each patient’s participation in this study is approximately 47 weeks. The 
planned duration of HGT-1110 treatment in this study is 38 weeks (20 IT injections of 
HGT-1110 EOW Weeks 0 to 38). 

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
Shire
Confidential
9
Study Inclusion and Exclusion Criteria:
Inclusion Criteria:
Patients must meet all of the following criteria to be considered eligible for enrollment:
For Cohorts 1-4:
1. Confirmed diagnosis of metachromatic leukodystrophy by both:
•
Arylsulfatase A (ASA) deficiency by assay in leukocytes 
AND
•
Elevated sulfatide in urine
2. Appearance of the first symptoms of disease at or before 30 months of age.
For Cohorts 1-3 only: 
3. Ambulatory at the time of screening. The minimum level of function required to meet 
this criterion is defined as the ability to walk forward 10 steps with one hand held.
4. The patient is less than 12 years of age at the time of screening.
For Cohort 4 only:
3.1 Minimum motor function requirements:
a.
A total GMFM-88 (percent) score ≥40 at the screening examination and a total 
GMFM-88 (percent) score ≥35 at the baseline examination, 
AND
b. GMFM-88 Dimension E: Walking, Running & Jumping, item 68 ("walk forward 
10 steps with one hand held") score of at least 1 "initiates" at the screening and 
baseline examinations (if applicable). 
4.1 The patient is less than 8 years of age at the time of screening.
For Cohorts 1-4:
5. Neurological signs of MLD must be present at the screening examination.
6. The patient and his/her parent/representative(s) must have the ability to comply with 
the clinical protocol.
7. Patient’s parent(s) or legally authorized representative(s) must provide written 
informed consent prior to performing any study-related activities. Study-related 
activities are any procedures that would not have been performed during normal 
management of the patient.
Exclusion Criteria:
Patients will be excluded from the study if there is evidence or history of any of the 
following criteria at screening:
For Cohorts 1-4:
1. History of hematopoietic stem cell transplantation (HSCT).
2. The patient has any known or suspected hypersensitivity to anesthesia or is thought to 
be at an unacceptably high risk for anesthesia due to airway compromise or other 
conditions. 

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
Shire
Confidential
10
3. Any other medical condition, serious intercurrent illness, or extenuating circumstance 
that, in the opinion of the Investigator, would preclude participation in the trial.
4. The patient is enrolled in another clinical study that involves the use of any 
investigational product (drug or device) other than HGT-1110 or the IDDD used in
this study within 30 days prior to study enrollment or at any time during the study.
5. The patient is pregnant or breastfeeding.
6. The patient has a condition that is contraindicated as described in the SOPH-A-PORT 
Mini S IDDD Instructions for Use (IFU), including:
a. The patient has had, or may have, an allergic reaction to the materials of 
construction of the SOPH-A-PORT Mini S device.
b. The patient’s body size is too small to support the size of the SOPH-A-PORT 
Mini S Access Port, as judged by the Investigator.
c. The patient has a known or suspected local or general infection.
d. The patient is at risk of abnormal bleeding due to a medical condition or 
therapy.
e. The patient has one or more spinal abnormalities that could complicate safe 
implantation or fixation.
f.
The patient has a functioning CSF shunt device.
g. The patient has shown an intolerance to an implanted device.
Clinical Assessments:
The main efficacy outcome assessment will be the change from baseline to Week 40 in 
motor function, using the GMFM-88 total score (percent).
Safety Assessments:
Safety will be assessed by the reporting of AEs, measurement of vital signs, physical 
examination, 12-lead ECGs, anti-HGT-1110 antibodies (CSF and serum), and laboratory 
evaluations including serum chemistry, hematology, urinalysis, and routine CSF analysis.
Pharmacokinetic Assessments:
The concentration of HGT-1110 in the serum and CSF will be determined as the PK 
variable. Serum PK parameter estimates of HGT-1110 will be calculated using standard 
noncompartmental analysis. The effect of anti-HGT-1110 antibodies on HGT-1110 
concentration-time profiles and PK parameters will be evaluated, if applicable.
Statistical Methods:
Statistical analyses of safety and efficacy outcomes will be descriptive and will be 
summarized by cohort. Summary statistics for continuous variables will include the 
number of patients, mean, standard deviation, median, minimum, and maximum. 
Categorical variables will be summarized in a contingency table by the number and 
percentage of patients in each category. 
Any statistical tests comparing cohorts will be 2-sided with a significance level of 
0.05 and considered exploratory or hypothesis generating. The mean change, mean 
difference in the change between cohorts, and corresponding 95% confidence intervals, 
may also be presented as appropriate.
The Safety population, defined as the set of patients who underwent the device implant 
surgery or received at least 1 dose of study drug, will be the primary analysis population. 

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
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Confidential
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Intrathecal device-related analyses will be performed in the subset of the Safety 
population who underwent the device implant surgery.
Original Protocol:  24 January 2011
Amendment 9:  26 August 2015

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
Shire
Confidential
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TABLE OF CONTENTS
SYNOPSIS.................................................................................................................................2
LIST OF IN-TEXT TABLES ..................................................................................................16
LIST OF IN-TEXT FIGURES.................................................................................................16
LIST OF APPENDICES..........................................................................................................16
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS..........................................18
1
INTRODUCTION ...........................................................................................................21
1.1
Disease Background ............................................................................................21
1.2
Study Rationale ...................................................................................................22
1.2.1
Current Therapeutic Options.......................................................................22
1.2.2
Study Design...............................................................................................24
2
STUDY OBJECTIVES....................................................................................................27
2.1
Primary Objectives ..............................................................................................27
2.2
Secondary Objectives ..........................................................................................27
2.3
Exploratory Objectives........................................................................................27
3
STUDY ENDPOINTS.....................................................................................................28
3.1
Primary Endpoints...............................................................................................28
3.2
Secondary Endpoints...........................................................................................28
3.3
Exploratory Endpoints.........................................................................................28
3.4
SOPH-A-PORT Mini S Assessments..................................................................29
4
INVESTIGATIONAL PLAN..........................................................................................30
4.1
Overall Study Design and Plan............................................................................30
4.1.1
Study Design...............................................................................................30
4.2
Investigational Drug Product Dose Escalation Guidelines .................................35
4.3
Study Duration.....................................................................................................36
5
STUDY POPULATION SELECTION ...........................................................................37
5.1
Study Population .................................................................................................37
5.2
Inclusion Criteria.................................................................................................37
5.3
Exclusion Criteria................................................................................................38
6
STUDY TREATMENTS.................................................................................................39
6.1
Description of Treatments...................................................................................39
6.1.1
Investigational Drug Product ......................................................................39
6.1.2
Intrathecal Drug Delivery Device...............................................................39
6.2
Treatment Administered......................................................................................40
6.3
Selection and Timing of Dose for Each Patient ..................................................41
6.3.1
Dose Selection.............................................................................................41
6.3.2
Dose Timing................................................................................................41

HGT-1110(recombinant human arylsulfatase A, rhASA)
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6.4
Method of Assigning Patients to Treatment Cohorts ..........................................41
6.5
Staggered Enrollment/Dose Escalation ...............................................................41
6.6
Concomitant Medications, Therapies, and Medical/Surgical Interventions .......42
6.6.1
Infusion/Hypersensitivity Reactions and Management ..............................42
6.7
Restrictions..........................................................................................................43
6.7.1
Therapy .......................................................................................................43
6.7.2
Pregnancy....................................................................................................43
6.7.3
Patient Activity Restrictions .......................................................................43
6.8
Treatment Compliance ........................................................................................43
6.9
Packaging and Labeling ......................................................................................43
6.9.1
Investigational Drug Product ......................................................................43
6.9.2
SOPH-A-PORT Mini S Access Port...........................................................43
6.10
Storage and Accountability .................................................................................44
6.10.1
Investigational Drug Product ......................................................................44
6.10.2
Investigational Drug Delivery Device ........................................................44
6.10.2.1
PORT-A-CATH Intrathecal Drug Delivery Device ..........................44
6.10.2.2
SOPH-A-PORT Mini S Intrathecal Drug Delivery Device...............44
6.11
Investigational Drug Product Retention at Study Site.........................................45
7
STUDY PROCEDURES .................................................................................................46
7.1
Informed Consent ................................................................................................46
7.2
Inclusion/Exclusion Criteria................................................................................46
7.3
Confirmation of Study Eligibility and MLD Diagnosis and Genotype...............46
7.4
Study Enrollment.................................................................................................47
7.5
Cross-reacting Immunologic Material.................................................................48
7.6
Medical History and Demographics....................................................................48
7.7
Height, Weight, and Head Circumference ..........................................................48
7.8
Anesthesia............................................................................................................48
7.9
Device-related Study Procedures ........................................................................49
7.9.1
Intrathecal Drug Delivery Device Implantation, Replacement, or 
Revision ......................................................................................................49
7.9.2
X-ray Verification of Intrathecal Drug Delivery Device Placement ..........49
7.9.3
Cerebrospinal Fluid Sampling Procedure ...................................................49
7.9.4
Intrathecal Drug Delivery Device Removal................................................50
7.10
Investigational Drug Product Administration .....................................................50
7.11
Pharmacokinetic Assessments.............................................................................51
7.12
Efficacy Outcome Assessments ..........................................................................51
7.12.1
Gross Motor Function Measure ..................................................................51
7.12.2
Global Impression of Motor Function Change and Severity ......................51

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7.12.3
Functional Endoscopic Evaluation of Swallowing .....................................52
7.12.4
Electroneurography.....................................................................................52
7.12.4.1
Motor Nerve Conduction Studies ......................................................52
7.12.4.2
Sensory Nerve Conduction Studies ...................................................52
7.12.5
Vineland Adaptive Behavior Scales, Second Edition.................................52
7.12.6
Caregiver Observed MLD Functioning and Outcomes Reporting Tool.....52
7.12.7
Assessments Using Stored Biological Samples..........................................53
7.12.7.1
Biomarker Assessments.....................................................................53
7.12.7.2
SOPH-A-PORT Mini S Assessments in Cerebrospinal Fluid and 
Serum .................................................................................................53
7.12.8
Magnetic Resonance Imaging and Brain Magnetic Resonance 
Spectroscopy...............................................................................................54
7.13
Safety Assessments .............................................................................................54
7.13.1
Physical Examination..................................................................................54
7.13.2
Vital Signs...................................................................................................54
7.13.3
Electrocardiography....................................................................................54
7.13.4
Clinical Laboratory Tests............................................................................54
7.13.4.1
Whole Blood Assessments.................................................................55
7.13.4.2
Serum Assessments............................................................................55
7.13.4.3
Urinalysis ...........................................................................................56
7.13.4.4
Cerebrospinal Fluid Assessments ......................................................56
7.14
Device Data .........................................................................................................57
7.15
Pregnancy Testing ...............................................................................................57
7.16
Sample Collection, Storage, and Shipping..........................................................58
7.17
Concomitant Medications, Therapies, and Medical/Surgical Interventions 
Assessments.........................................................................................................58
7.18
Adverse Events Assessments ..............................................................................58
7.18.1
Definitions of Adverse Events and Serious Adverse Events ......................58
7.18.1.1
Adverse Event....................................................................................58
7.18.1.2
Serious Adverse Event.......................................................................59
7.18.2
Device-associated Definitions.....................................................................60
7.18.2.1
Device Revision (Partial and Full).....................................................60
7.18.2.2
Device Malfunction ...........................................................................60
7.18.2.3
Device Failure....................................................................................60
7.18.2.4
Device Adjustment.............................................................................60
7.18.3
Classification of Adverse Events and Serious Adverse Events ..................61
7.18.4
Clarification Between Serious and Severe..................................................61
7.18.5
Relatedness of Adverse Events and Serious Adverse Events.....................61

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7.18.5.1
Adverse Events with Respect to Investigational Drug Product, 
Investigational Drug Product Administration, Device, and Associated 
Procedures..........................................................................................62
7.18.6
Procedures for Recording and Reporting Adverse Events..........................64
7.18.6.1
Adverse Event Monitoring and Period of Observation......................64
7.18.6.2
Reporting Serious Adverse Events ....................................................65
7.19
Pregnancy ............................................................................................................66
7.20
Abuse, Overdose, and Medication Error .............................................................66
7.21
Removal of Patients from the Trial or Investigational Drug Product .................67
7.22
Safety-related Study Stopping Rules...................................................................68
7.23
Appropriateness of Measurements ......................................................................68
8
STUDY ACTIVITIES .....................................................................................................71
8.1
Phase 1:  Screening (Days -40 to -11 for Cohorts 1-3; Days -40 to Day -1 for 
Cohort 4)..............................................................................................................71
8.2
Phase 2: IDDD Implantation (Day -10 to Day -1 for Cohorts 1-3; Day -10 to 
Day +28 for Cohort 4).........................................................................................72
8.3
Phase 3:  Baseline and Treatment (Weeks 0 to 38).............................................72
8.3.1
Baseline:  Week 0 (3 days for IT injection of HGT-1110).......................72
8.3.2
Treatment Weeks (Weeks 2 through 38, excluding Weeks 16 and 28)......74
8.3.3
Treatment and Evaluation: Weeks 16 and 28 (±3 days for IT injection of 
HGT-1110, -5 days for assessments) ..........................................................75
8.4
Phase 4: End of Study:  Week 40 (-5, +3 days)..................................................76
8.5
Phase 5:  Safety Follow-up Visit: Week 42 (±3 days) ........................................77
9
QUALITY CONTROL AND ASSURANCE .................................................................78
10
STATISTICAL ANALYSIS ...........................................................................................79
10.1
General Methodology..........................................................................................79
10.2
Determination of Sample Size.............................................................................79
10.3
Method of Assigning Patients to Treatment Cohorts ..........................................79
10.4
Analysis Populations ...........................................................................................79
10.5
Patient Disposition...............................................................................................80
10.6
Demographics and Baseline Characteristics .......................................................80
10.7
Primary Endpoints...............................................................................................80
10.8
Secondary Endpoints...........................................................................................80
10.9
Exploratory Endpoints.........................................................................................81
10.10
SOPH-A-PORT Mini S Assessments..................................................................81
10.11
Pharmacokinetic Analysis ...................................................................................81
10.12
Primary Analyses.................................................................................................82
10.13
Secondary Analyses.............................................................................................82
10.14
Exploratory Analyses ..........................................................................................84

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10.15
Intrathecal Drug Delivery Device Analyses........................................................84
10.16
Interim Analysis ..................................................................................................85
11
ADMINISTRATIVE CONSIDERATIONS....................................................................86
11.1
Investigators and Study Administrative Structure...............................................86
11.2
Institutional Review Board or Independent Ethics Committee Approval...........86
11.3
Ethical Conduct of the Study...............................................................................86
11.4
Patient Information and Consent/Assent.............................................................86
11.5
Patient Confidentiality.........................................................................................87
11.6
Study Monitoring.................................................................................................88
11.7
Case Report Forms and Study Records...............................................................88
11.7.1
Critical Documents......................................................................................88
11.8
Data Safety Monitoring Board ............................................................................89
11.9
Device Failure Review Process...........................................................................89
11.10
Protocol Violations/Deviations ...........................................................................89
11.11
Premature Closure of the Study...........................................................................90
11.12
Access to Source Documentation........................................................................90
11.13
Data Generation and Analysis.............................................................................90
11.14
Retention of Data.................................................................................................91
11.15
Financial Disclosure ............................................................................................91
11.16
Publication and Disclosure Policy.......................................................................91
12
LIST OF REFERENCES.................................................................................................92
LIST OF IN-TEXT TABLES
Table 1-1
Major Features of the Late Infantile, Juvenile, and Adult Forms of 
MLD ...........................................................................................................22
Table 7-1
Routine Serum Chemistry Assessments.....................................................55
Table 7-2
Summary of Cerebrospinal Fluid Assessments..........................................57
Table 7-3
Adverse Event Severity..............................................................................61
Table 7-4
Adverse Event Relatedness ........................................................................62
LIST OF IN-TEXT FIGURES
Figure 4-1
Overall Study Design:  Cohorts 1-3 ...........................................................31
Figure 4-2
Overall Study Design:  Cohort 4 ................................................................31
LIST OF APPENDICES
Appendix 1
Study Schedule of Events: Cohorts 1, 2, and 3...........................................95
Appendix 2
Study Schedule of Events: Cohort 4 .........................................................100
Appendix 3
Expected Adverse Device Effects.............................................................105

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Appendix 4
Protocol Signature Page............................................................................107
Appendix 5
Summary of Changes for Amendment 9...................................................108

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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS
Abbreviation
Definition
λZ
apparent terminal rate constant
AE
adverse event
AMP
amplitude
ANCOVA
analysis of covariance
aPTT
activated partial thromboplastin time
ASA  
arylsulfatase A 
AUC0-last
area under the serum concentration-time curve from time zero to the last sampling 
time at which serum concentrations were measurable
AUC0-∞
area under the serum concentration-time curve extrapolated to infinity 
β-hCG
β human chorionic gonadotropin
BMI
body mass index
BMT
bone marrow transplant
CBC
complete blood count
CFR
Code of Federal Regulations
CIOMS
Council for International Organizations of Medical Sciences
CL/F
clearance after intrathecal administration
CMAP
compound motor action potential  
Cmax
maximum observed serum concentration
CNS
central nervous system
COMFORT
Caregiver Observed MLD Functioning and Outcomes Reporting Tool
CRIM
cross-reacting immunological material
CRO
contract research organization
CS
clinically significant
CSF
cerebrospinal fluid
DL
distal latency
DSMB
Data Safety Monitoring Board
ECG
electrocardiogram
ECL
electrochemiluminescence

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Abbreviation
Definition
eCRF
electronic case report form
ENG
electroneurography
EOS
end of study
EOW
every other week
ERT
enzyme replacement therapy
FEES
Functional Endoscopic Evaluation of Swallowing
FDA
Food and Drug Administration
GCP
Good Clinical Practice
GIMF-C
global impression of motor function-change
GIMF-S
global impression of motor function-severity
GMFM-88
Gross Motor Function Measure-88
HSCT
hematopoietic stem cell transplant
ICH
International Conference on Harmonisation 
IDDD
intrathecal drug delivery device
IEC
Independent Ethics Committee
IFU
Instructions for Use
IND
Investigational New Drug 
IRB
Institutional Review Board
IT
intrathecal
IV
intravenous
LP
lumbar puncture
MedDRA
Medical Dictionary for Regulatory Activities
MDR
medical device report
MLD
metachromatic leukodystrophy
MPS
mucopolysaccharidosis
MRI
magnetic resonance imaging
MRS
magnetic resonance spectroscopy 
NCI CTCAE
National Cancer Institute Common Terminology Criteria for Adverse Events

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Abbreviation
Definition
NCV
nerve conduction velocity
NOAEL
no observable adverse effect level
PBMC
peripheral blood mononuclear cells
PK
pharmacokinetic(s)
PNS
peripheral nervous system
PT
prothrombin time
rhASA
recombinant human arylsulfatase A or HGT-1110
rhHNS
recombinant human heparan N-sulfatase
SAE
serious adverse event
SAP 1
saposin B-1
SAS
Statistical Analysis System
SD
standard deviation
Shire
Shire Human Genetic Therapies, Inc.
SUSAR
suspected unexpected serious adverse reaction
t1/2
terminal half-life
TEAE
treatment-emergent adverse event
UADE
unanticipated adverse device effect
US
United States
USA
United States of America
VABS-II
Vineland Adaptive Behavior Scales, Second Edition
Vz/F
volume of distribution based on the terminal phase after intrathecal administration
WHO-DD
World Health Organization – Drug Dictionary

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1
INTRODUCTION
1.1
Disease Background
Metachromatic leukodystrophy (MLD) is an inherited, autosomal recessive disorder of lipid 
metabolism characterized by deficient activity of the lysosomal enzyme, arylsulfatase A (ASA). 
Deficient enzymatic activity results in progressive accumulation of 
galactosylceramide-3-O-sulfate (cerebroside sulfate or sulfatide), which is a major constituent of 
myelin. A cytotoxic metabolite of sulfatide (lysosulfatide or galactosylsphingosine-3-O-sulfate) 
also accumulates.1-3 Sulfatide is normally metabolized by hydrolysis of the Cer-Gal-3-sulfate 
linkage to form galactocerebroside through the combined action of ASA and saposin B-1 
(SAP 1), a non-catalytic protein that serves as a detergent. Progressive accumulation of sulfatide 
within oligodendrocytes and Schwann cells, which are the myelin forming cells of the central 
(CNS) and peripheral nervous system (PNS) respectively, leads to cellular injury and ultimately 
cell death. The consequence of these molecular and cellular events is progressive demyelination 
and axonal loss within the CNS and PNS, which is accompanied clinically by severe motor and 
cognitive dysfunction. 4 In general, the rapidity with which the disease progresses clinically 
correlates with the level of residual enzymatic activity within the lysosomes. 
Metachromatic leukodystrophy is a rare orphan disease with an estimated overall incidence in 
the western world of approximately 1 in 100,000 live births.5-8
Human ASA gene structure has been determined, and many polymorphisms and disease-related 
mutations have been identified. At least 110 mutations have been described with a causal 
relationship to MLD. 9 The mutant alleles causing MLD can be divided into 2 groups. The first 
group (A) contains alleles that are associated with low amounts of residual lysosomal enzymatic 
activity, and the second group (B) contains alleles in which the mutation does not allow the 
synthesis of any functional enzyme. 
Analysis of the distribution of these alleles among patients with different clinical forms of MLD 
reveals a general genotype-phenotype correlation. Homozygosity for group B mutations causes a 
severe late infantile type of disease. Having one mutation from group A and one from group B 
mitigates the course to an intermediate juvenile type of disease, and having 2 group A mutations 
usually produces a milder adult form of MLD.
MLD has a full range of disease severity with patients presenting at varying ages and with a wide 
range and severity of signs and symptoms. To better understand this spectrum, there has been an 
attempt to divide disease presentation into types (see Table 1-1). While this grouping into types 
is useful clinically and for genetic counseling, MLD actually describes a continuum of clinical 
severity and the typing is somewhat arbitrary with an overlap of these types in many cases. 
Three presentations of the disease are recognized. The late infantile form of MLD is the most 
frequent presentation of the disorder and is usually diagnosed in the second year of life.10 The 
major presenting symptom is a progressive gait disturbance that rapidly makes independent 
locomotion impossible. The disease is typically lethal during childhood as a result of 
complications arising from advanced motor system dysfunction.

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The juvenile type has an onset between 4 and 16 years of age with presenting signs and 
symptoms of gait disturbances and motor dysfunction. Typical signs and symptoms also include 
behavioral abnormalities, poor school performance, and language regression. The disease is 
progressive and most children with a juvenile phenotype die in a quadriplegic decerebrate state 
5 to 10 years after the onset of symptoms. 
The adult type typically begins after 16 years of age, but onset can be as late as 60+ years of age. 
The dominant symptoms are a gradual decline in intellectual abilities with poor school or job 
performance, psychiatric disturbances, and memory deficits evolving to dementia. Patients are 
often initially diagnosed as suffering from psychosis11 or schizophrenia. 12 Signs of peripheral 
neuropathy are often absent, but clumsiness of movements and incontinence are seen. A slowly 
progressive spastic paresis of the arms and legs develops later in the course of the disease. 
During the final stages of the illness, patients lose speech and vision and become bedridden and 
unresponsive.13 The duration of the disease ranges from a few years to several decades.
Table 1-1
Major Features of the Late Infantile, Juvenile, and Adult Forms of 
MLD
Type
Age at 
onset 
(years)
Main clinical manifestations
Spinal 
fluid 
protein
Nerve 
conduction 
velocity
Urinary 
sulfatide 
excretion
Late 
Infantile
0.5-4
Gait disturbance, decreased 
tendon reflexes, mental 
regression, loss of speech, optic 
atrophy, ataxia, progressive 
spastic quadriparesis
Elevated
Slowed
Elevated
Juvenile
4-16
Gait and postural abnormalities, 
emotional and behavioral 
disturbances, optic atrophy, 
progressive spastic 
quadriparesis, language 
regression, poor school 
performance
Elevated
Slowed
Elevated
Adult
>16
Mental regression, psychiatric 
symptoms, slowly progressive 
spastic quadriparesis, 
incontinence
Normal or 
elevated
Normal or 
slowed
Elevated
Abbreviations:  MLD = metachromatic leukodystrophy
Source: von Figura K et al. 13
1.2
Study Rationale
1.2.1
Current Therapeutic Options 
There are no approved therapies for MLD. The only treatment option for MLD is bone marrow 
transplantation (BMT) or hematopoietic stem cell transplantation (HSCT), which have shown 
little or no efficacy. 

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Although HSCT may stabilize central demyelination in selected patients with late onset MLD 
(juvenile and adult forms) if performed early in the course of the disease, the procedure does not 
arrest progression in late infantile MLD.14 HGT-1110 is a recombinant human arylsulfatase A 
(rhASA) that is under development as enzyme replacement therapy (ERT) for the treatment of 
MLD. 
A particular challenge for lysosomal storage disorders that affect the brain is how to target ERT 
to the CNS.15 In animal toxicology studies, ERT was administered intrathecally via an intrathecal
(IT) drug delivery device (IDDD) and was well tolerated. Direct CNS delivery is being 
investigated because when ERT is administered intravenously (IV) it does not cross the blood 
brain barrier after the immediate postnatal period of life.16-18 Precedent for intraspinal ERT has 
been published and has been shown to be both safe and effective for spinal cord compression in 
mucopolysaccharidosis (MPS) I.19 In this study, a patient with MPS I received 4 intrathecal 
doses of enzyme (laronidase) at 1-month intervals. Safety evaluations included cerebrospinal 
fluid (CSF) opening pressure, serum chemistry and CSF protein, glucose, and cell count, in 
addition to clinical efficacy studies. No changes in safety evaluations were observed.
In a recent study, a patient with MPS VI and spinal cord compression received IT injections of 
enzyme (galsulfase) monthly, for 4 months. Cerebrospinal fluid analysis revealed no 
inflammatory reaction, nor were other types of drug-related adverse events (AEs) observed.20
Several patients with MPS I have been treated since 2005 with IT laronidase (recombinant 
α-L-iduronidase) in a clinical trial (ClinicalTrials.gov identifiers NCT00215527, NCT00786968) 
studying efficacy on spinal cord compression. This study has been terminated.21 A study further 
investigating the effectiveness of IT ERT as a treatment for another neurological symptom in 
MPS I, cognitive decline, is ongoing (ClinicalTrials.gov identifier NCT00852358).22
The following describes the 9 Shire Human Genetic Therapies, Inc. (Shire)–sponsored IT studies 
other than HGT-MLD-070:
•
a Phase I/II open-label extension of study HGT-MLD-070 evaluating long term safety 
and efficacy of IT administration of HGT-1110 in patients with MLD (HGT-MLD-071)
•
a Phase I/II safety and dose escalation study of monthly idursulfase-IT intrathecal 
injection for cognitively impaired patients with Hunter syndrome (Study HGT-HIT-045; 
NCT00920647), and the open-label extension to this study (HGT-HIT-046; 
NCT01506141)
•
a Phase II/III controlled, randomized, two-arm open-label, assessor-blinded study of 
idursulfase-IT administered in conjunction with Elaprase® in pediatric patients with 
Hunter Syndrome and early cognitive impairment (Study HGT-HIT-094; 
NCT02055118) and the open-label extension to this study (Study SHP-609-302; 
NCT02412787)
•
a Phase I/II ascending dose and dose frequency study of monthly IT injection of 
recombinant human heparan N-sulfatase (rhHNS) in patients with Sanfilippo Syndrome 
Type A (Study HGT-SAN-055; NCT01155778), and the open-label extension to this 
study (HGT-SAN-067; NCT 01299727)

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•
a Phase IIb, randomized, controlled, open-label, multicenter, safety and efficacy study of 
HGT-1410 (recombinant heparan N-sulfatase) administration via an intrathecal drug 
delivery device in pediatric patients with early stage mucopolysaccharidosis Type IIIA 
disease (Study HGT-SAN-093; NCT02060526) and the open-label extension to this 
study (Study SHP-610-201 ; NCT02350816)
In light of the higher than expected complications experienced with the PORT-A-CATH IDDD, 
the SOPH-A-PORT Mini S device will be introduced for those patients requiring replacement or 
revision of their existing PORT-A-CATH IDDD or for initial implantation of their device. This 
new device has design features anticipated to reduce complications encountered with the 
PORT-A-CATH IDDD. Device assessments are included in the protocol to collect information 
specific to the SOPH-A-PORT Mini S device safety and function.
Cohorts 1-3 of this study were conducted to evaluate the safety of up to 3 dose levels of 
HGT-1110, administered via an IDDD to children with MLD to inform dose selection for future 
clinical studies. Since the initiation of Cohorts 1-3, changes were introduced to the original drug 
substance manufacturing process for HGT-1110 (referred to as Process A) to improve process 
robustness and efficiency in preparation for future clinical studies. Cohort 4 of this study is being 
conducted in order to evaluate the safety of HGT-1110 produced with the revised drug substance
manufacturing process (referred to as Process B). Please refer to the current edition of the 
Investigator’s Brochure for further information concerning the drug products produced with 
Process A and Process B.
1.2.2
Study Design 
Nonclinical experience with IT administration of HGT-1110 has demonstrated improvement in 
histological markers of disease in MLD mice and biodistribution into the lysosomes of 
oligodendrocytes in the deep white brain matter of monkeys. 
It is postulated that CNS injections of HGT-1110 in patients with MLD will restore a level of 
ASA enzymatic activity within both the CNS and the PNS that is sufficient to hydrolyze 
accumulated sulfatide and slow or prevent further substrate accumulation. Reduced accumulation 
of sulfatide may stabilize or slow progression of neurological dysfunction.
The key design considerations for this Phase I/II study are the target population, enzyme dose 
and dose administration route, and primary outcome.
The greatest opportunity to demonstrate benefits of enzyme replacement in MLD occurs early in 
the course of the illness prior to the onset of significant irreversible brain injury. The study is 
designed to be a combined Phase I/II study with a patient population selected based on disease 
progression. Metachromatic leukodystrophy has a full spectrum of disease severity with pediatric 
patients at the severe end of the spectrum and adults at the mild end. Patients who present with 
clinical signs and symptoms within the first few years of life have rapid progression of disease 
with measurable changes in symptoms over months. This same progression of disease in adults 
can take years to decades. The target patient population for this study, children with MLD who
are ambulatory at enrollment, will be instrumental in assessing the safety and efficacy of 
HGT-1110 and will support the selection of appropriate dosing for a pivotal trial. This 

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population of children is expected to be less than 5 years of age, and no older than age 12, at 
enrollment. Based on published literature23 and analysis of the LeukoNet natural history data 
set,24 substantial clinical progression is anticipated over 9 months in ambulatory children with 
MLD. To assess clinical progression of motor function, the Gross Motor Function 
Measure-88 (GMFM-88) total score (percent) will serve as the main efficacy outcome 
measurement.
The goal of enzyme replacement is to slow or prevent accumulation of toxic quantities of 
sulfatide within oligodendrocytes in a setting of rapidly progressive disease. This is a 
first-in-human, multicenter, Phase I/II dose escalation study of HGT-1110 in children with MLD 
to evaluate the safety of HGT-1110. In this study, HGT-1110 will be administered directly to the 
CNS through an IDDD or, if the IDDD is non-functional, via lumbar puncture (LP). The 
advantage of using an IDDD is that it obviates the need for anesthesia and multiple LPs for drug 
delivery that would otherwise be required each time this procedure is performed. The data 
available for intrathecal administration of proteins indicate that this route of administration poses 
no untoward safety risks. With no treatments currently available for this progressive, ultimately 
fatal genetic neurological disease, a clear medical need exists for novel disease-modifying 
approaches that hold the potential to alter the clinical course of disease progression.
The study was initiated with the PORT-A-CATH IDDD. Following protocol Amendment 6, if 
patients require revision and/or replacement of the PORT-A-CATH IDDD, it will be removed 
and replaced with the SOPH-A-PORT Mini S device at a time judged appropriate by the 
Investigator. The SOPH-A-PORT Mini S device will also be implanted in any newly enrolled 
patients.
The initial dose level in this clinical study is based on a minimum safety factor of 10. The factors 
of risk for HGT-1110 administration were considered, and the no observable adverse effect level 
(NOAEL) was used to determine a safe starting dose.25 In nonclinical toxicology studies, and in 
the proposed Phase I/II clinical trial, HGT-1110 is given as a nominal dose (mg). The nominal 
(mg) dose is divided by the approximate brain weight of the animal (kg) to determine the mg/kg 
of brain weight dose to allow scaling based on anatomical compartment size.26
The safety factor is then calculated as the normalized animal NOAEL (mg/kg) divided by the 
normalized human dose (mg/kg). For all species investigated, there is a minimum of a 10-fold 
safety factor for the proposed clinical starting dose (10 mg). 
For the highest proposed clinical dose (100 mg), there is a 3.5-fold safety factor from the rat 
NOAEL, a 3.1-fold safety factor from the 6-month juvenile monkey study, and a 1.0 fold safety 
factor from the 3-month juvenile monkey study. 
In order to estimate a minimally effective dose of HGT-1110 in humans, the levels of ASA in 
normal humans and MLD patients were evaluated. Patients with MLD have very low levels of 
ASA in the brain, generally less than 5%.27, 28 Up to 1 to 2% of the European population has a 
condition known as “pseudodeficiency of ASA” in which they have low levels of ASA activity 
(5% to 15% of normal), but are apparently normal.28 Based on this information, achieving a 
target level of 10% of normal in the CNS tissues is estimated to be a minimally effective dose. 
Three every-other-week (EOW) doses in administration of HGT-1110 at 1.8 mg/dose (30 mg/kg) 

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in juvenile cynomolgus monkeys achieved this enzyme level. This suggests that at 30 mg/kg of 
brain weight (30 mg/dose in the clinic for a child with an assumed brain mass of 1 kg29), 
HGT-1110 given EOW for at least one month is expected to deliver therapeutically relevant 
amounts of rhASA to all tissues of the brain.
Three dose-escalating cohorts will be enrolled. A staggered enrollment will be employed for this 
study to facilitate adequate safety monitoring per cohort. Dose selection for potential future 
studies will be determined by the safety profile and efficacy outcomes for each dose.
In order to minimize the degree of burden and foreseeable risk to study patients, study 
assessments were carefully selected to closely resemble assessments that are performed as part of 
current standard clinical care for patients with MLD. Some assessments, such as those including 
the need for anesthesia, will be coordinated with other safety assessments to minimize the 
number of times anesthesia is needed. The planned assessments are scheduled at the minimum 
possible frequency needed to fully assess the safety and establish potential efficacy for the 
investigational drug product with the lowest burden and risk to the patient. 
The effect of IT EOW HGT-1110 on several efficacy outcome measures will be assessed. 
Change from baseline in motor function using the GMFM-88 total score (percent) after 38 weeks 
of EOW HGT-1110 IT injections will serve as the main efficacy outcome measure. The CSF 
sulfatide and lysosulfatide levels may be important markers for extent of brain involvement in 
patients with MLD. Cerebrospinal fluid, serum, and urine sulfatide and lysosulfatide levels will 
be monitored as surrogate measures of CNS disease burden. In addition, the integrity of neurons 
and axons within the central white matter will be monitored by proton magnetic resonance 
spectroscopy (MRS; N-acetylaspartate levels). 
Please refer to the current edition of the Investigator’s Brochure for further information 
concerning the safety and clinical development of HGT-1110.

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2
STUDY OBJECTIVES
2.1
Primary Objectives
•
Cohorts 1-3: The primary objective is to determine the safety of ascending doses of 
HGT-1110 administered by IT injection for 38 weeks in children with MLD.
•
Cohort 4: The primary objective is to determine the safety of HGT-1110 produced with 
a revised drug substance manufacturing process administered by IT injection for 
38 weeks in children with MLD.
2.2
Secondary Objectives 
•
To evaluate the effects of IT administration of HGT-1110 on gross motor function
•
To evaluate the effects of IT administration of HGT-1110 on the ability to swallow
•
To evaluate the effects of IT administration of HGT-1110 on nerve conduction 
capabilities
•
To evaluate the effects of IT administration of HGT-1110 on adaptive behavior
•
To evaluate the effects of IT administration of HGT-1110 on health status and the ability 
to carry out activities of daily life
•
To assess single and repeated-dose pharmacokinetics (PK) of HGT-1110 in serum 
•
To assess concentrations of HGT-1110 in CSF
2.3
Exploratory Objectives
The exploratory objectives of this study are the following:
•
To evaluate the effects of IT administration of HGT-1110 on CSF, serum, and urine 
biomarkers 
•
To evaluate the effects of IT administration of HGT-1110 on N-acetylaspartate 
metabolite levels
•
To evaluate the effects of IT administration of HGT-1110 on the MLD severity score as 
measured by magnetic resonance imaging (MRI) of the brain
•
To determine the safety and performance of the SOPH-A-PORT Mini S
•
To evaluate the minimal clinically important change in GMFM-88 response

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3
STUDY ENDPOINTS
3.1
Primary Endpoints 
Safety will be measured by the following endpoints:
•
Reporting of treatment-emergent adverse events (TEAEs)
•
Change from baseline in clinical laboratory testing (serum chemistry including liver 
function tests, hematology, and urinalysis)  
•
Change from baseline in 12-lead electrocardiograms (ECGs), vital signs, physical 
examinations, and CSF chemistry (including cell counts, glucose, and protein)
•
Determination of the presence of anti-HGT-1110 antibodies in CSF and/or serum 
3.2
Secondary Endpoints
The secondary endpoints of this study are the following:
•
Change from baseline in motor function using the GMFM-88 total score (percent)
•
Change from baseline in the ability to swallow as measured by the Functional 
Endoscopic Evaluation of Swallowing (FEES) 
•
Change from baseline in nerve conduction as measured by the electroneurography 
(ENG) assessments of nerve conduction velocity (NCV), compound motor action 
potential (CMAP), amplitude (AMP), and distal latency (DL)
•
Change from baseline in the adaptive behavior composite standard score as measured by 
the Vineland Adaptive Behavior Scales, Second Edition (VABS-II)
•
Change from baseline in the domain-specific Caregiver Observed MLD Functioning and 
Outcomes Reporting Tool (COMFORT) scores
•
Single and repeated-dose PK parameter estimates for HGT-1110 in serum
•
Concentrations of HGT-1110 in CSF at selected time points after single- and 
repeated-investigational drug product administration
3.3
Exploratory Endpoints
The exploratory endpoints of this study are the following:
•
Change from baseline in CSF, serum, and urine biomarkers (ie, sulfatide and 
lysosulfatide)
•
Percent change from baseline in N-acetylaspartate metabolite levels in the deep white 
matter of the brain as assessed by proton MRS
•
Change from baseline in the total MLD severity score based on MRI of the brain

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•
Categorical assessment in the global impression of motor function-severity (GIMF-S)
•
Categorical assessment in the global impression of motor function-change (GIMF-C)
3.4
SOPH-A-PORT Mini S Assessments
The SOPH-A-PORT Mini S device will be evaluated using assessments of device implantation, 
device function, device longevity, and AEs associated with the implant surgery or device. This
data will be collected on the patient’s electronic case report form (eCRF) from the time of initial
implantation.

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4
INVESTIGATIONAL PLAN
4.1
Overall Study Design and Plan
This is a multicenter open-label dose-escalation study designed to evaluate the safety of 
HGT-1110 in 4 cohorts. In Cohorts 1-3, three dose levels (10, 30, or 100 mg) of HGT-1110 were 
administered. In Cohort 4, patients will be administered 100 mg of HGT-1110. HGT-1110 is 
administered via an IDDD EOW (20 IT injections of HGT-1110 from Weeks 0 to 38) to male or 
female children with a confirmed diagnosis of MLD. Patients in Cohorts 1-3 were expected to be 
less than 12 years of age at screening. The study also includes the assessment of HGT-1110 drug 
product produced with a revised drug substance manufacturing process (referred to as Process B)
in a fourth cohort (Cohort 4). Patients in Cohort 4 are expected to be less than 8 years of age at 
screening.
For Cohorts 1-3, 18 patients were enrolled, 6 in each of the 3 dose level cohorts. The dose level 
cohorts will be enrolled sequentially starting with the 10 mg dose as follows.
• Cohort 1 (10 mg):  HGT-1110 EOW (6 patients)
• Cohort 2 (30 mg): HGT-1110 EOW (6 patients)
• Cohort 3 (100 mg):  HGT-1110 EOW (6 patients) 
Cohorts 1-3 received HGT-1110 drug product manufactured using Process A.
Patient eligibility will be based on a confirmed diagnosis of MLD in patients who are ambulatory 
and who show neurological signs of MLD at the time of screening. Patients whose 
parent(s)/legal representative(s) have provided written informed consent to participate in this 
study will undergo screening procedures. All patients must be consented prior to any study 
evaluations. 
Cohort 4 will be enrolled following Cohort 3, after Data Safety Monitoring Board (DSMB) 
review of Cohorts 1-3 and drug product manufactured with Process B becomes available. 
Approximately 6 patients who undergo device implant surgery or receive at least 1 dose of study 
drug will be included in Cohort 4, which will receive 100 mg HGT-1110 EOW for a total of 
38 weeks.
During the course of their participation in the study, a patient may request a transfer to a different 
qualified site, if agreed by both the sites and the Sponsor.
4.1.1
Study Design
Schematics of the overall study design are presented in Figure 4-1 for Cohorts 1-3 and in
Figure 4-2 for Cohort 4.

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Figure 4-1
Overall Study Design:  Cohorts 1-3
Figure 4-2
Overall Study Design:  Cohort 4

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This study will have the following 5 phases:  
Cohorts 1-3: Phases 1-3
Phase 1:  Screening:  Day -40 through Day -11
Upon obtaining informed consent, the procedures and assessments required for the 
determination of the patient’s eligibility will be completed at the clinical site within 40 days 
of the baseline visit (Week 0). Sample collection for diagnostic testing should take place 
between Day -40 and Day -29 to ensure diagnostic results are received prior to IDDD 
implantation in Phase 2 of the study.
Sites will be allowed one opportunity to re-screen any patient who fails initial screening or 
withdraws consent prior to device implantation. If the patient subsequently screen fails, the 
patient will no longer be considered for inclusion in the study.
Phase 2:  Surgical Implantation of the IDDD:  Day -10 to Day -1
Patients will undergo surgical implantation of an IDDD and a post-surgical assessment.
Phase 3:  Baseline and Treatment Week 0 to Week 38 (±3 days for injection of 
HGT-1110)  
Upon confirmation of study eligibility, baseline assessments (ie, those scheduled for Week 0) 
may be performed at any time prior to dosing, including the Phase 2 period of the study, but 
baseline assessments should be performed as close to dosing as possible. Patients will 
undergo pre-dose baseline assessments at Week 0, which will include a standard battery of 
clinical laboratory tests (serum chemistry, hematology, and urinalysis), serum assessments of 
anti-HGT-1110 antibodies and CSF assessments (cell counts, protein, glucose, albumin, 
anti-HGT-1110 antibodies, and HGT-1110 levels) as well as safety assessments (ie, vital 
signs, physical examination, routine CSF analysis, pregnancy testing [if applicable], AEs, 
and concomitant medication/therapies/procedures assessments).
Baseline efficacy outcome assessments including the GMFM-88, FEES, ENG studies, 
VABS-II, COMFORT questionnaire, and brain MRI and MRS will be performed as well as 
sample collection for CSF, serum, and urine biomarker assessments. 
Patients will receive their first dose (Week 0) and begin the HGT-1110 EOW dosing period 
(through Week 38). At Week 0, blood will also be drawn for a PK assessment at the time 
points specified in the Schedule of Events. 
During the EOW treatment period (Weeks 2 through 38), all assessments will be performed 
prior to IT injection of HGT-1110 unless otherwise indicated. Safety assessments (ie, vital 
signs, physical examination, routine CSF analysis, pregnancy testing [if applicable], AEs, 
and concomitant medication/therapies/procedures assessments) will be performed. Patients 
will remain under observation in the hospital setting for at least 36 hours following dosing 
and will be discharged when deemed clinically stable by the Investigator. Additionally, 
anti-HGT-1110 antibody sampling, the standard battery of clinical laboratory tests (serum 
chemistry, hematology, and urinalysis) and sample collection for analysis of CSF 

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concentration of HGT-1110, and CSF, serum, and urine biomarkers will be performed every 
4 weeks. 
In addition to the scheduled assessments performed Weeks 2 through 38, Weeks 16 and 
28 will also include the efficacy outcome assessments of the GMFM-88, FEES, ENG studies, 
VABS-II, COMFORT questionnaire, and brain MRI and MRS. For Weeks 16 and 28, the 
window for assessments will be -5 days. In addition, at Week 38 blood will be drawn for a 
PK assessment at the time points specified in the Schedule of Events.
It is anticipated that the IDDD will be used to obtain CSF samples and to deliver all 20 IT 
injections of HGT-1110. If the IT space is not accessible via the IDDD, investigational drug 
product may be administered by LP. Should the IDDD become clogged, undergo mechanical 
complications or otherwise not be accessible, the CSF sample may also be obtained by LP. 
Anesthesia may be required for injections of investigational drug product and some 
evaluations, and can be used at the discretion of the Investigator. The IDDD Manual provides 
details on the investigation and management of any IDDD-related issues. 
Cohort 4: Phases 1-3
Note:  Enrollment may occur prior to IDDD implantation or the first dose (baseline); however, 
implantation of the device should occur within 28 days of the first dose.
Phase 1:  Screening:  Day-40 through Day -1
Upon obtaining informed consent, the procedures and assessments required for the 
determination of the patient’s eligibility, including GMFM-88, will be completed at the 
clinical site within 40 days prior to the baseline visit (Week 0). Sample collection for central
diagnostic testing should take place at the screening visit to ensure diagnostic results are 
received promptly. Local laboratory results confirming the MLD diagnosis (analysis of urine 
sulfatide, ASA activity in leukocytes) will be accepted to confirm the MLD diagnosis 
enrollment criteria while waiting for the central laboratory results so that dosing of the study 
medication can occur as soon as possible.
Sites will be allowed one opportunity to re-screen any patient who fails initial screening or 
withdraws consent prior to device implantation or dose administration (if administration to be 
initiated by LP prior to device implantation). If the patient subsequently screen fails, the 
patient will no longer be considered for inclusion in the study.
Phase 2:  Surgical Implantation of the IDDD:  Day -10 to Day +28
To confirm the patient meets eligibility criteria at baseline, specifically the baseline GMFM-
88 assessment will be performed as close as possible to, but before device implantation or 
prior to first dose administration, whichever occurs first. Patients who do not continue to 
meet eligibility criteria will be discontinued from the study prior to device implantation 
and/or initial dosing. If device implantation and/or initial dosing occur within 7 days of the 
screening GMFM-88 assessment, the baseline GMFM-88 assessment will not be required. 
However, if more than 7 days has passed since the screening GMFM-88 assessment, the 
baseline GMFM-88 assessment will need to be completed prior to IDDD implantation or first 

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dose, and prior to any other baseline assessments in order to confirm eligibility for 
enrollment (per inclusion criterion 3.1 in Section 5.2).
Upon confirmation of eligibility, patients will undergo surgical implantation of an IDDD and 
a post-surgical assessment. The patients may receive study drug by LP until the device is 
implanted. Device implantation should be scheduled within 28 days of enrollment unless a 
delay is required due to clinical judgment for medical reasons (eg, infection).
Phase 3:  Baseline and Treatment Week 0 to Week 38 (±3 days for injection of 
HGT-1110)  
Upon confirmation of study eligibility, baseline assessments (ie, those scheduled for Week 0) 
may be performed at any time prior to dosing, including the Phase 2 period of the study, but 
baseline assessments should be performed as close to dosing as possible. Patients will 
undergo pre-dose baseline assessments at Week 0, which will include a standard battery of 
clinical laboratory tests (serum chemistry, hematology, and urinalysis), serum assessments of 
anti-HGT-1110 antibodies and CSF assessments (cell counts, protein, glucose, albumin, 
anti-HGT-1110 antibodies, and HGT-1110 levels) as well as safety assessments (ie, vital 
signs, physical examination, routine CSF analysis, pregnancy testing [if applicable], AEs, 
and concomitant medication/therapies/procedures assessments).
Baseline efficacy outcome assessments including the GMFM-88, FEES, ENG studies, 
VABS-II, COMFORT questionnaire, and brain MRI and MRS will be performed as well as 
sample collection for CSF, serum, and urine biomarker assessments. If device implantation 
and/or initial dosing occur within 7 days of the screening GMFM-88 assessment, the baseline 
GMFM-88 assessment will not be required.
Patients will receive their first dose (Week 0) and begin the HGT-1110 EOW dosing period 
(through Week 38). At Week 0, blood will also be drawn for a PK assessment at the time 
points specified in the Schedule of Events. 
During the EOW treatment period (Weeks 2 through 38), all assessments will be performed 
prior to IT injection of HGT-1110 unless otherwise indicated. Safety assessments (ie, vital 
signs, physical examination, routine CSF analysis, pregnancy testing [if applicable], AEs, 
and concomitant medication/therapies/procedures assessments) will be performed. Patients 
will remain under observation in the hospital setting for at least 36 hours following dosing 
and will be discharged when deemed clinically stable by the Investigator. Additionally, 
anti-HGT-1110 antibody sampling, the standard battery of clinical laboratory tests (serum 
chemistry, hematology, and urinalysis) and sample collection for analysis of CSF 
concentration of HGT-1110, and CSF, serum, and urine biomarkers will be performed every 
4 weeks. 
In addition to the scheduled assessments performed Weeks 2 through 38, Weeks 16 and 
28 will also include the efficacy outcome assessments of the GMFM-88, FEES, ENG studies, 
VABS-II, COMFORT questionnaire, and brain MRI and MRS. For Weeks 16 and 28, the 
window for assessments will be -5 days. In addition, at Week 38 blood will be drawn for a 
PK assessment at the time points specified in the Schedule of Events.

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It is anticipated that the IDDD will be used to obtain CSF samples and to deliver all 20 IT 
injections of HGT-1110. If eligibility has been confirmed, and IDDD implantation cannot be 
scheduled to occur within the Phase 2 window, or it is desired to shorten the screening period 
to promptly initiate first dose administration, investigational drug product may be 
administered by means of an LP. 
If the IT space is not accessible via the IDDD, investigational drug product may be 
administered by LP. Should the IDDD become clogged, undergo mechanical complications 
or otherwise not be accessible, the CSF sample may also be obtained by LP until the device 
is repaired or replaced. Anesthesia may be required for injections of investigational drug 
product and some evaluations, and can be used at the discretion of the Investigator. The 
IDDD Manual provides details on the investigation and management of any IDDD-related 
issues. 
All Cohorts (1-4): Phases 4 and 5
Phase 4:  End of Study:  Week 40 (-5, +3 days)
The assessments scheduled at Week 40, 2 weeks after the last HGT-1110 dose, will be the 
same as those at Weeks 16 and 28 with the addition of a 12-lead ECG and an X-ray (to
confirm that the IDDD remains positioned correctly). Patients who discontinue early will 
have an end-of-study (EOS) visit 2 weeks (-5, +3 days) after the last IT injection of 
HGT-1110. All EOS assessments should be performed. Patients will have the IDDD removed 
when they discontinue from or complete the study, unless the patient is continuing to receive 
treatment through another mechanism (eg, a different study or commercially available). 
Phase 5:  Safety Follow-up:  Week 42 (±3 days)
The Safety Follow-up visit will be conducted at Week 42 or 4 weeks (±3 days) after the last 
injection of HGT-1110 or 2 weeks after the removal of the IDDD, whichever occurs later, for 
patients who discontinue. The follow-up safety assessments (AEs and concomitant 
medications/therapies/procedures) may be performed via telephone from the clinical site.
Patients who complete all requirements in Study HGT-MLD-070 through Week 40 may be 
eligible to participate in an extension study. However, patients are not obligated to participate in 
any additional studies, and the Sponsor cannot guarantee that such studies will occur. 
4.2
Investigational Drug Product Dose Escalation Guidelines
Study eligibility will be confirmed, followed by surgical implantation of an IDDD and 
administration of IT treatment with HGT-1110 by means of an IDDD EOW at fixed doses based 
on the assigned IT dose (Cohort 1: 10 mg, Cohort 2: 30 mg, or Cohorts 3 and 4: 100 mg). The 
decision to escalate to the next higher dose level (ie, escalation to Cohorts 2 and 3 only) was
based on a DSMB review of the safety data obtained for the previous cohort after all patients in 
the cohort have each received a minimum of 2 IT doses. Dose escalation guidelines are provided 
in Section 6.5 and apply only to Cohorts 1-3. 

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4.3
Study Duration
The duration for each patient’s participation in this study is approximately 47 weeks. The 
planned duration of HGT-1110 treatment in this study is 38 weeks (20 IT injections of 
HGT-1110 EOW Weeks 0 to 38). 

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5
STUDY POPULATION SELECTION
5.1
Study Population
Approximately 24 patients are planned who are less than 12 years of age with a confirmed 
diagnosis of MLD, approximately 6 per cohort. Patients must be ambulatory at the time of 
screening and untreated with investigational drug products for MLD. 
5.2
Inclusion Criteria
Patients must meet all of the following criteria to be considered eligible for enrollment:
For Cohorts 1-4:
1. Confirmed diagnosis of metachromatic leukodystrophy by both:  
•
Arylsulfatase A (ASA) deficiency by assay in leukocytes 
AND
•
Elevated sulfatide in urine
2. Appearance of the first symptoms of disease at or before 30 months of age.
For Cohorts 1-3 only:  
3. Ambulatory at the time of screening. The minimum level of function required to meet this 
criterion is defined as the ability to walk forward 10 steps with one hand held.
4. The patient is less than 12 years of age at the time of screening.
For Cohorts 4 only:  
3.1 Minimum motor function requirements:
a.
A total GMFM-88 (percent) score ≥40 at the screening examination and a total 
GMFM-88 (percent) score ≥35 at the baseline examination, 
AND
b. GMFM-88 Dimension E: Walking, Running & Jumping, item 68 ("walk forward 10 steps 
with one hand held") score of at least 1 "initiates" at the screening and baseline 
examinations (if applicable). 
4.1 The patient is less than 8 years of age at the time of screening.
For Cohorts 1-4:
5. Neurological signs of MLD must be present at the screening examination.
6. The patient and his/her parent/representative(s) must have the ability to comply with the 
clinical protocol.
7. Patient’s parent(s) or legally authorized representative(s) must provide written informed 
consent prior to performing any study-related activities. Study-related activities are any 
procedures that would not have been performed during normal management of the patient.

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5.3
Exclusion Criteria
Patients will be excluded from the study if there is evidence or history of any of the following 
criteria at screening:
For Cohorts 1-4:
1. History of hematopoietic stem cell transplantation (HSCT).
2. The patient has any known or suspected hypersensitivity to anesthesia or is thought to be at 
an unacceptably high risk for anesthesia due to airway compromise or other conditions. 
3. Any other medical condition, serious intercurrent illness, or extenuating circumstance that, in 
the opinion of the Investigator, would preclude participation in the trial.
4. The patient is enrolled in another clinical study that involves the use of any investigational 
product (drug or device) other than HGT-1110 or the IDDD used in this study within 30 days 
prior to study enrollment or at any time during the study.
5. The patient is pregnant or breastfeeding.
6. The patient has a condition that is contraindicated as described in the SOPH-A-PORT Mini S 
IDDD Instructions for Use (IFU), including:
a. The patient has had, or may have, an allergic reaction to the materials of construction 
of the SOPH-A-PORT Mini S device.
b. The patient’s body size is too small to support the size of the SOPH-A-PORT Mini S 
Access Port, as judged by the Investigator.
c. The patient has a known or suspected local or general infection.
d. The patient is at risk of abnormal bleeding due to a medical condition or therapy.
e. The patient has one or more spinal abnormalities that could complicate safe 
implantation or fixation.
f.
The patient has a functioning CSF shunt device.
g. The patient has shown an intolerance to an implanted device.

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6
STUDY TREATMENTS
6.1
Description of Treatments
6.1.1
Investigational Drug Product
The following description applies to both the drug product manufactured with Process A and
Process B.
Recombinant human arylsulfatase A (rhASA, HGT-1110) is a multimeric glycoprotein produced 
using a genetically engineered human cell line (HT-1080) to secrete the human lysosomal
enzyme, arylsulfatase A. The mature form of the enzyme consists of 489 amino acids. The drug 
product is a sterile solution for IT administration. It is formulated at 30 mg/mL rhASA in an 
aqueous isotonic solution containing 154 mM sodium chloride, 0.005% polysorbate 20 at pH 6.0. 
The drug product is packaged in single use vials and is stored at 2 to 8°C. 
Please refer to the current edition of the Investigator’s Brochure for further information 
concerning the drug products produced with Process A and Process B.
6.1.2
Intrathecal Drug Delivery Device
The use of the IDDD will be restricted to study-related activities only and should not be accessed 
for any other purpose. The PORT-A-CATH IDDD will continue to be used for the 
administration of drug product for each patient until such time as an IDDD replacement may be 
required. Following protocol Amendment 6, any replacements will be performed using the 
SOPH-A-PORT Mini S and any newly enrolled patients will receive the SOPH-A-PORT Mini S.
After IDDD replacement the drug product will be administered via the SOPH-A-PORT Mini S 
Implantable Access Port. The SOPH-A-PORT Mini S device is intended for long-term, 
intermittent access to the IT space for the delivery of investigational drug.
The SOPH-A-PORT Mini S is comprised of the following 7 components:
•
One SOPH-A-PORT Mini S Access Port
•
One intrathecal port closed-tip catheter
•
One guidewire
•
Two suture wings
•
One 14-gauge Tuohy needle
•
One 22-gauge non-coring Huber needle
•
One Luer lock connector
Further details are provided in the IFU.

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6.2
Treatment Administered
For Cohort 4 only, if eligibility has been confirmed, and IDDD implantation cannot be scheduled 
to occur within the Phase 2 window (see Section 8.2), or it is desired to shorten the screening 
period to promptly initiate first dose administration, investigational drug product may be 
administered by means of an LP. 
Following successful surgical implantation of the IDDD and assessment of baseline procedures 
with no safety concerns, patients will receive their first IT injection of HGT-1110. Patients may 
receive anesthesia at the discretion of the Investigator. 
If use of the IDDD is precluded on a scheduled day of dosing, the investigational drug product 
may be administered by means of an LP. 
The initial implantation and revision and/or explantation of the SOPH-A-PORT Mini S will be 
performed by pediatric or general neurosurgeons or anesthesiologists who have experience in 
port and catheter implant procedures and IT access procedures. Please refer to the IFU for further 
details.
Drug administration will be performed in a clinical setting by appropriately trained and skilled 
healthcare providers (nurses or physicians) with knowledge of the patient’s drug regimen and 
experienced in accessing vascular or CNS ports or CNS infusion pumps. Patients and patients’ 
families will not be directly using the device to administer drugs and will have limited direct 
interaction with the device as there is minimal care required both during the immediate 
postoperative period as the implant site heals and also at times of drug administration.
Patients will receive their appropriate dose of HGT-1110 via slow push/injection over 2 to 
5 minutes in a hospital setting supervised by a healthcare provider. Patients will remain under 
observation in the hospital setting for at least 36 hours following dosing and will be discharged 
when deemed clinically stable by the Investigator. An attempt will be made to replace the total 
volume of CSF fluid removed with drug solution and sterile normal saline (as needed). Vital 
signs will be obtained within 30 minutes prior to IT administration, and 30 (±10) minutes, 
60 (±10) minutes, 4 hours (±30 minutes), 8 hours (±30 minutes), 16 hours (±30 minutes), 
24 hours (±30 minutes), and 36 hours (±30 minutes) post IT administration. See the Manual of 
Operations for complete details.
If there is any evidence of infection involving the CNS, IDDD, or area involved with port access 
at the time of planned dosing, then the dose should not be administered. Doses may also be 
delayed or missed if the Investigator believes that the patient is not well enough for dose 
administration due to an illness. Once the patient is well enough for dose administration, delayed 
doses can be administered per the instructions in Section 6.3.

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6.3
Selection and Timing of Dose for Each Patient
6.3.1
Dose Selection
This is a multicenter open-label dose-escalation study designed to evaluate the safety of up to 
3 dose levels (10, 30, and 100 mg) of HGT-1110 administered via an IDDD EOW for a total of 
38 weeks (20 injections, Weeks 0 to 38) to children with MLD. 
The DSMB agreed to open enrollment of the final dose-escalation cohort (Cohort 3), which has 
an assigned dose level of 100 mg (Process A). As the highest dose level being administered to 
patients, the 100 mg dose level was selected as the dose level for Cohort 4. Safety data in 
Cohorts 1-3 will be reviewed by the DSMB.
6.3.2
Dose Timing
In all cohorts, if a patient does not receive a scheduled dose within the planned visit window, the 
site should administer the dose as soon as possible. After the dose is administered, the next 
scheduled dose may be administered as soon as 7 days later. Administration of subsequent doses 
will return to the original schedule, which is based on the date of the patient’s first dose. If a 
patient has a delay in 2 consecutive scheduled doses, the patient can receive doses as frequently 
as every 7 days until the site is able to resume the original dosing schedule set by the first dose. 
If more than 2 consecutive doses are delayed, the third and any subsequent consecutive dose will 
be considered missed due to lack of nonclinical toxicology data to support weekly dosing beyond 
4 weeks. 
6.4
Method of Assigning Patients to Treatment Cohorts
After study eligibility was confirmed, patients were enrolled in 1 of 3 sequential, escalating, dose 
cohorts:
•
Cohort 1:  HGT-1110 by IT injection 10 mg EOW  
•
Cohort 2:  HGT-1110 by IT injection 30 mg EOW  
•
Cohort 3:  HGT-1110 by IT injection 100 mg EOW
Cohort 4 will be enrolled following Cohort 3, after DSMB review of Cohorts 1-3 and drug 
product manufactured with Process B becomes available. Cohort 4 will receive 100 mg 
HGT-1110 EOW by IT injection.
6.5
Staggered Enrollment/Dose Escalation
A staggered enrollment was utilized for this study to facilitate adequate safety monitoring per 
cohort. Within each cohort, administration of HGT-1110 was contingent on normal results for 
the relevant safety laboratory tests and measures (eg, CSF and serum). 
The decision to escalate to the next higher dose level (Cohort 2) was based on review of the 
safety data obtained for patients in dose Cohort 1 (included a minimum of 2 HGT-1110 doses 

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received by all patients in the cohort) by an independent DSMB and representatives from the 
Sponsor. As all relevant clinical and laboratory tests indicated a satisfactory safety profile and 
there were no safety concerns, enrollment and dosing in Cohort 2 (30 mg EOW IT dose level) 
started. The decision to escalate to the next higher dose level (Cohort 3 at 100 mg EOW IT) 
followed the same safety review process as that used for Cohort 2. A DSMB meeting will be 
held after completion of Cohorts 1-3. 
No further dose escalation was to take place if either 50% of the patients in a cohort suffer 
clinically significant (moderate or severe) AEs or if 1 patient experienced an unacceptable severe 
AE that was determined to be related to investigational drug product.
6.6
Concomitant Medications, Therapies, and Medical/Surgical Interventions
All non-protocol treatments and procedures that occur from the time of informed consent (or 
assent, if applicable) through the Safety Follow-up visit are regarded as concomitant and will be 
documented on the appropriate pages of the eCRF. Concomitant therapy includes medications, 
therapies/interventions administered to patients, and medical/surgical procedures performed on 
the patients. 
Changes in medications are acceptable if necessary according to clinical judgment. All changes 
will be recorded on the appropriate eCRF. Concomitant medications will be coded using World 
Health Organization – Drug Dictionary (WHO-DD).
6.6.1
Infusion/Hypersensitivity Reactions and Management
Infusions of proteins can be associated with reactions to the infusion that may or may not be 
immune-mediated (hypersensitivity reactions). Thus, potential reactions to the infusion of 
investigational drug are unpredictable. It is often difficult to clinically distinguish infusion 
reactions from hypersensitivity reactions. Symptoms may include headache, fever, feeling of 
warmth, sensory paresthesias (including feeling of warmth, tingling, or pain), rash, pruritus, or 
autonomic symptoms, such as dry mouth or gustatory abnormalities (including loss of smell and 
metallic taste). Changes in mental status or level of consciousness that are not caused by 
pre-medication may either occur acutely or develop post-injection over time. 
The management of infusion reactions and hypersensitivity reactions is similar. The following 
steps may be taken, at the discretion of the Investigator, in the event of a suspected infusion 
related/hypersensitivity reaction and the management of such reactions should be based on the 
severity of the reaction:
•
Treatment with medications such as antihistamines, antipyretics, and/or corticosteroids 
•
Stopping and resuming treatment
•
Pretreatment with antihistamines and/or corticosteroids may prevent subsequent 
reactions in those cases where symptomatic treatment was required

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6.7
Restrictions
6.7.1
Therapy
The use of any investigational drug product other than HGT-1110 is restricted within 30 days 
prior to study enrollment and during the study.
6.7.2
Pregnancy
Pregnancy testing will be performed for females of child-bearing potential who are sexually 
active or who become sexually active during the study. If the patient has a positive pregnancy 
test result, the procedures described in Section 7.15 are to be followed.
6.7.3
Patient Activity Restrictions
For patients implanted with the SOPH-A-PORT Mini S please refer to the SOPH-A-PORT 
Mini S IFU for details regarding patient activity restrictions for patients to be implanted with this 
device.
6.8
Treatment Compliance
Investigational drug product HGT-1110 will be administered in accordance with the protocol, 
under the direction of the Investigator or sub-Investigator as listed on the Form Food and Drug 
Administration (FDA) 1572 and recorded on the eCRF.
6.9
Packaging and Labeling
6.9.1
Investigational Drug Product
The following description applies to both the drug product manufactured with Process A and 
Process B.
Investigational drug product will be supplied in a clear, colorless glass (Type I) vial. The closure 
is a 13 mm stopper composed of butyl rubber with a fluoro resin lamination. The overseal is an 
aluminum seal with a flip-off, plastic, tamper evident cap. 
Investigational drug product will be clearly labeled according to country specifications. This will 
include, but is not limited to:  manufacturer’s name, protocol number, lot number, storage 
conditions, and expiration date.
See the Pharmacy Manual for additional details.
6.9.2
SOPH-A-PORT Mini S Access Port
The SOPH-A-PORT Mini S Access Port is available in one size, individually packaged, with 
other SOPH-A-PORT Mini S components in double peel-off, sterile, pyrogen-free packaging, 
sterilized with ethylene oxide. Instructions for Use are also included in the packaging. A 
guidewire is provided in separate double pouch, sterile, pyrogen-free packaging.

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Labels are provided on the outer carton, and on both the SOPH-A-PORT Mini S box and 
guidewire/cannula package inside.
6.10
Storage and Accountability
6.10.1
Investigational Drug Product
The following information should be considered when storing and using the investigational drug 
product.
Investigational drug product should be stored refrigerated (2 to 8°C). Do not shake. Avoid 
exposure to intense direct sun light. Investigational drug product may not be stored beyond the
expiration date on the vial.
The disposition of all investigational drug product delivered to a Principal Investigator must be 
recorded on a patient-by-patient basis by completing the accountability log. The date and time of 
administration of the investigational drug product must be documented on the appropriate eCRF.
The Principal Investigator, Clinical Research Coordinator, or designee (eg, Pharmacist) must 
ensure that all documentation regarding investigational drug product receipt, storage, dispensing,
loss/damaged and return of used/unused product is complete, accurate, and ready for review at 
each monitoring visit or audit. The sites must ensure that the investigational drug product is 
available for the monitor to inventory and prepare for return shipment to the Sponsor or 
designee, if required. 
6.10.2
Investigational Drug Delivery Device
6.10.2.1
PORT-A-CATH Intrathecal Drug Delivery Device
Please refer to the relevant IDDD Manual for return instructions.
6.10.2.2
SOPH-A-PORT Mini S Intrathecal Drug Delivery Device
The disposition of all SOPH-A-PORT Mini S intrathecal drug delivery devices delivered to a 
Principal Investigator must be recorded on a patient-by-patient basis by completing the 
accountability log. The date and time of administration of the investigational drug product and 
use of the SOPH-A-PORT Mini S device must be documented on the patient’s appropriate 
eCRF.
The Principal Investigator, Clinical Research Coordinator, or designee (eg, Pharmacist) must 
ensure that all documentation regarding receipt, storage, dispensing, loss/damaged 
SOPH-A-PORT Mini S intrathecal drug delivery devices and return of used/unused intrathecal 
drug delivery devices) is complete, accurate, and ready for review at each monitoring visit and/or 
audit. The sites must ensure that the SOPH-A-PORT Mini S devices are available for the monitor 
to inventory and prepare for return shipment to the Sponsor or designee, if required.
The SOPH-A-PORT Mini S and its components are sterile, single-use devices.

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Please refer to the relevant IDDD Manual for device return instructions.
6.11
Investigational Drug Product Retention at Study Site
The process for return and destruction of investigational drug product must be determined and 
documented during the study start-up phase. If the sites do not have an Investigational Drug 
Product Returns or Destruction Process/Policy, the Sponsor or designee must provide guidelines 
to the sites. Sites must retain copies of these documents within the Site Regulatory Binder.
If the investigational drug product is to be destroyed by the sites, sites must follow their own 
process/policy that describes such activities. Sites must retain copies of these documents within 
the Site Regulatory Binder. Sites must ensure that the accountability and destruction log is 
complete, accurate, and ready for review or audit at each monitoring visit. 
All manifests documenting shipments of investigational drug product must be retained as well as 
copies of any investigational drug product return forms.
See the Pharmacy Manual for additional details.

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7
STUDY PROCEDURES 
Detailed descriptions of patient evaluations required for this protocol are described in this 
section. These evaluations will be performed during the indicated times, days, and weeks of the 
study described in Section 8 and the Schedule of Events tables in Appendix 1 (Cohorts 1-3) and 
Appendix 2 (Cohort 4). 
All data collected are to be recorded on the appropriate eCRF. 
Additional details for study procedures, including sample collection, are described in the Manual 
of Operations or Laboratory Manual as appropriate for this study.
7.1
Informed Consent
Prior to conducting any study-related procedures, written informed consent must be obtained 
from the patient’s parent(s) or legally authorized representative(s) and assent from the patient (if 
applicable). At a minimum, the date of the initial consent will be captured on the eCRF.
The nature, scope, and possible consequences, including risks and benefits, of the study will be 
explained to the patient, the patient’s parent(s), or the patient’s legally authorized representative 
by the Investigator or designee in accordance with the guidelines described in Section 11.4. 
Documentation of the consent process and filing of informed consent documents should be 
completed according to Section 11.4. 
7.2
Inclusion/Exclusion Criteria
At Screening, each patient will be reviewed for eligibility against the study entrance criteria. 
Patients who do not continue to meet the study entrance criteria will not be allowed to participate 
in the study. The reason(s) for the patient’s ineligibility for the study will be documented. Refer 
to the eCRF Completion Manual for additional instructions for patient screen failures.
7.3
Confirmation of Study Eligibility and MLD Diagnosis and Genotype
Cohorts 1-3:  
Patient eligibility according to the study inclusion and exclusion criteria will be assessed during 
the Screening period. Sites will be allowed one opportunity to re-screen any patient who fails 
initial screening or withdraws consent prior to device implantation). If the patient subsequently 
screen fails, the patient will no longer be considered for inclusion in the study.
Assays for leukocyte arylsulfatase A enzyme activity, urine sulfatide, and genotype 
determination will be performed by specialty laboratory(ies) designated by Shire to confirm the 
diagnosis of MLD.5, 30 Biochemical confirmation of MLD diagnosis is required for study 
eligibility, but genotype results are not.
Local leukocyte arylsulfatase A enzyme activity and urine sulfatide will be allowed to confirm 
the diagnosis of MLD, if available and deemed sufficient by the Principal Investigator and 

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Medical Monitor. Sample collection for diagnostic testing will still be performed if local results 
are used to confirm the diagnosis of MLD.
Cohort 4:
Patient eligibility according to the study inclusion and exclusion criteria will be assessed during 
the Screening period. Sites will be allowed one opportunity to re-screen any patient who fails 
initial screening or withdraws consent prior to device implantation or dose administration (if 
administration to be initiated by LP prior to device implantation. If the patient subsequently 
screen fails, the patient will no longer be considered for inclusion in the study.
Assays for leukocyte arylsulfatase A enzyme activity, urine sulfatide, and genotype 
determination will be performed by specialty laboratory(ies) designated by Shire to confirm the 
diagnosis of MLD.5, 30 Biochemical confirmation of MLD diagnosis is required for study 
eligibility, but genotype results are not.
Local laboratory results for leukocyte arylsulfatase A enzyme activity and urine sulfatide will be
allowed to confirm the diagnosis of MLD, if available and deemed sufficient by the Principal 
Investigator and Medical Monitor, while waiting for the central laboratory results so that dosing 
of the study medication could occur as soon as possible. Sample collection for diagnostic testing 
will still be performed at Screening if local results are used to confirm the diagnosis of MLD. If 
local laboratory results are not in agreement with central laboratory results and the patient has 
already been dosed with study medication and/or has received device implantation, then the 
central laboratory tests will be repeated. If repeat central laboratory results confirm a positive 
local laboratory result then the patient will continue in the study. However, if the repeat central 
laboratory results are in discordance with the local laboratory results then the Investigator must 
contact the Shire Medical Monitor to evaluate what action should be taken regarding this patient. 
Dosing will be stopped if the Investigator and Medical Monitor determine that the patient does 
not have a diagnosis of MLD; however, such a patient would still be followed for safety.
To confirm the patient meets eligibility criteria at baseline, the baseline GMFM-88 assessment 
will be performed as close as possible to, but before device implantation or prior to first dose 
administration, whichever occurs first. Patients who do not continue to meet eligibility criteria 
will be discontinued from the study prior to device implantation and/or initial dosing. If device 
implantation and/or initial dosing occur within 7 days of the screening GMFM-88 assessment, 
the baseline GMFM-88 assessment will not be required. However, if more than 7 days has 
passed since the screening GMFM-88 assessment, the baseline GMFM-88 assessment will need 
to be completed prior to IDDD implantation or first dose, and prior to any other baseline 
assessments in order to confirm eligibility for enrollment (per inclusion criterion 3.1 in 
Section 5.2).
7.4
Study Enrollment
After all screening procedures are completed, diagnosis of MLD is confirmed, the patient has 
met all eligibility criteria, including confirmation of eligibility at baseline, and the patient has 
undergone device implant surgery or received at least 1 dose of study drug, the patient will be 
enrolled in the study.

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7.5
Cross-reacting Immunologic Material
A blood sample will be obtained from each patient at Screening and the leukocytes from it will 
be tested for the presence of ASA cross-reacting immunological material (CRIM). 
The peripheral blood mononuclear cells (PBMC) will be isolated and the tests will be performed 
at Shire or its designee. 
7.6
Medical History and Demographics
Demographic information will be recorded for each patient and will include the following 
information:  gender, age, and ethnic origin. MLD-related history will be recorded and will 
include age at onset of first MLD symptoms, age at MLD diagnosis, evidence of ASA 
deficiency, genotype, and family history of MLD. 
Medical and surgical history will include the following systems:  head, neck, eyes, mouth, ears, 
nose, throat, chest, lungs, cardiovascular, abdomen, gastrointestinal, genito-urinary, skin, 
musculoskeletal, neurological, and psychiatric system. 
7.7
Height, Weight, and Head Circumference
Height and weight will be recorded for all patients. 
Height or length (cm) measured with the patient in a supine position on a standard measuring 
board and weight (kg) will be recorded and used to calculate growth velocity. The clinical site 
staff will be instructed to use calibrated scales for weight measurement. It is recommended that 
the same scale be used at the clinical site for all patients at each specified time point during the 
study.
Body weight and height measurements will be used to calculate the body mass index (BMI).
Head circumference will be measured in a uniform manner for all patients. 
7.8
Anesthesia
Anesthesia may be required for certain procedures (at the discretion of the Investigator). Any 
anesthesia used will be recorded as Concomitant Medications (see Section 6.6).
Administration of anesthesia may be given prior to obtaining CSF, if the use of the IDDD is 
precluded. 
Anesthesia may also be administered prior to performing the following:
•
Brain MRI and MRS
•
ENG studies (motor and sensory conduction)
•
Implantation of the IDDD
•
Injection of HGT-1110

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The physical examination and GMFM-88, FEES, and VABS-II assessments must be performed 
prior to the administration of anesthesia or after the patient has fully recovered from anesthesia.
7.9
Device-related Study Procedures
7.9.1
Intrathecal Drug Delivery Device Implantation, Replacement, or Revision
The IDDD will be surgically implanted at the clinical site. Procedures for implantation are
detailed in the device’s IFU Manual. Standard hospital procedures for surgery will be followed; 
the patient may be under general anesthesia for this procedure. It is planned that device 
explantation will occur at the main site unless urgent device removal is medically required to be 
performed locally or patient travel to the main site is medically inadvisable.
An additional medical device, the catheter passer, is necessary for the implantation procedure for 
patients receiving the SOPH-A-PORT Mini S. The catheter passer is a sterile, single-use device 
that will be used in the subcutaneous placement of the catheter. The Phoenix Neuro Disposable 
Catheter Passer, manufactured by Sophysa, is CE-marked in the European Union and cleared 
under K853370 in the United States (US) and may be provided; however, use of other catheter 
passers compatible with the SOPH-A-PORT Mini S is allowed.
At a minimum, the date of the implantation and spinal placement will be documented on the 
eCRF. If the device becomes nonfunctional at any time during the study, it will be removed and 
may be replaced or revised as appropriate.
7.9.2
X-ray Verification of Intrathecal Drug Delivery Device Placement
A post-operative X-ray check of the IDDD will be performed following surgery to verify proper 
installation and confirmation of IDDD placement at the mid-thoracic level. X-rays may be 
performed to check placement of the device, as needed, throughout the study. An X-ray will be 
performed at the end of the study (to verify that the IDDD is in the correct position). 
At a minimum, the date of the X-ray verifying correct IDDD placement and the date that the 
X-ray is read will be documented on the eCRF. If the device requires revision or replacement 
during the study, additional X-rays will be taken to document proper positioning of the device. 
Fluoroscopy should be used during device implantation procedures.
7.9.3
Cerebrospinal Fluid Sampling Procedure
Cerebrospinal fluid will be obtained from patients via an IDDD in aliquots appropriate for the 
specified analyses prior to each IT injection. If on a scheduled day of dosing, the use of the 
IDDD is precluded, the CSF samples may be obtained by LP, under anesthesia (if deemed 
necessary by the Investigator). Instructions for CSF withdrawal are included in the Manual of 
Operations.

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7.9.4
Intrathecal Drug Delivery Device Removal
If at the time of a scheduled dosing, due to a device-related issue it is not possible to aspirate 
CSF prior to dose administration, administer a full medication dosage using the standard 
administration steps detailed in the device’s IFU, or flush the system following dose 
administration, the IDDD will be declared a device malfunction. If the device malfunction is 
irreversible and cannot be corrected without a partial or full device revision or removal, the 
IDDD will be declared a device failure, starting from the date of the initial malfunction. The 
IDDD will then be surgically removed or revised and a new device and/or device components 
will be re-implanted at the earliest possible opportunity, preferably at the same time.
Patients who have a PORT-A-CATH IDDD failure will have this device replaced by a 
SOPH-A-PORT Mini S.
Details of the device removal will be recorded in the patient’s eCRF. Refer to the relevant IFU 
for further details.
If the IT space is not accessible via the IDDD, investigational drug product may be administered 
by LP and CSF may be collected by LP.
Patients will have the IDDD removed when they discontinue from or complete the study, unless 
the patient is continuing to receive treatment through another mechanism (eg, a different study or 
commercially available).
7.10
Investigational Drug Product Administration 
HGT-1110 will be administered EOW by means of an IDDD. A visual examination of both the 
port and catheter track will be performed before each IT injection. Patients will remain under 
observation in the hospital setting for at least 36 hours following dosing and will be discharged 
when deemed clinically stable by the Investigator. Please refer to Sections 6.2 and 6.3 for details. 
If the IT space is not accessible via the IDDD, investigational drug product may be administered 
by LP.
A 22-gauge Huber non-coring needle is to be used for access to the implanted port; standard 
hypodermic needles would damage the septum and may cause leakage. If no needle-free 
connector is present, either a stopcock of the Huber needle infusion set’s clamp is to be used to 
prevent CSF backflow and to mitigate the risk of air entering the system. It is possible to use 
other brands of Huber non-coring needles, provided that their specifications are identical to that 
of the Huber needle supplied by Sophysa in a SOPH-A-PORT Mini S (22-gauge). Please refer to 
the Manual of Operations and the Pharmacy Manual for more details regarding investigational 
drug product administration.
The injection date, injection start/stop time, planned dose, injection volume, and flush volume 
will be recorded on the eCRF. 

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7.11
Pharmacokinetic Assessments
Blood and CSF samples for determination of HGT-1110 concentration will be collected from 
patients for PK evaluations.
Blood samples will be obtained at Week 0 and Week 38, and will be drawn at the following 
nominal times: within 1 hour prior to IT injection of HGT-1110 and then 0.5, 1, 2, 4, 8, 12, 24, 
and 48 hours following completion of the IT injection.
The concentration of HGT-1110 in CSF will be assessed at Weeks 0 (Baseline), 4, 8, 12, 16, 20, 
24, 28, 32, 36, and 40 (EOS). The CSF samples will be drawn prior to IT injection of HGT-1110. 
The concentration of HGT-1110 in CSF will also be assessed when any delayed doses are 
administered (see Section 6.3). Should the IDDD become clogged, undergo mechanical 
complications, or otherwise not be accessible, the CSF sample may also be obtained by LP until 
the device is repaired or replaced. 
7.12
Efficacy Outcome Assessments
The change from baseline in motor function using the GMFM-88 total score (percent) after EOW 
IT injections of HGT-1110 for 38 weeks (Weeks 0 to 38) will serve as the main efficacy 
outcome measurement. Additional efficacy outcome measures include changes from baseline in 
FEES, ENG studies, VABS-II, COMFORT questionnaire, CSF, serum, and urine sulfatide and 
lysosulfatide levels,  brain MRI and MRS, and GIMF-C and GIMF-S. 
7.12.1
Gross Motor Function Measure
The GMFM-8831 will be used to measure motor function. The GMFM-88 will be performed by a
trained physiotherapist. It will be administered in the morning when the child is well rested and 
the assessments will be video-recorded. The video recordings may be used for an independent 
assessment. Patients will be evaluated in a one-on-one format. 
The test requires approximately 60 minutes of exercise. This measurement is validated for 
cerebral palsy; however, as the GMFM-88 records motor skills that are typical of normal 
development, it is useful for assessments in children with other neurological diagnoses. The 
original validation sample included children 5 months to 16 years old. The GMFM-88 is 
appropriate for children whose motor skills are at or below those of a 5-year-old child without 
any motor disability.31
The GMFM-88 item scores can be used to calculate domain-specific percent score for each of 
the 5 GMFM-88 dimensions (lying and rolling; sitting; crawling and kneeling; standing; 
walking, running, and jumping).
7.12.2
Global Impression of Motor Function Change and Severity
The GIMF-C and GIMF-S will be used to evaluate the minimal clinically important change in 
GMFM-88 response to IT administration of HGT-1110. Each questionnaire contains 6 items 
addressing the clinician’s global impression of change or severity in the 5 GMFM-88 dimensions 

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and overall. These assessments are to be administered after each GMFM-88 assessment and will 
only be performed for patients in Cohort 4.
7.12.3
Functional Endoscopic Evaluation of Swallowing 
A Functional Endoscopic Evaluation of Swallowing (FEES) will be performed to fully evaluate 
the structure and function of the upper throat during swallowing and for an assessment of 
aspiration risk. Each patient will have this assessment performed at the clinical site using 
transnasal flexible laryngoscopy. The examination will be video recorded.
7.12.4
Electroneurography
Evaluation of peripheral nerve function via ENG studies may be performed under anesthesia by a 
neurophysiologist by measurement of NCV, CMAP, AMP, and DL.
7.12.4.1
Motor Nerve Conduction Studies
For motor nerves, NCV, CMAP, and DL will be measured in the median and peroneal nerves of 
each patient (may be performed under anesthesia). In the event that no relevant signal can be 
generated at baseline in either of these nerves, the ulnar nerve, the tibial nerve, or both will be 
evaluated as well. One nerve in the arm and one in the leg will be selected on the basis of 
available responses for repeated evaluations.
7.12.4.2
Sensory Nerve Conduction Studies
For sensory nerves, NCV, AMP, and DL will be measured in the median and sural nerves at 
baseline for each patient (this may be performed under anesthesia). One median and one sural 
nerve will be selected for repeated evaluations.
7.12.5
Vineland Adaptive Behavior Scales, Second Edition
The VABS-II Survey Interview Form will be used to measure the personal and social skills of 
patients serially over time; these scales are organized within a 3-domain structure: 
Communication, Daily Living, and Socialization. In addition, the VABS-II offers a Motor Skills 
Domain and an optional Maladaptive Behavior Index. The VABS-II Survey Interview Form 
assesses what a patient actually does, rather than what he or she is able to do. The VABS-II 
Survey Interview Form will be administered to the patient’s parent(s) or legally authorized 
representative(s) by a trained medical professional. It will be conducted in available, validated 
languages.
7.12.6
Caregiver Observed MLD Functioning and Outcomes Reporting Tool
The Caregiver Observed MLD Functioning and Outcomes Reporting Tool (COMFORT) is a
questionnaire that will be used to assess health status and the impact of disease on the ability of 
patients with MLD to carry out activities of daily life. The questionnaire is organized by 
8 domains (ie, Personal Care, Positioning, Transfer or Mobility, Eating, Pain and Discomfort 
During the Day, Sleep, Emotions, Communication, Play and Leisure Activities) and will be 

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completed by the patient’s parent(s) or legally authorized representative(s). It will be conducted 
in available, validated languages.
7.12.7
Assessments Using Stored Biological Samples 
7.12.7.1
Biomarker Assessments
Samples of blood, urine, and CSF will be collected from patients participating in this study 
according to the Schedule of Events and stored for biomarker studies that may elucidate the 
pathogenesis of MLD and help to better characterize the response to the experimental treatment. 
Testing of residual blood, urine, and CSF samples for additional biomarker research is optional. 
The patient and/or patient’s parent(s) or legal representative(s) has the option to allow this testing 
for additional research assessments.
A biomarker is defined as a characteristic that is objectively measured and evaluated as an 
indicator of normal biologic processes, pathogenic processes, or pharmacologic responses to a 
therapeutic intervention. 
The identification of biomarkers that reflect the disease process and/or treatment response 
represent a potentially important exploratory aspect to this study that may contribute to patient 
and/or dose selection for future trials. Given our incomplete understanding of the pathogenesis of 
MLD, the range of biomarkers that might be informative is extensive. The CSF, blood, and urine 
samples will be examined for accumulation of sulfatide and lysosulfatide, which are known to 
reflect the primary biochemical lesion in MLD. 
Additional testing of residual sample volumes may include biomarkers that reflect the known 
pathological processes in MLD – demyelination, neuroaxonal degeneration and 
neuroinflammation, as well as markers of lysosomal dysregulation (lysosomal proteins, enzymes,
and their substrates). 
Urine and blood-derived serum and/or plasma will be examined in parallel with CSF samples to: 
•
Assess CSF/blood quotients for biomarkers of interest to provide insight into their CNS 
versus peripheral provenance
•
Identify potential peripheral urinary and/or blood biomarkers that might reflect CNS 
disease and/or treatment response
7.12.7.2
SOPH-A-PORT Mini S Assessments in Cerebrospinal Fluid and Serum
As part of the assessment of the SOPH-A-PORT Mini S, it may be necessary to determine the 
levels of leachables from the device into the CSF and blood. The patient and/or patient’s 
parent(s) or legal representative(s) has the option to allow testing of residual CSF and serum 
samples to determine the levels of leachable materials related to the IDDD.

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7.12.8
Magnetic Resonance Imaging and Brain Magnetic Resonance Spectroscopy
Each patient will have an MRI and MRS of the brain (may be performed under anesthesia), using 
methods specified in the Imaging Protocol contained in the Imaging Manual. Review of the 
images will focus on MLD-related abnormalities with measurement of metabolite levels 
(N-acetylaspartate, choline, and creatine) in regions of interest, for example, the frontal and 
parieto-occipital white matter, corpus callosum, centrum semiovale, and occipital cortex. Other 
metabolites and regions of interest may be explored.
7.13
Safety Assessments
7.13.1
Physical Examination
A complete physical examination will be performed, which will include an evaluation of the port 
and catheter track.
If results of the physical examination show clinically significant worsening from baseline or the 
previous visit, the change will be documented as an AE/serious AE (SAE) in the eCRF and will 
be followed as an AE consistent with the procedure outlined in Section 7.18. Clinical 
significance is defined as any variation in physical findings that has medical relevance resulting 
in an alteration in medical care. The Investigator will continue to monitor the patient until the 
parameter returns to baseline levels or until the Investigator determines that follow-up is no 
longer medically necessary.
7.13.2
Vital Signs
For all patients, vital signs (blood pressure, heart rate, respiratory rate, and body temperature 
measured when the child is not irritable or crying) will be obtained at each visit and recorded on 
the eCRF. Vital signs measured on IT dosing days will be obtained at times detailed in 
Section 8.3 and the Schedule of Events (see Appendix 1 and Appendix 2). Vital signs do not 
need to be measured if the patient is asleep.
7.13.3
Electrocardiography
Twelve-lead ECGs will be performed in accordance with the clinical site’s standard practice(s). 
Identification of any clinically significant findings and conduction abnormalities will be recorded 
as AEs on the eCRF. 
7.13.4
Clinical Laboratory Tests
Blood, urine, and CSF samples will be collected as described in the Laboratory Manual in the 
section for clinical laboratory testing. A central laboratory, a local laboratory, laboratories at 
Shire, or specialty laboratories will be used for analyzing samples and for reporting clinical 
laboratory values. 
The Screening and Baseline visit required approximately 24 and 20 mL of blood for all patients
in Cohorts 1-3, respectively, and will require 28 and 20 mL of blood, respectively, for patients in 
Cohort 4. The remaining visits will require approximately 11 mL of blood for the required 

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assessments (Weeks 4, 8, 12, 16, 20, 24, 28, 32, 36, 38, and 40). Approximately 7 mL of CSF 
will be drawn to approximate the volume of investigational drug product and flush to be injected. 
The CSF will be used for required and optional assessments at each treatment visit and the EOS 
visit.
7.13.4.1
Whole Blood Assessments
All blood samples will be collected via venipuncture. Patients will be in a seated or supine 
position during blood collection.
HEMATOLOGY
The following hematology parameters will be evaluated:  
•
Complete blood count (CBC) with differential and platelet count
•
Prothrombin time (PT) and activated partial thromboplastin time (aPTT) (Screening visit 
only)
ASSESSMENT OF POTENTIAL ASSAYS FOR NEWBORN SCREENING
Blood samples will be collected for the potential future development of newborn screening 
assays for the diagnosis of MLD. 
7.13.4.2
Serum Assessments
SERUM CHEMISTRY
Blood samples will be collected for serum chemistry testing that will include the assessments 
listed in Table 7-1.
Table 7-1
Routine Serum Chemistry Assessments
alanine aminotransferase (ALT)
creatine kinase
aspartate aminotransferase (AST)
gamma-glutamyl transferase (GGT)
albumin
iron
alkaline phosphatase
potassium
amylase
lactate dehydrogenase (LDH) 
total bilirubin
sodium
calcium
inorganic phosphate
creatinine
magnesium
SERUM SULFATIDES (BIOMARKER ASSESSMENT)
Blood samples will be collected for biomarker assessments to determine serum sulfatide and 
lysosulfatide levels. Additional biomarker testing and additional testing related to the 

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SOPH-A-PORT Mini S may be performed with any residual volume of samples (see 
Section 7.12.7), which will determine serum levels of other analytes. 
SERUM IMMUNOASSAY FOR ANTI-HGT-1110 ANTIBODIES
Blood samples will be collected for the determination of anti-HGT-1110 antibodies and, as 
appropriate, for neutralizing activity as well. Anti-HGT-1110 antibodies in blood samples are 
tested following a tiered approach per regulatory guidance and industry best practices. Samples 
are first screened using an electrochemiluminescence (ECL) bridging assay. Samples screened 
positive are then confirmed by competition with HGT-1110. The titers of confirmed positive 
samples are determined, and all confirmed positive samples are also further characterized using 
an enzyme activity based neutralization assay.
7.13.4.3
Urinalysis
STANDARD URINALYSIS
Urine samples will be collected for routine urinalysis.
Urinalysis will include the following:  
•
pH
•
Macroscopic evaluations
•
Microscopic evaluations
URINE SULFATIDES (CONFIRMATION OF DIAGNOSIS AND BIOMARKER ASSESSMENT)
A urine sample will be collected for the analysis of urinary sulfatide levels for confirmation of 
diagnosis. The assay will be performed at a reference laboratory. 
Urine samples will be collected for the quantitative analysis of urinary sulfatides (sulfatide and 
lysosulfatide). The assay will be performed at a specialty laboratory. Additional testing may be 
performed with any residual volume of sample (see Section 7.12.7), which will determine urine 
levels of other analytes. 
Refer to the Laboratory Manual for more information.
7.13.4.4
Cerebrospinal Fluid Assessments
Each CSF sample collected will be analyzed for cell count, protein, glucose, albumin, HGT-1110 
levels, anti-HGT-1110 antibodies, and sulfatide and lysosulfatide levels. A summary of CSF 
analyses is presented in Table 7-2. 
Additional biomarker testing and additional testing related to the SOPH-A-PORT Mini S  may 
be performed with any residual volume of sample (see Section 7.12.7), which will determine the 
CSF levels of other analytes.

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Table 7-2
Summary of Cerebrospinal Fluid Assessments
CSF Analysis Type
Purpose of Analysis
Lab at Which Analysis Will be 
Performed
Routine Analyses
CSF will be collected for the 
evaluation of glucose, protein, 
albumin, and cell count.
Local site
Biomarkers
CSF will be collected as 
described in the study Laboratory 
Manual for analysis of sulfatide 
and lysosulfatide (optional 
consent required for other 
biomarkers).
Shire or designee
Anti-HGT-1110 Antibodies
CSF will be collected for 
determination of anti-HGT-1110 
antibodies.a
Shire or designee
HGT-1110 
Levels/Concentration
CSF will be collected for the 
determination of HGT-1110 
concentration.
Shire or designee
Abbreviations:  CSF=cerebrospinal fluid
a
Anti-HGT-1110 antibodies in CSF samples are tested following a tiered approach per regulatory 
guidance and industry best practices. Samples are first screened using an electrochemiluminescence 
(ECL) bridging assay. Samples screened positive are then confirmed by competition with HGT-1110. 
The titers of confirmed positive samples are determined and all confirmed positive samples are also 
further characterized using an enzyme activity based neutralization assay. 
7.14
Device Data
The SOPH-A-PORT Mini S device will be evaluated using assessments of device implantation, 
device function, device longevity, and AEs associated with the implant surgery or device. This
data will be collected on the patient’s eCRF from the time of initial implantation.
7.15
Pregnancy Testing 
Female patients of child-bearing potential who are sexually active or who become sexually 
active during the study will have a pregnancy test at each study visit.
Pregnancy testing will be performed with a urine test. If the urine test is positive, a blood sample 
will be collected for serum β-human chorionic gonadotropin (β-hCG) testing. The clinical site’s 
local laboratory will analyze and report all pregnancy testing results. If a urine pregnancy test 
result is positive at any time during the study, the patient will not receive the planned injection(s) 
of investigational drug product until the result of the serum test is available. If the β-hCG result 
is also positive, no additional doses of investigational drug product are to be administered and 
the Investigator must contact the Shire Medical Monitor (see Section 7.19).

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7.16
Sample Collection, Storage, and Shipping
Biological material will be stored and secured, in a way that ensures patient confidentiality and 
that ensures unauthorized access is prohibited and the samples are not lost, deteriorated, or 
accidentally or illegally destroyed. 
The blood and CSF samples will be analyzed at central, local, or specialty laboratories or at 
Shire. Biorepositories will be maintained where samples will be archived in order to facilitate 
specimen management, batch testing, and storage. 
Detailed instructions for laboratory sample collection, processing, and shipping instructions will 
be provided in the Laboratory Manual and will include country-specific requirements, as 
appropriate.
7.17
Concomitant Medications, Therapies, and Medical/Surgical Interventions 
Assessments
All medications, therapies/interventions administered to and medical/surgical procedures 
performed on the study patients from the time of informed consent through the Safety Follow-up 
visit (Week 42) are regarded as concomitant and will be documented on the eCRF. 
7.18
Adverse Events Assessments
7.18.1
Definitions of Adverse Events and Serious Adverse Events
7.18.1.1
Adverse Event
An AE is any noxious, pathologic, or unintended change in anatomical, physiologic, or 
metabolic function as indicated by physical signs, symptoms, or laboratory changes occurring in 
any phase of a clinical study, whether or not considered investigational drug product-related. 
This includes an exacerbation of a pre-existing condition. Once the patient’s parents/legal 
representative(s) signs the informed consent, all AEs must be reported. Adverse events will be 
collected until 4 weeks (±3 days) after the last dose of investigational drug product or 2 weeks 
after the removal of the IDDD, whichever occurs later. Adverse events will be followed until the 
event has been resolved/stabilized or an outcome is reached, whichever comes first.

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Adverse events include the following:
•
Worsening (change in nature, severity, or frequency) of conditions present at the onset of 
the study
•
Intercurrent illnesses
•
Drug interactions
•
Events related to or possibly related to concomitant medications
•
Abnormal laboratory values (this includes significant shifts from baseline  within the 
range of normal that the Investigator considers to be clinically important)
•
Clinically significant abnormalities in physical examination, vital signs, and weight
Throughout the study, the Investigator must record all AEs on the AE case report form (eCRF), 
regardless of the severity or relationship to investigational drug product, IDDD, device surgical 
procedure, or IT administration process. The Investigator should treat patients with AEs 
appropriately and observe them at suitable intervals until the events stabilize or resolve. Adverse 
events may be discovered through observation or examination of the patient, questioning of the 
patient, complaint by the patient, or by abnormal clinical laboratory values.
In addition, AEs may also include laboratory values that become significantly out of range. In 
the event of an out-of-range value, the laboratory test should be repeated until it returns to 
normal or can be explained and the patient’s safety is not at risk. 
All AEs should be recorded with causality assessment as described in Section 7.18.3.
Additional illnesses present at the time when informed consent is given are regarded as 
concomitant illnesses and will be documented on the appropriate pages of the eCRF. Illnesses 
first occurring or detected during the study and worsening of a concomitant illness during the 
study are to be regarded as AEs and must be documented as such in the eCRF. 
7.18.1.2
Serious Adverse Event 
A serious AE (SAE) is any AE occurring at any dose that results in any of the following 
outcomes:
•
Death
•
Is life-threatening
•
Requires hospitalization
•
Requires prolongation of existing hospitalization
•
For the purposes of this study, overnight hospitalizations post intrathecal administration 
of HGT-1110 that are based on practical or logistical considerations rather than safety 
(see Section 7.10) will not result in an SAE designation.
•
A persistent or significant disability or incapacity 

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•
A congenital anomaly or birth defect
Important medical events that do not meet the above criteria may be considered an SAE when, 
based upon appropriate medical judgment, they may jeopardize the patient and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. A 
life-threatening AE is defined as an AE that placed the patient, in the view of the initial reporter, 
at immediate risk of death from the AE as it occurred (ie, it does not include an AE that, had it 
occurred in a more severe form, might have caused death).
Hospitalization that is the result of elective or previously scheduled surgery for a pre-existing 
condition, which has not worsened after initiation of treatment, should not result in an SAE 
designation. This does not apply to device failures resulting in scheduled surgical revisions, 
which should be reported as SAEs.
An unanticipated adverse device effect (UADE) is any serious adverse effect on health or safety
or any life-threatening problem or death caused by, or associated with, a device, if that effect, 
problem, or death was not previously identified in nature, severity, or degree of incidence in the 
investigational plan or application (including a supplementary plan or application), or any other 
unanticipated serious problem associated with a device that relates to the rights, safety, or 
welfare of patients (21 Code of Federal Regulations [CFR] 812.3[s] or other regulatory 
requirements, as applicable).
7.18.2
Device-associated Definitions
7.18.2.1
Device Revision (Partial and Full)
Partial device revision: surgical revision/replacement of one or more component(s) of the 
device; other component(s) of the original device remain implanted and are not affected (eg, port 
revision).
Full device revision: the device is removed (explanted) in its entirety and a completely new 
device is implanted.
7.18.2.2
Device Malfunction
The device does not perform as intended, based on the description in the device’s IFU, but does 
not require either a partial or full device revision.
7.18.2.3
Device Failure
The device irreversibly fails to perform as intended and requires either a partial or full device 
revision or removal.
7.18.2.4
Device Adjustment
Surgery of the device which does not result in partial or complete device revision or removal (eg, 
surgical exploration only or placement of additional sutures, tissue glue, and/or fascial repair).

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7.18.3
Classification of Adverse Events and Serious Adverse Events
The severity of AEs will be assessed by the Investigator using the National Cancer Institute 
Common Terminology Criteria for Adverse Events (NCI CTCAE) Version 4.0 grading scale 
(provided in the Study Operations Manual). If an AE is not described in the NCI CTCAE, the 
severity should be recorded based on the scale below (Table 7-3). The severity of all AEs/SAEs 
should be recorded on the appropriate eCRF page as Grade 1, 2, 3, 4, or 5 corresponding, 
respectively, to a severity of mild, moderate, severe, life-threatening, or fatal.
Table 7-3
Adverse Event Severity
Severity
Definition
Grade 1 (Mild)
No limitation of usual activities.
Grade 2 (Moderate)
Some limitation of usual activities.
Grade 3 (Severe)
Inability to carry out usual activities.
Grade 4 (Life-threatening)
Immediate risk of death.
Grade 5 (Fatal)
Death
7.18.4
Clarification Between Serious and Severe
The term “severe” is often used to describe the intensity (severity) of a specific event (as in mild, 
moderate, or severe myocardial infarction); the event itself, however, may be of relatively minor 
medical significance (such as severe headache). This is not the same as “serious,” which is based 
on the outcome or action criteria usually associated with events that pose a threat to life or 
functioning. Seriousness (not severity) and causality serve as a guide for defining regulatory 
reporting obligations.
7.18.5
Relatedness of Adverse Events and Serious Adverse Events
Relationship of an AE or SAE to investigational drug product, device, device surgical procedure, 
or IT administration process is to be determined by the Investigator based on the definitions in 
Table 7-4.

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Table 7-4
Adverse Event Relatedness
Relationship to Product(s)
Definition
Not Related
Unrelated to investigational drug product, device, device 
surgical procedure, or IT administration process.
Possibly Related
A clinical event or laboratory abnormality with a reasonable 
time sequence to administration of investigational drug product, 
device, device surgical procedure, or IT administration process, 
but which could also be explained by concurrent disease or 
other drugs or chemicals.
Probably Related
A clinical event or laboratory abnormality with a reasonable 
time sequence to administration of investigational drug product, 
device, device surgical procedure, or IT administration process 
unlikely to be attributable to concurrent disease or other drugs 
and chemicals and which follows a clinically reasonable 
response on de-challenge. The association of the clinical event 
or laboratory abnormality must also have some biologic 
plausibility, at least on theoretical grounds.
Definitely Related
The event follows a reasonable temporal sequence from 
administration of the investigational drug product, device, 
device surgical procedure, or IT administration process, and 
follows a known or suspected response pattern to the 
investigational drug product, device, device surgical procedure, 
or IT administration process, is confirmed by improvement 
upon stopping the investigational drug product, device, device 
surgical procedure, or IT administration process (de-challenge), 
and reappears upon repeated exposure (re-challenge). Note that 
this is not to be construed as requiring re-exposure of the patient 
to investigational drug product, device, device surgical 
procedure, or IT administration process; however, the 
determination of definitely related can only be used when 
recurrence of event is observed.
7.18.5.1
Adverse Events with Respect to Investigational Drug Product, Investigational 
Drug Product Administration, Device, and Associated Procedures 
Adverse events of special interest will be recorded in this first-in-human study of HGT-1110. 
Please refer to the current Investigator’s Brochure, Section 6.1.3, Adverse Reactions, for 
additional safety information. Adverse events of special interest in this study include the 
following:
DEVICE SURGICAL PROCEDURE-RELATED ADVERSE EVENTS
Examples of AEs related to device surgical procedures include, but are not limited to, the 
physiologic consequences of the following:  events that occur during or shortly following IDDD 
implant/explant, IDDD adjustment, full revision, partial revision, IDDD removal, and delayed 
re-implantation after previous IDDD removal (such as complications of anesthesia, excessive 

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bleeding, wound hematoma), and post-operative complications (such as post-operative 
infection). These events are related to the surgical procedure itself.
INTRATHECAL DRUG DELIVERY DEVICE-RELATED ADVERSE EVENTS
Examples of AEs related to use of the IDDD include, but are not limited to, the physiologic 
consequences (noxious, pathologic, or unintended change in anatomical, physiologic, or 
metabolic function as indicated by physical signs, symptoms, or laboratory changes) of the 
following:  device failure, device malfunction, incorrect connection of IDDD components, 
erosion of the portal/catheter through the skin, fibrin sheath formation around the catheter tip, 
hematoma, implant rejection, migration of the portal/catheter, and occlusion of the 
portal/catheter, portal site, or subcutaneous tract infection. A malfunction of the device (defined 
in Section 7.18.2.2) should not be entered as an AE unless it has physiological consequences. In 
the event of a device failure (defined in Section 7.18.2.3), the device will need to be replaced or 
repaired by removal and replacement of a component or removed in its entirety. “Device failure” 
will be reported as the SAE term. Details of the cause of the IDDD malfunction or failure will be 
recorded on the device malfunction and failure eCRF and the SAE form (where applicable).
A list of the most common IDDD AEs is included in the list of complications in Appendix 3.
INTRATHECAL ADMINISTRATION PROCESS ADVERSE EVENTS
Intrathecal administration process AEs may include those caused by anesthesia during drug 
administration and other drug administration issues (eg, extravasation during infusion or 
hematoma due to Huber needle) or complications of lumbar puncture.
HGT-1110 - RELATED ADVERSE EVENTS
To support a proposed Phase I/II clinical study, a comprehensive nonclinical program has been 
conducted to investigate HGT-1110 administered intrathecally to rats and juvenile monkeys to 
mimic human exposure at different age groups. Nonclinical studies were performed to compare 
Process A and B HGT-1110 drug product. Pharmacodynamic and pharmacokinetics were 
comparable for Process A and B HGT-1110, and no new safety findings were identified for 
Process B HGT-1110. In a first-in-human study of intrathecally administered HGT-1110, it is not 
possible to predict study IT drug-related AEs in humans. However, examples of AEs observed in 
published clinical trials with other intrathecally administered peptides or proteins include, but are 
not limited to the following:  headache, fever, feeling of warmth, sensory paresthesias (including 
feelings of warmth, tingling, or pain), and autonomic symptoms such as dry mouth or gustatory 
abnormalities (including loss of smell and metallic taste). Changes in mental status or level of 
consciousness that are not caused by pre-medication may either occur acutely or develop post-
injection, over time.
Although in this study HGT-1110 is only administered via the IT route, some proportion of the 
drug is likely to diffuse from the CSF into the peripheral circulation. The resulting systemic 
exposure may cause events that have been seen in patients receiving other enzyme replacement 
therapies known as infusion-related or hypersensitivity reactions, as well as possible 
development of antibodies to HGT-1110. 

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RISKS ASSOCIATED WITH ANESTHESIA REQUIRED FOR STUDY ASSESSMENTS
The use of an IDDD has been chosen to minimize the risks inherent in utilizing novel delivery 
systems and to alleviate the need for multiple administrations of anesthesia required for drug 
injection via repeated LP. The general risks include respiratory depression, aspiration, cardiac 
events, hypoxia, hypotension and hypertension, difficult intubations and extubations, stroke, 
rapid changes in body temperature, laryngospasm or laryngeal edema, and allergic reaction. 
Risks from anesthesia include death from complications such as changes in heartbeat, blood 
pressure, body temperature, or breathing. Patients will be closely monitored for changes in vital 
signs and related events. 
RISKS ASSOCIATED WITH LUMBAR PUNCTURE
Risks associated with LP include pain at the injection site, infection, meningitis, encephalitis, 
cerebritis, failed procedure, bleeding, dural tears, spinal headache, spinal fluid leakage, nerve 
damage, and focal and non-focal neurological injury (including paralysis). Patients may require 
anesthesia prior to an LP. Risks from anesthesia are discussed separately in this section 
(Section 7.18.5.1).
RISKS ASSOCIATED WITH FUNCTIONAL ENDOSCOPIC EVALUATION OF SWALLOWING
Risks associated with FEES include discomfort, gagging, vomiting, fainting, nose bleeds, and 
laryngospasm.
7.18.6
Procedures for Recording and Reporting Adverse Events
7.18.6.1
Adverse Event Monitoring and Period of Observation
Adverse events will be monitored continuously throughout the study.
For the purposes of this study, the period of observation extends from the time at which 
the patient’s parent(s) or the patient’s legally authorized representative(s) gives informed consent 
until the patient’s final evaluation of the study. For safety purposes, the final evaluation will be 
defined as the follow-up evaluation performed approximately 4 weeks after the last dose or 
2 weeks after the removal of the IDDD, whichever occurs later. Patients may be allowed to 
enroll in an HGT-1110 extension study, if eligible, after completing all requirements of 
HGT-MLD-070. Any patient enrolled in such an extension study will not participate in the 
Safety Follow-up visit, unless there is a delay in enrollment in the extension study. The final 
evaluation for any patient enrolled in such an extension study will be defined as the patient’s last 
visit in Study HGT-MLD-070.
If the Investigator considers it necessary to report an AE in a study patient after the end of the 
safety observation period, he or she should contact the Sponsor to determine how the AE should 
be documented and reported.

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(Note:  This includes a situation where the test article is not used as directed at the dose 
prescribed by the protocol.)
•
Overdose – Intentional or unintentional intake of a dose of investigational drug product 
higher than that prescribed for the patient in this study 
•
Medication Error – A mistake made in prescribing, dispensing, administration or use of 
the investigational drug product
All investigational drug product provided to pediatric patients should be supervised by the 
parent/legally authorized representative. The required process for reporting abuse, overdose, and 
medication errors is provided in the Manual of Operations.
7.21
Removal of Patients from the Trial or Investigational Drug Product
A patient’s participation in the study may be discontinued at any time at the discretion of the 
Investigator. The following may be justifiable reasons for the Investigator to remove a patient 
from the study:
•
Non-compliance, including failure to appear at 1 or more study visits
•
The patient was erroneously included in the study.
•
The patient develops an exclusion criterion.
•
The patient undergoes HSCT at any time during the study.
•
The patient suffers an intolerable AE.
•
The study is terminated by the Sponsor.
•
The patient experiences an adverse event NCI CTCAE Grade 3 or higher that is 
possibly, probably, or definitely related to treatment.
The patient’s parent(s) or the patient’s legally authorized representative(s) acting on behalf of the 
patient is free to withdraw consent and discontinue participation in the study at any time without 
prejudice to further treatment.
If a patient’s parent(s) or the patient’s legally authorized representative(s), acting on behalf of the 
patient, discontinues patient participation in the study or the patient is discontinued by the 
Investigator, the Patient Completion/Discontinuation eCRF describing the reason for 
discontinuation must be completed. 
Any AEs experienced up to the point of discontinuation must be documented on the AE CRF. If 
AEs are present when the patient withdraws from the study, the patient will be re-evaluated 
within 30 days of withdrawal. All ongoing SAEs at the time of withdrawal will be followed until 
resolution.

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7.22
Safety-related Study Stopping Rules
If at least 1 patient experiences a life-threatening (Grade 4) AE or death (Grade 5) that is 
considered either possibly, probably, or definitely related to treatment with investigational drug 
product or the IDDD (ie, a UADE), or if 2 or more patients experience at least one Grade 3 or 
higher AE during the study that is considered possibly, probably, or definitely related to 
treatment with HGT-1110, then dose escalation may not occur (see Section 6.5) and all sites will 
be instructed to halt further administration of HGT-1110 to all patients. An ad hoc DSMB 
meeting will be convened and all available data relating to the safety of HGT-1110 will be 
reviewed. Following the review of safety data and consultation with Regulatory Authorities as 
necessary, the study will be either:
•
Resumed unchanged
•
Resumed with modifications to the protocol 
•
Terminated
Patient safety will be monitored on a continuous basis during this study until the last patient 
completes his or her last scheduled study visit/assessment. 
7.23
Appropriateness of Measurements 
The safety, clinical effect, and PK parameters selected for this study were chosen based upon 
knowledge of the disease process and experience with intrathecal ERT in other lysosomal 
storage disorders.
The main efficacy outcome variable, change from baseline in motor function as assessed with the 
GMFM-88 total score (percent), provides a clinically meaningful measurement of neurological 
function in children with progressive degenerative brain disease accompanied by rapid loss of 
motor function. Portions of the GMFM-88 that focus on timed motor activities, such as the 
ability to sit without support, will provide valuable supplemental information on disease 
progression as it related to motor function deficit.32 The GMFM-88 item scores can be used to 
calculate a domain-specific percent score for each of the 5 GMFM-88 dimensions, which are the 
following:
•
Lying and rolling
•
Sitting
•
Crawling and kneeling
•
Standing
•
Walking, running, and jumping
The domain-specific percent scores are averaged to obtain the total score (percent). The 
GMFM-88 tool is validated for children with cerebral palsy33 and Down syndrome.34 The 
original validation sample included children with cerebral palsy who ranged in age from 

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5 months to 15 years of age.31 It is appropriate for children whose motor skills are at or below 
those of a 5-year-old child without any motor disability. Because the GMFM-88 measures motor 
skills that are typical of normal development, it is appropriate for use in MLD and other 
neurological diagnoses.35
Quantitative assessment of the ability to swallow (FEES), ENG measurements, CSF sulfatide 
and lysosulfatide, and white matter spectroscopic measure of N-acetylaspartate levels will 
provide supplemental information on CNS disease burden. 
Children with MLD often present with impairments in adaptive behavior, which is a composite 
of various dimensions. The scales of the VABS-II36 are organized within a 3-domain structure: 
Communication, Daily Living, and Socialization. This structure corresponds to the following 
3 broad domains of adaptive functioning defined by the American Association of Intellectual and 
Developmental Disabilities: Conceptual, Practical, and Social. In addition, VABS-II offers a 
Motor Skills Domain and an optional Maladaptive Behavior Index. The scores are interpreted by 
means of score equivalents for the raw scores in each domain, percentile ranks, age equivalents, 
adaptive levels, and maladaptive levels. Children with MLD often present with behavioral and 
intellectual impairments that would be detected with the VABS-II Survey Interview Form. The 
VABS-II Survey Interview Form measures adaptive behaviors, including the ability to cope with 
environmental changes, to learn new everyday skills and to demonstrate independence. It is an 
instrument that supports the diagnosis of intellectual and developmental disabilities, which are 
also often reflected in the presentation of MLD symptoms in children. It is an appropriate test for 
the age range of the patient population (<12 years of age), encompassing ages from birth to 
90 years. 
An assessment of the ability of children with MLD to carry out activities of daily life is an 
important measure because of the severity of the disease and its rapid progression, which impact 
cognitive function and the motor system. The COMFORT questionnaire was developed 
specifically for patients with MLD to evaluate key clinical domains affected by MLD. The 
questionnaire has a total of 59 questions spanning the following 8 domains: 
•
Personal Care
•
Positioning, Transfer, or Mobility
•
Eating
•
Pain and Discomfort During the Day
•
Sleep 
•
Emotions
•
Communication
•
Play and Leisure Activities
The COMFORT questionnaire will be used to evaluate the effect of HGT-1110 beyond efficacy 
outcome measures such as the GMFM-88 and FEES. Effective treatment would be expected to 
stabilize or improve a patient’s COMFORT result. 

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Evaluation of all chosen parameters will document the safety and impact of HGT-1110 on 
clinical manifestations of MLD and on the ability to carry out activities in daily life and will 
provide evidence on the risk-benefit profile of the product.

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8
STUDY ACTIVITIES
Patients in Cohorts 1, 2, 3, and 4 will undergo the schedule of procedures as presented at all 
visits listed in this section. 
8.1
Phase 1:  Screening (Days -40 to -11 for Cohorts 1-3; Days -40 to Day -1 for 
Cohort 4)
Written informed consent must be obtained from the patient’s parent(s) or legal representative(s) 
before any study related procedures are performed. Upon obtaining informed consent, the 
following procedures and assessments required for the determination of the patient’s eligibility 
must be completed at least 11 days prior to the baseline visit (Week 0), with exceptions noted 
below. 
Screening visit procedures will include the following:
•
Assess inclusion/exclusion criteria, including GMFM-88 (Cohort 4 only) (see note 
below)
•
Confirmation of MLD diagnosis (analysis of urine sulfatide, ASA activity in leukocytes, 
and genotype, as noted below). Samples for MLD diagnosis should be collected between 
Day -40 and Day -29 (for Cohorts 1-3) or Day -40 to Day -1 (for Cohort 4).
•
Medical history and demographic information
•
Physical examination
•
Vital signs
•
Height and weight
•
Head circumference 
•
Perform a 12-lead ECG
•
Urine sample collection for:
−
Routine urinalysis and sulfatide level (between Day -40 and Day -29)
•
Blood sample collection for:
−
Serum chemistry (including albumin) and hematology, including PT and aPTT
−
Arylsulfatase A activity in leukocytes (between Day -40 and Day -29 for Cohorts 1-3 
or Day -40 to Day -1 for Cohort 4)
−
Presence of arylsulfatase A cross-reacting immunological material (CRIM) in 
leukocytes
−
Genotyping (between Day -40 and Day -29)
−
Development of newborn screening tests
•
Urine pregnancy test (if applicable)
•
Begin AE reporting

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•
Begin monitoring concomitant medications/therapies/procedures
NOTE:  If a patient does not meet inclusion/exclusion criteria, no further procedures will occur 
at that time. Sites will be allowed one opportunity to re-screen any patient who fails initial 
screening or withdraws consent prior to 1) device implantation or 2) dose administration (if 
administration to be initiated by LP prior to device implantation for Cohort 4 only). If the patient 
subsequently screen fails, the patient will no longer be considered for inclusion in the study. 
8.2
Phase 2: IDDD Implantation (Day -10 to Day -1 for Cohorts 1-3; Day -10 to 
Day +28 for Cohort 4) 
For Cohort 4 only:  To confirm the patient meets eligibility criteria at baseline, specifically the 
baseline GMFM-88 assessment will be performed as close as possible to, but before device 
implantation or prior to first dose administration, whichever occurs first. Patients who do not 
continue to meet eligibility criteria will be discontinued from the study prior to device 
implantation and/or initial dosing. If device implantation and/or initial dosing occur within 
7 days of the screening GMFM-88 assessment, the baseline GMFM-88 assessment will not be 
required. However, if more than 7 days has passed since the screening GMFM-88 assessment, 
the baseline GMFM-88 assessment will need to be completed prior to IDDD implantation or first 
dose, and prior to any other baseline assessments in order to confirm eligibility for enrollment 
(per inclusion criterion 3.1 in Section 5.2).
Upon confirmation of eligibility, patients will have an IDDD surgically implanted. Surgical 
implantation of the IDDD includes surgical implantation of the IDDD and a post-surgical 
assessment. The IDDD placement may require anesthesia. The patient may receive study drug by 
LP until the device is implanted. Device implantation should be scheduled within 28 days of 
enrollment unless a delay is required due to clinical judgment for medical reasons (eg, infection).
•
IDDD implantation and post-surgical assessment
•
X-ray to verify IDDD was placed at the mid-thoracic level in the spinal canal and 
correctly installed
•
Vital signs
•
Urine pregnancy test (if applicable)
•
Enrollment (A patient will be considered enrolled in the study once they have undergone 
device implant surgery or received at least 1 dose of study drug.)
•
Concomitant medications/therapies/procedures monitoring
•
AE reporting
8.3
Phase 3:  Baseline and Treatment (Weeks 0 to 38)
8.3.1
Baseline:  Week 0 (3 days for IT injection of HGT-1110) 
For Cohort 4 only:  To confirm the patient meets eligibility criteria at baseline, the baseline 
GMFM-88 will be performed as close as possible to, but before device implantation or prior to 

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first dose administration, whichever occurs first. Upon confirmation of study eligibility, all other 
baseline assessments may be performed at any time prior to dosing, including the Phase 2 period 
of the study (Section 8.2), but should be performed as close to dosing as possible. For Cohort 4, 
patients who do not continue to meet eligibility criteria will be discontinued from the study prior 
to device implantation and/or initial dosing. If device implantation and/or initial dosing occur 
within 7 days of the screening GMFM-88 assessment, the baseline GMFM-88 assessment will 
not be required.
The following Week 0 assessments will be performed at the clinical site:
•
Physical examination
•
GMFM-88 (as applicable, for Cohort 4:  if device implantation and/or initial dosing 
occur within 7 days of the screening GMFM-88 assessment, the baseline GMFM-88 
assessment will not be required.)
•
GIMF-C and GIMF-S questionnaires
•
FEES
•
The following assessments may be performed under anesthesia:
−
Motor and sensory nerve conduction studies (ENG studies)
−
Brain MRI and MRS
•
VABS-II
•
COMFORT questionnaire
•
Blood sample collection for:
−
Serum chemistry (including albumin) and hematology
−
Serum biomarkers (sulfatide and lysosulfatide levels)
−
Serum anti-HGT-1110 antibodies 
•
Urine sample collection for: 
−
Urinalysis 
−
Biomarkers (sulfatide and lysosulfatide levels)
•
CSF sample collection for:
−
Routine analysis, including albumin
−
Anti-HGT-1110 antibodies
−
Concentration of HGT-1110
−
Biomarkers (sulfatide and lysosulfatide levels)
•
Concomitant medications/therapies/procedures monitoring 
•
Urine pregnancy test (if applicable)
•
AE reporting

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•
Blood sample collection for PK:  within 1 hour prior to IT injection and then at 0.5, 1, 2, 
4, 8, 12, 24, and 48 hours following completion of IT injection.
•
Administer HGT-1110 by IT injection. Patients will remain under observation in the 
hospital setting for at least 36 hours following dosing and will be discharged when 
deemed clinically stable by the Investigator. The first day of dosing will be defined as 
Day 0. (All subsequent doses will be administered at 14 (±3) days (ie, 2-week) 
intervals based on the timing of the initial dose.)
•
Vital signs within 30 minutes prior to IT administration, and 30 (±10) minutes, 
60 (±10) minutes, 4 hours  (±30 minutes), 8 hours (±30 minutes), 
16 hours (±30 minutes), 24 hours (±30 minutes), and 36 hours (±30 minutes) post IT 
administration.
•
Enrollment – (A patient will be considered enrolled in the study once they have 
undergone device implant surgery or received at least 1 dose of study drug.)
8.3.2
Treatment Weeks (Weeks 2 through 38, excluding Weeks 16 and 28)
The following assessments will be performed at Weeks 2, 4, 6, 8, 10, 12, 14, 18, 20, 22, 24, 26, 
30, 32, 34, 36, and 38 (each visit window will be ±3 days) and prior to IT injection of HGT-1110 
unless otherwise indicated:
•
Physical examination
•
CSF sample collection for routine analysis, including albumin
•
Administer HGT-1110 by IT injection. Patients will remain under observation in the 
hospital setting for at least 36 hours following dosing and will be discharged when 
deemed clinically stable by the Investigator.
•
Vital signs within 30 minutes prior to IT administration, and 30 (±10) minutes, 
60 (±10) minutes, 4 hours (±30 minutes), 8 hours  (±30 minutes), 16 hours 
(±30 minutes), 24 hours (±30 minutes), and 36 hours (±30 minutes) post IT 
administration.
•
Urine pregnancy test (if applicable)
•
Concomitant medications/therapies/procedures monitoring
•
AE reporting
The following assessments will be performed at Weeks 4, 8, 12, 20, 24, 32, and 36 (each visit 
window will be ±3 days) in addition to those listed immediately above, and prior to IT injection 
of HGT-1110 unless otherwise indicated:
•
CSF sample collection for analysis for:
−
Anti-HGT-1110 antibodies
−
Concentration of HGT-1110

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−
Biomarkers (sulfatide and lysosulfatide levels) 
•
Blood sample collection for:
−
Serum chemistry (including albumin) and hematology
−
Serum anti-HGT-1110 antibodies
−
Serum for biomarkers (sulfatide and lysosulfatide levels)
•
Urine sample collection for:
−
Urinalysis 
−
Urine biomarkers (sulfatide and lysosulfatide levels)
On Week 38 only, the following PK sampling will be performed:
•
Blood sample collection for PK:  within 1 hour prior to IT injection and then at 0.5, 1, 2, 
4, 8, 12, 24, and 48 hours following completion of IT injection. 
See Section 8.3.3 for the list of assessments to be performed at Weeks 16 and 28.
8.3.3
Treatment and Evaluation: Weeks 16 and 28 (±3 days for IT injection of 
HGT-1110, -5 days for assessments) 
At Weeks 16 and 28, the window for IT injection of HGT-1110 will be ±3 days and the window 
for assessments will be -5 days. All assessments will be performed prior to dosing unless 
otherwise indicated in the list that follows. The following assessments will be performed at 
Weeks 16 and Week 28:
•
Physical examination
•
Vital signs within 30 minutes prior to IT administration and 30 (±10) minutes, 
60 (±10) minutes, 4 hours (±30 minutes), 8 hours  (±30 minutes), 16 hours 
(±30 minutes), 24 hours (±30 minutes), and 36 hours (±30 minutes) post IT 
administration.
•
Height and weight
•
Head circumference
•
GMFM-88
•
GIMF-C and GIMF-S questionnaires
•
FEES
•
The following assessments may be performed under anesthesia:
−Motor and sensory nerve conduction studies (ENG studies)
−Brain MRI and MRS
•
VABS-II

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•
COMFORT questionnaire 
•
Urine sample collection for:
−Urinalysis 
−Urine biomarkers (sulfatide and lysosulfatide levels)
•
Blood sample collection for:
−Serum chemistry (including albumin) and hematology
−Serum anti-HGT-1110 antibodies
−Serum biomarkers (sulfatide and lysosulfatide levels)
•
CSF sample collection for:
−Routine analysis, including albumin
−Anti-HGT-1110 antibodies
−Concentration of HGT-1110
−Biomarkers (sulfatide and lysosulfatide levels)
•
Urine pregnancy test (if applicable)
•
Concomitant medications/therapies/procedures monitoring
•
Administer HGT-1110 by IT injection. Patients will remain under observation in the 
hospital setting for at least 36 hours following dosing and will be discharged when 
deemed clinically stable by the Investigator.
•
AE reporting
8.4
Phase 4: End of Study:  Week 40 (-5, +3 days) 
The EOS visit will occur at Week 40. Patients who discontinue early will have an EOS visit 
2 weeks (-5, +3 days) after the last IT injection of HGT-1110. The following procedures will be 
performed at the EOS visit:
•
Physical examination
•
12-lead ECG
•
Vital signs
•
Height and weight
•
Head circumference
•
GMFM-88
•
GIMF-C and GIMF-S questionnaires
•
The following assessments may be performed under anesthesia:
−Motor and sensory nerve conduction studies (ENG studies)

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−Brain MRI and MRS 
•
FEES
•
VABS-II
•
COMFORT questionnaire
•
Urine sample collection for: 
−Urinalysis
−Biomarkers (sulfatide and lysosulfatide levels) 
•
Blood sample collection for:
−Serum chemistry (including albumin) and hematology
−Serum anti-HGT-1110 antibodies 
−Serum biomarkers (sulfatide and lysosulfatide levels)
•
CSF sample collection for:
−Routine analysis, including albumin
−Anti-HGT-1110 antibodies
−Concentration of HGT-1110
−Biomarkers (sulfatide and lysosulfatide)
•
X-ray confirmation of IDDD placement
•
IDDD removal unless the patient is continuing to receive treatment through another 
mechanism (eg, a different study or commercially available)
•
Urine pregnancy test (if applicable)
•
AE reporting
•
Concomitant medications/therapies/procedures monitoring
8.5
Phase 5:  Safety Follow-up Visit: Week 42 (±3 days)
The Safety Follow-up visit will occur at Week 42 or at 4 weeks (±3 days) after the last dose of 
HGT-1110 or removal of the IDDD, whichever occurs later (for patients who discontinue early 
from the study). Patients may be allowed to enroll in an HGT-1110 extension study, if eligible, 
after completing all requirements in Study HGT-MLD-070 through Week 40. Any patient 
enrolled in such an extension study will not participate in the Safety Follow-up visit, unless there 
is a delay in enrollment in the extension study. The following procedures will be performed at 
the Safety Follow-up visit and may be performed by telephone from the clinical site:  
•
AE reporting
•
Concomitant medications/therapies/procedures monitoring

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9
QUALITY CONTROL AND ASSURANCE
Training will occur at an Investigator meeting or at the site initiation visit or both, and instruction 
manuals will be provided to aid consistency in data collection and reporting across sites.
Clinical sites will be monitored by the Sponsor or its designee to ensure the accuracy of data 
against source documents.
The required data will be captured in a validated clinical data management system that is 
compliant with the FDA 21 CFR Part 11 Guidance. The clinical trial database will include an 
audit trail to document any evidence of data processing or activity on each data field by each 
user. Users will be trained and given restricted access, based on their role(s) in the study, through 
a password-protected environment.
Data entered in the system will be reviewed manually for validity and completeness against the 
source documents by a clinical monitor from the Sponsor or its designee. If necessary, the study 
site will be contacted for corrections or clarifications; all missing data will be accounted for.
Serious adverse event information captured in the clinical trial database will be reconciled with 
the information captured in the Pharmacovigilance database.

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10
STATISTICAL ANALYSIS
10.1
General Methodology
All statistical analyses will be performed by the Shire Biometrics department (with the exception 
of the PK analysis, which will be performed by the Shire Clinical Pharmacology and 
Pharmacokinetics department). Statistical analyses will be performed using SAS® software 
Version 9.3 or higher. Data will be summarized by cohort and overall, if appropriate. Summary 
statistics for continuous variables will include the number of patients, mean, standard deviation 
(SD), median, minimum, and maximum. Categorical variables will be summarized in a 
contingency table by the number and percentage of patients in each category (including a 
missing category, if applicable). Any statistical tests comparing cohorts will be 2-sided with a 
significance level of 0.05 and considered exploratory or hypothesis generating. The mean 
change, mean difference in the change between cohorts, and the corresponding 95% confidence 
intervals (CIs), may also be presented as appropriate.
Safety data summaries will be descriptive, and based on all post-baseline assessments including 
the frequency of TEAEs and the frequency of clinically notable abnormal vital signs and 
laboratory values. 
10.2
Determination of Sample Size
Approximately 24 patients are planned for 4 cohorts (up to 6 enrolled patients in Cohorts 1-3 and 
approximately 6 patients in Cohort 4 who undergo device implant surgery or receive at least 1 
dose of study drug). The sample size was determined outside of statistical considerations and is 
based on the practicalities of enrolling this number of patients with this rare disease. 
10.3
Method of Assigning Patients to Treatment Cohorts  
This is a multicenter open-label dose-escalation study to evaluate the safety of HGT-1110. Each 
of the first 3 cohorts of patients was assigned in an ascending order of the dose level 
sequentially. The Cohort 1 patients were assigned to the lowest dose level of HGT-1110 (10 mg), 
Cohort 2 patients were assigned to the middle dose level (30 mg), and Cohort 3 patients were 
assigned to the highest dose level (100 mg) EOW treatment. Cohort 4 will be assigned to the 
100 mg dose level administered EOW.
10.4
Analysis Populations
The Safety population, defined as the set of patients who underwent the device implant surgery 
or received at least 1 dose of study drug, will be the primary analysis population. Intrathecal 
device-related analyses will be performed in the subset of the Safety population who underwent 
the device implant surgery.
The Pharmacokinetic Population is defined as all patients in the Safety Population for whom the 
primary pharmacokinetic data are considered sufficient and interpretable. All the 
pharmacokinetic analyses will be performed using the Pharmacokinetic Population.

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10.5
Patient Disposition
The number of patients who had baseline assessments, who were dosed, and completed the 
study, as well as the number who discontinued, will be reported in summary tables using number 
and percentage of patients per category by cohort; reasons for discontinuation/withdrawal will be 
presented.
10.6
Demographics and Baseline Characteristics
Descriptive statistics of patient demographic and baseline characteristics data will be 
summarized by cohort and overall using the Safety population. The continuous variables 
(eg, age, weight, and height) will be summarized by descriptive statistics using n, mean, median, 
SD, minimum, and maximum. The categorical variable (eg, sex and race) will be tabulated using 
frequency and percentage for each category of interest (including a missing category, if 
applicable). 
10.7
Primary Endpoints
Safety will be measured by the following endpoints:
•
Reporting of TEAEs
•
Change from baseline in clinical laboratory testing (serum chemistry including liver 
function tests, hematology, and urinalysis)  
•
Change from baseline in 12-lead ECGs, vital signs, physical examinations, and CSF 
chemistry (including cell counts, glucose, and protein)
•
Determination of the presence of anti-HGT-1110 antibodies in CSF and/or serum 
10.8
Secondary Endpoints
The secondary endpoints of this study are the following:
•
Change from baseline in motor function using the GMFM-88 total score
•
Change from baseline in the ability to swallow as measured by the FEES 
•
Change from baseline in nerve conduction as measured by the ENG assessments of 
NCV, CMAP, AMP, and DL
•
Change from baseline in the adaptive behavior composite standard score as measured by 
the VABS-II
•
Change from baseline in the domain-specific COMFORT scores
•
Single and repeated-dose PK parameter estimates for HGT-1110 in serum
•
Concentrations of HGT-1110 in CSF at selected time points after single and repeated 
investigational drug product administration

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10.9
Exploratory Endpoints
The exploratory endpoints of this study are the following:
•
Change from baseline in CSF, serum, and urine biomarkers (ie, sulfatide and 
lysosulfatide)
•
Percent change from baseline in N-acetylaspartate metabolite levels in the deep white 
matter of the brain as assessed by proton MRS
•
Change from baseline in the total MLD severity score based on MRI of the brain
•
Categorical assessment in the GIMF-S
•
Categorical assessment in the GIMF-C
10.10 SOPH-A-PORT Mini S Assessments
The SOPH-A-PORT Mini S device will be evaluated using assessments of device implantation, 
device function, device longevity, and AEs associated with the implant surgery or device. This
data will be collected on the patient’s eCRF from the time of initial implantation.
10.11 Pharmacokinetic Analysis 
The concentrations of HGT-1110 in the serum and CSF samples will be determined. Individual 
serum HGT-1110 concentration-time profiles will be reported. Individual PK parameters will be 
calculated if sufficient HGT-1110 concentration time points exist to derive values. The PK 
parameters will be derived using noncompartmental analysis, and the actual blood collection 
times relative to the start of the IT administration will be used in the analysis. Individual CSF 
HGT-1110 concentration at each time point will be reported. The association of the presence of 
anti-HGT-1110 antibodies and HGT-1110 concentration-time profiles and PK parameters will be 
evaluated, if applicable. 
Pharmacokinetic parameters calculated will include the following: 
•
Maximum observed serum concentration (Cmax) 
•
Time of Cmax (Tmax) 
•
Area under the serum concentration-time curve from time zero to the last sampling time 
at which serum concentrations were measurable (AUC0-last) 
•
Area under the serum concentration-time curve extrapolated to infinity (AUC0-∞) 
•
Apparent terminal rate constant (λZ) derived from the slope of the log-linear regression 
of the log-linear terminal portion of the serum concentration-time curve. 
•
Terminal half-life (t1/2) calculated as 0.693/apparent terminal rate constant (λZ)
•
Clearance after IT administration (CL/F) 
•
Volume of distribution based on the terminal phase after IT administration (Vz/F)

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Summary statistics (number of observations, mean, SD, coefficient of variation, median, 
maximum, minimum, and geometric mean) will be determined for all PK parameters and 
presented by cohort, visit, and drug product (Process A and Process B). Serum concentrations of 
HGT-1110 at each nominal sampling time will also be summarized by treatment and visit using 
descriptive statistics.
10.12 Primary Analyses
The analysis of safety data will be performed using the Safety population, primarily on the total 
number of patients and frequency of TEAEs and on the frequency of clinically significant (CS) 
laboratory values and clinically notable abnormal vital signs, change in vital signs, and abnormal 
12-lead ECG parameters. The proportion of patients with TEAEs and CS abnormal laboratory 
values during the study will be presented by cohort and overall.
Adverse events will be collected throughout the study and at early termination if a patient 
prematurely withdraws from the study. Adverse events and medical conditions will be coded 
using the Medical Dictionary for Regulatory Activities (MedDRA).
Treatment-emergent AEs, defined as all AEs occurring at or after the first dose of study drug or 
device implant surgery (whichever occurs first) and through the last follow-up date in 
HGT-MLD-070, will be summarized by system organ class and preferred term for the Safety 
population and by cohort. In addition, the severity and relationship to investigational drug 
product of the TEAE will be summarized overall and by cohort. Those events that resulted in 
death or were otherwise classified as serious will be presented in a by-patient data listing. For 
each of the clinical laboratory parameters (serum chemistry including liver function tests, 
hematology, and urinalysis), both the observed results and changes from baseline at each 
post-baseline visit will be summarized overall and by cohort.
Anti-HGT-1110 antibody formation will be monitored throughout the study. Antibody assay 
results will be summarized by cohort including, number and percentage of positive and negative 
values by cohort and study visits, for both serum and CSF. These results may also be presented 
in the by-patient data listings.
Anti-HGT-1110 antibodies will be evaluated for enzyme neutralizing activity using an in vitro 
assay. Results will be presented in summary tables by assay methodology used to identify 
antibodies and enzyme-neutralizing activity. 
All safety data may also be presented in data listings.
10.13 Secondary Analyses
The change from baseline in motor function using the GMFM-88 total score (percent) will be 
summarized descriptively at each study visit. The cohorts will be compared at the end of study 
visit using an analysis of covariance (ANCOVA) model with change from baseline as the 
dependent variable including the cohort as a fixed effect and baseline values of the GMFM-88 
total score (percent) as the single continuous covariate. The adjusted mean for each cohort and 
the difference in means between cohorts and the associated 95% confidence intervals and 

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p-values will be estimated. If the parametric assumptions are not justified, then the ANCOVA 
model will be analyzed using the rank data. The total score (percent) is calculated by averaging 
the percent scores for each of the 5 domains (ie, lying and rolling; sitting; crawling and kneeling; 
standing; and walking, running, and jumping) and rounding to the nearest whole number.31
Pharmacokinetic analysis of HGT-1110 in serum will be performed using individual 
concentration-time data and the PK parameters will be derived. Summary tabulations of PK 
parameters will be presented by cohort, visit, and drug process (Process A and Process B).
Continuous data will be summarized with descriptive statistics: number of observations, mean, 
SD, geometric mean, co-efficient of variation, median, minimum, and maximum values. 
Individual HGT-1110 concentrations in CSF at each time point will be reported.
Unless otherwise indicated, all below secondary analyses will be performed by cohort.
The FEES assessment will be performed to fully evaluate the structure and function of the upper 
throat during swallowing, and for an assessment of aspiration risk. Data will be presented by 
individual patient; summary statistics or shift tables will be prepared, as appropriate. In 
particular, the within-patient shift in aspiration risk (low; moderate; high) over time will be of 
particular importance.
The observed values and change from baseline will be summarized for sensory and motor nerves
by left and right side, if appropriate, for NCV, CMAP, AMP, and DL as measured by ENG. This 
data will be summarized descriptively by cohort and overall. Data may be presented graphically 
over time. 
The VABS-II Survey Interview Form will be used to measure the personal and social skills of 
patients serially over time. These scales assess what a patient actually does, rather than what he 
or she is able to do and those activities will be assessed by a trained medical professional. The 
observed value and change from baseline in the standard score (standardized to other people of 
the same age) within each of 4 domains (communication; daily living skills; socialization; motor 
skills), as well as the adaptive behavior composite standard score across all 4 domains will be 
presented. Data may be presented graphically over time. 
To understand the effect that HGT-1110 has on patients’ ability to carry out activities in daily 
life, the COMFORT questionnaire will be implemented throughout the study. The questions, 
presented on a Likert scale, ask about some activities a patient with MLD has to do on most 
days. There are several domains and a summary score is calculated within each domain. All of 
the statistical analyses will be performed within a domain. The observed data and change from 
baseline in the domain-specific summary scores will be presented. Data may be presented 
graphically over time. 
All secondary endpoint data may be presented in data listings.

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10.14 Exploratory Analyses
The exploratory endpoints listed in Section 10.9 will be summarized descriptively at each study 
visit. 
In addition, correlations of efficacy outcome measures with the CSF, serum, and urine sulfatide 
and lysosulfatide levels and with spectroscopic data (N-acetylaspartate) will be examined for 
exploratory purposes at baseline, Week 40, and change from baseline to Week 40. A measure of 
the linear association between variables at each time point will be obtained using Pearson 
correlation or the Spearman rank correlation as appropriate. 
Additionally, the correlations will be estimated of the GMFM-88 total score (percent) versus the 
following variables:  N-acetylaspartate, CSF, serum, and urine sulfatide and lysosulfatide.
Each patient will have a serially measured MRI of the brain. Based on a visual scoring method of 
the MRI, a total MLD severity score (range: 0-34) will be calculated for each patient at each 
time point where higher scores indicate more severe brain involvement. The pairwise 
comparison between cohorts will be conducted at the EOS visit using an ANCOVA model with 
change from baseline as the dependent variable including the cohort as a fixed effect and 
baseline values of the total MLD severity score as the single continuous covariate.
In addition, change from baseline in GMFM-88 domain scores will be summarized descriptively 
at each study visit.
The items of the GIMF-C and GIMF-S will be summarized by the number and percentage of 
patients by study visit for each dose cohort.
All exploratory endpoint data may be presented in data listings.
10.15 Intrathecal Drug Delivery Device Analyses
Intrathecal drug delivery device safety and performance will be summarized for implanted 
patients. Difficulties associated with the implant procedure (eg, excessive bleeding, CSF 
leakage) will be summarized. A summary of abnormal findings from the IDDD radiological 
assessments will also be presented. 
Intrathecal drug delivery device and procedure-related AEs will be summarized within system 
organ class by preferred term. Adverse events will be tabulated by severity (mild, moderate, 
severe) and degree of relatedness. Separate tabulations will be provided for AEs related to the 
IDDD, device surgical procedure and IT administration process.
The proportion of patients with at least one IDDD failure and/or malfunction, as well as the 
number of and reasons for IDDD failures/malfunctions will be summarized. The rate of IDDD 
failures/malfunctions and 95% confidence interval will also be estimated. The time from initial 
implant surgery to first IDDD failure and/or malfunction will be summarized. Patients without an 
IDDD failure/malfunction will be censored at their last investigational drug product injection 
date. A by-patient listing of the device failure/malfunction data may be displayed.

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The rate of successful IDDD injections will be calculated for each patient and summarized 
descriptively. The IDDD success rate will be calculated as the number of IDDD injections given 
as a percentage of IDDD injections given plus any malfunctions reported for inability to dose. 
The corresponding 95% confidence interval for the mean rate will be estimated, where 
appropriate. Injections that are not administered for patient-related reasons (e.g. patient 
uncooperative, competing medical issue, etc) will not be included in the determination of the 
injection success rate.
10.16 Interim Analysis
An interim analysis of all data will be performed after all enrolled patients in Cohorts 1-3 have 
completed the study. All data from Cohorts 1-3 will be entered into the database, reviewed, and 
discrepancies resolved for this analysis. Because any hypothesis testing is considered 
exploratory, no adjustment for multiplicity will be made. The analysis methods will be detailed 
in an interim statistical analysis plan, and an interim study report based on these data will be 
completed. Other descriptive analyses of the data before trial completion may be performed for 
additional safety monitoring, regulatory reporting, or general planning (Section 11.8).

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11
ADMINISTRATIVE CONSIDERATIONS
11.1
Investigators and Study Administrative Structure
Before initiation of the study, the Investigators must provide the Sponsor with a completed 
Form FDA 1572. Investigational drug product may be administered only under the supervision 
of the Investigators listed on this form. Curriculum vitae must be provided for the Investigators 
and sub-investigators listed on Form FDA 1572 or Investigator Agreement.
The Investigator should ensure that all persons assisting with the study are adequately informed 
about the protocol, any amendments to the protocol, the study treatments, and their study-related 
duties and functions. The Investigator must maintain a list of sub-investigators and other 
appropriately qualified persons to whom he or she has delegated significant study-related duties.
A coordinating Investigator will be selected based on overall contribution to the study and 
development program.
11.2
Institutional Review Board or Independent Ethics Committee Approval
Before initiation of the study, the Investigator must provide the Sponsor with a copy of the 
written IRB/IEC approval of the protocol and the informed consent form. This approval must 
refer to the informed consent form and to the study title, study number, and version and date of 
issue of the study protocol, as given by the Sponsor on the cover page of the protocol.
Status reports must be submitted to the IRB/IEC at least once per year. The IRB/IEC must be 
notified of completion of the study. Within 3 months of study completion or termination, a final 
status report must be provided to the IRB/IEC. A copy of these reports will be sent to the study 
clinical monitor. The Investigators must maintain an accurate and complete record of all 
submissions made to the IRB/IEC, including a list of all reports and documents submitted. 
Adverse events that are reported to the US FDA or other Regulatory agencies (Investigational 
New Drug [IND] Safety Reports) must be submitted promptly to the IRB/IEC.
11.3
Ethical Conduct of the Study
The procedures set out in this study protocol, pertaining to the conduct, evaluation, and 
documentation of this study, are designed to ensure that the Sponsor and Investigators abide by 
good clinical practice (GCP) as described in the 21 CFR Parts 50, 56, and 312 and the 
International Conference on Harmonisation (ICH) GCP Guidelines. Compliance with these 
regulations and guidelines also constitutes compliance with the ethical principles described in the 
Declaration of Helsinki.
11.4
Patient Information and Consent/Assent
Before enrolling in the clinical study, the patient’s parent(s) or legally authorized 
representative(s) must provide consent for the patient to participate in the study, after the nature, 
scope, and possible consequences of the clinical study have been explained in a form 
understandable to him or her.

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An informed consent form (assent form if applicable) that includes information about the study 
will be prepared and given to the patient or the patient’s parent(s) or legally authorized 
representative(s). This document will contain all FDA and ICH-required elements. 
The informed consent (or assent) form must be in a language understandable to the patient or the 
patient’s parent (s) or legally authorized representative(s) and must specify who informed the 
patient, the patient’s parent(s), or the patient’s legally authorized representative(s). Patient assent 
will be obtained, as applicable.
After reading the informed consent document, the patient’s parent(s) or legally authorized 
representative(s) must give consent in writing. Consent must be confirmed at the time of consent 
by the personally dated signature of the patient’s parent(s) or the patient’s legally authorized 
representative(s) and by the personally dated signature of the person conducting the informed 
consent discussions.
If the patient’s parent(s) or legally authorized representative(s) is unable to read, oral 
presentation and explanation of the written informed consent form and information to be 
supplied must take place in the presence of an impartial witness. Consent must be confirmed at 
the time of consent orally and by the personally dated signature or a local legally recognized 
alternative (eg, the thumbprint or mark) of the patient’s parent(s) or the patient’s legally 
authorized representative. The witness and the person conducting the informed consent 
discussions must also sign and personally date the informed consent document. It should also be 
recorded and dated in the source document that consent was given.
A copy of the signed and dated consent document(s) must be given to the patient’s parent(s) or 
legal representative(s). The original signed and dated consent document will be retained by the 
Investigator.
The Investigator will not undertake any measures specifically required solely for the clinical 
study until valid consent has been obtained.
A model of the informed consent form to be used in this study will be provided to the sites 
separately from this protocol.
11.5
Patient Confidentiality
Patient names will not be supplied to the Sponsor. Only the patient number and date of birth, as 
applicable per country regulations, will be recorded in the eCRF, and if the patient name appears 
on any other document, it must be obliterated before a copy of the document is supplied to the 
Sponsor. Study findings stored on a computer will be stored in accordance with local data 
protection laws. The patients will be told that representatives of the Sponsor, a designated CRO, 
the IRB/IEC, or regulatory authorities may inspect their medical records to verify the 
information collected, and that all personal information made available for inspection will be 
handled in strictest confidence and in accordance with local data protection laws. The 
Investigator will maintain a personal patient identification list (patient numbers with the 
corresponding patient names) to enable records to be identified.

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11.6
Study Monitoring
Monitoring procedures that comply with current GCP guidelines will be followed. Review of the 
eCRFs for completeness and clarity, cross-checking with source documents, and clarification of 
administrative matters will be performed.
The study will be monitored by the Sponsor or its designee. Monitoring will be performed by a 
representative of the Sponsor (Clinical Study Monitor) who will review the eCRFs and source 
documents. The site monitor will ensure that the investigation is conducted according to protocol 
design and regulatory requirements by frequent site visits and communications (letter, telephone, 
and facsimile).
11.7
Case Report Forms and Study Records
Case report forms are provided for each patient. All forms must be filled out by authorized study 
personnel. All corrections to the original eCRF entry must indicate the reason for change. The 
Investigator is required to sign the eCRF after all data have been captured for each patient. If 
corrections are made after review and signature by the Investigator, he or she must be made 
aware of the changes, and his or her awareness documented by re-signing the eCRF.
11.7.1
Critical Documents
Before Shire initiates the study (ie, obtains informed consent from the first patient), it is the 
responsibility of the Investigator to ensure that the following documents are available to Shire or 
their designee:
•
Completed FDA Form 1572 (Statement of Investigator), signed, dated, and accurate
•
Curricula vitae of Investigator and sub-investigator(s) (current, dated and signed within 
24 months of study initiation)
•
Current copy of Investigator and sub-investigator(s) medical license (indicating license 
number and expiration date)
•
Signed and dated agreement of the final protocol
•
Signed and dated agreement of any amendment(s), if applicable
•
Approval/favorable opinion from the IRB/IEC clearly identifying the documents 
reviewed by name, number and date of approval or reapproval:  protocol, any 
amendments, Subject Information/Informed Consent Form, and any other written 
information to be provided regarding subjects’ recruitment procedures
•
Copy of IRB/IEC approved Subject Information/Informed Consent Form/any other 
written information/advertisement (with IRB approval stamp and date of approval)
•
Current list of IRB/IEC Committee members/constitution (dated within 12 months prior 
to study initiation)
•
Financial Disclosure Form signed by Investigator and sub-investigator(s)
•
Current laboratory reference ranges (if applicable)

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•
Certification/Quality Assurance scheme/other documentation (if applicable)
Regulatory approval and notification as required must also be available; these are the 
responsibility of Shire.
11.8
Data Safety Monitoring Board
An independent DSMB will be established to provide an ongoing, independent review and 
assessment of safety data, to safeguard the interests and safety of the patients participating in the 
study, and to make recommendations with respect to dose escalation and the start of Cohort 4. 
The DSMB will consist of 3 clinical experts. 
The DSMB will adhere to a prospectively determined charter, which will be written by Shire and 
approved by the DSMB. The charter will define the responsibilities of the DSMB and Shire, 
describe the conduct and frequency of the meetings and define the data sets to be reviewed. 
Planned DSMB meetings will occur prior to each dose escalation (see Section 6.5). A DSMB 
meeting will be held after completion of Cohorts 1-3. In addition, an ad hoc DSMB meeting will 
be convened if the safety-related study stopping rules are met (see Section 7.22).
The DSMB will be notified of all IDDD failures and IDDD-related complications at times 
defined in the DSMB charter.
11.9
Device Failure Review Process
The final cause for SOPH-A-PORT Mini S device failures will be reviewed by Shire by 
examining the device failure information in the clinical database, safety database, and 
manufacturer investigation of returned SOPH-A-PORT Mini S devices.
11.10 Protocol Violations/Deviations
The Investigator will conduct the study in compliance with the protocol. The protocol will not be 
initiated until the IRB/IEC and the appropriate regulatory authorities have given 
approval/favorable opinion. Modifications to the protocol will not be made without agreement of 
the Sponsor. Changes to the protocol will require written IRB/IEC approval/favorable opinion 
prior to implementation, except when the modification is needed to eliminate an immediate 
hazard(s) to patients. The IRB/IEC may provide, if applicable regulatory authorities permit, 
expedited review and approval/favorable opinion for minor change(s) in ongoing studies that 
have the approval/favorable opinion of the IRB/IEC. The Sponsor will submit all protocol 
modifications to the regulatory authorities in accordance with the governing regulations.
A record of patients screened, but not entered into the study, is also to be maintained. No 
protocol exemptions are to be allowed. 
When immediate deviation from the protocol is required to eliminate an immediate hazard(s) to 
patients, the Investigator will contact the Sponsor or its designee, if circumstances permit, to 
discuss the planned course of action. Any departures from the protocol must be fully documented 

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as a protocol deviation. Protocol deviations will need to be reviewed by the Medical Monitor and 
may also be required to be submitted to the IRB/IEC.
Protocol modifications will only be initiated by the Sponsor and must be approved by the 
IRB/IEC and submitted to the FDA or other applicable international regulatory authority before 
initiation.
11.11 Premature Closure of the Study
If the Sponsor, Investigator, or regulatory authorities discover conditions arising during the study 
that indicate that the clinical investigation should be halted due to an unacceptable patient risk, 
the study may be terminated after appropriate consultation between the Sponsor and the 
Investigator(s).
In addition, a decision on the part of the Sponsor to suspend or discontinue development of the 
investigational drug product may be made at any time. It will be the responsibility of the 
Investigator(s) to promptly inform the study patients of any change in study status. Conditions 
that may warrant termination of the study or site include, but are not limited to the following:
•
The discovery of an unexpected, significant, or unacceptable risk to the patients enrolled 
in the study
•
Failure of the Investigator to comply with pertinent global regulations
•
Submission of knowingly false information from the study site to the Sponsor or other 
pertinent regulatory authorities
•
Insufficient adherence by the Investigator to protocol requirements
11.12 Access to Source Documentation
Regulatory authorities, the IRB/IEC, or the Sponsor may request access to all source documents, 
eCRFs, and other study documentation for on-site audit or inspection. Direct access to these 
documents must be guaranteed by the Investigator, who must provide support at all times for 
these activities. Monitoring and auditing procedures that comply with current GCP guidelines 
will be followed. On-site review of the eCRFs for completeness and clarity, cross-checking with 
source documents, and clarification of administrative matters will be performed.
11.13 Data Generation and Analysis
The clinical database will be developed and maintained by a CRO or an electronic data capture 
technology provider as designated by Shire. Shire or its designee will be responsible for 
performing study data management activities. 
Adverse events will be coded using MedDRA. Concomitant medication will be coded using 
WHO-DD. Centralized laboratories will be employed as described in the study manual to aid in 
consistent measurement of efficacy outcome and safety parameters.

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11.14 Retention of Data
Essential documents should be retained until at least 2 years after the last approval of a 
marketing application and until there are no pending or contemplated marketing applications or 
at least 2 years have elapsed since the formal discontinuation of clinical development of the 
investigational drug product. The Sponsor will notify the Investigator if these documents must be 
retained for a longer period of time. It is the responsibility of the Sponsor to inform the 
Investigator or institution as to when these documents no longer need to be retained.
11.15 Financial Disclosure
The Investigator should disclose any financial interests in the Sponsor as described in 
21 CFR Part 54 prior to beginning this study. The appropriate form will be provided to the 
Investigator by the Sponsor, which will be signed and dated by the Investigator, prior to the start 
of the study. 
11.16 Publication and Disclosure Policy
All information concerning the study material, such as patent applications, manufacturing 
processes, basic scientific data, and formulation information supplied by the Sponsor and not 
previously published are considered confidential and will remain the sole property of the 
Sponsor. The Investigator agrees to use this information only in accomplishing this study and 
will not use it for other purposes.
It is understood by the Investigator that the information developed in the clinical study may be 
disclosed as required to the authorized regulatory authorities and governmental agencies. In 
order to allow for the use of the information derived from the clinical studies, it is understood 
that there is an obligation to provide the Sponsor with complete test results and all data 
developed in the study in a timely manner.
The Investigator and any other clinical personnel associated with this study will not publish the 
results of the study, in whole or in part, at any time, unless they have consulted with Shire and 
have provided Shire a copy of the draft document intended for publication. Shire’s written 
consent for such publication is required to ensure that publication standards are met (eg, removal 
of any Shire confidential information (excluding study results), request for publication delay for 
to allow for patent filing). All information obtained during the conduct of this study will be 
regarded as confidential. Shire will use the information for registration purposes and for the 
general development of the drug.

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12
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Journal of inherited metabolic disease 2000;23:2-6.
13. von Figura K, Gieselmann V, Jaeken J. Metachromatic Leukodystrophy. In: Charles Scriver 
AB, William Sly, David Valle, Barton Childs, Kenneth Kinzler, Bert Vogelstein, ed. The 
Metabolic and Molecular Basis of Inherited Disease. 8 ed: McGraw-Hill Professional; 
2000:3695-723.
14. Sevin C, Aubourg P, Cartier N. Enzyme, cell and gene-based therapies for metachromatic 
leukodystrophy. Journal of inherited metabolic disease 2007;30:175-83.
15. Vellodi A. Lysosomal storage disorders. Br J Haematol 2005;128:413-31.

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16. Hemsley KM, Beard H, King BM, Hopwood JJ. Effect of high dose, repeated intra-CSF 
injection of sulphamidase on neuropathology in MPS IIIA mice. Genes, Brain, and Behavior 
2008:740-53.
17. Hemsley KM, Hopwood JJ. Delivery of recombinant proteins via the cerebrospinal fluid as a 
therapy option for neurodegenerative lysosomal storage diseases. Int J Clin Pharmacol Ther 
2009;47 Suppl 1:S118-23.
18. Urayama A, Grubb JH, Sly WS, Banks WA. Mannose 6-phosphate receptor-mediated 
transport of sulfamidase across the blood-brain barrier in the newborn mouse. Molecular 
therapy : the journal of the American Society of Gene Therapy 2008;16:1261-6.
19. Munoz M, Horovitz D, Vieira T, et. a. Intrathecal enzyme replacement therapy in a child 
with mucopolysaccharidosis VI and symptomatic spinal cord compression.  Ameri Soc of 
Hum Genet. San Diego, CA2007.
20. Muñoz-Rojas M, Dain D, Horovitz G, et al. Intrathecal administration of recombinant human 
N-acetylgalactosamine 4-sulfatase to a MPS VI patient with pachymeningitis cervicalis. 
Molecular Genetics and Metabolism 2010;99:346-50.
21. Dickson PI, Kaitila I, Harmatz P, et al. Safety of laronidase delivered into the spinal canal for 
treatment of cervical stenosis in mucopolysaccharidosis I. Mol Genet Metab 2015.
22. Chen A, Dickson P, Shapiro E, Lyons B, Kan S, Guillaume D. A study of intrathecal enzyme 
replacement for cognitivedecline in mucopolysaccharidosis. Mol Genet Metab 2010;99:S13-
S4.
23. MacFaul R, Cavanagh N, Lake BD, Stephens R, Whitfield AE. Metachromatic 
leucodystrophy: review of 38 cases. Archives of disease in childhood 1982;57:168-75.
24. Kehrer C, Blumenstock G, Gieselmann V, Krageloh-Mann I. The natural course of gross 
motor deterioration in metachromatic leukodystrophy. Dev Med Child Neurol 2011;53:850-
5.
25. Guideline on Strategies to Identify and Mitigate Risks for First-In-Human Clinical Trials 
with Investigational Medicinal Products. Ref.EMEA/CHMP/SWP/28367/07 European 
Medicines Agency (EMA), 2007. (Accessed October 18, 2011, at 
http://www.emea.europa.eu/pdfs/human/swp/2836707enfin.pdf )
26. Estimating the Maximum Safe Starting Dose in Clinical Trials for Therapeutics in Adult 
Healthy Volunteers. United States Food and Drug Administration, Center for Drug 
Evaluation and Research (CDER): July; 2005.
27. Austin J, McAfee D, Armstrong D, O'Rourke M, Shearer L, Bachhawat B. Abnormal 
sulphatase activities in two human diseases (metachromatic leucodystrophy and gargoylism). 
The Biochemical journal 1964;93:15C-7C.
28. Neufeld E, Muenzer J. The Mucopolysaccharidoses. In: Scriver CR, Beaudet AL, Sly WS, 
Valle D, eds. The Metabolic and Molecular Bases of Inherited Disease. 8th ed. New York: 
McGraw-Hill; 2001:3421-52.
29. Dekaban AS. Changes in brain weights during the span of human life: relation of brain 
weights to body heights and body weights. Annals of neurology 1978;4:345-56.

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30. Farrell DF. Heterozygote detection in MLD. allelic mutations at the ARA locus. Hum Genet 
1981;59:129-34.
31. Russell D, Rosenbaum P, Avery L, Lane M. The Gross Motor Function Measure (GMFM-66 
and GMFM-88) User's Manual. London, UK: MacKeith Press; 2002.
32. Lundkvist Josenby A, Jarnlo GB, Gummesson C, Nordmark E. Longitudinal construct 
validity of the GMFM-88 total score and goal total score and the GMFM-66 score in a 5-year 
follow-up study. Phys Ther 2009;89:342-50.
33. Russell DJ, Rosenbaum PL, Cadman DT, Gowland C, Hardy S, Jarvis S. The gross motor 
function measure: a means to evaluate the effects of physical therapy. Developmental 
medicine and child neurology 1989;31:341-52.
34. Russell D, Palisano R, Walter S, et al. Evaluating motor function in children with Down 
syndrome: validity of the GMFM. Dev Med Child Neurol 1998;40:693-701.
35. Tieman BL, Palisano RJ, Sutlive AC. Assessment of motor development and function in 
preschool children. Ment Retard Dev Disabil Res Rev 2005;11:189-96.
36. Sparrow S, Balla D, Cicchetti D. Vineland Adaptive Behavior Scales (Second Edition). 4201 
Woodland Road Circle Pines, MN 55014-1796: American Guidance Service, Inc; 2005.

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Appendix 3
Expected Adverse Device Effects
The information in this appendix was taken from the SOPH-A-PORT Mini S intrathecal drug 
delivery device Instructions for Use.
Procedure-Related Complications
•
Components handled improperly before, during, or after implantation 
•
Access port implanted incorrectly
•
Catheter positioned improperly
•
Injection through septum performed incorrectly
•
Injection of incorrect medication through access port
•
Injection outside the access port into pocket or subcutaneous tissue or extravasation
•
Pocket seroma, hematoma, erosion, or infection
Intrathecal Access Complications
•
Surgical complications such as hemorrhage or hematoma
•
Infection of the implant site or catheter track
•
Radiculitis or arachnoiditis
•
Intrathecal space infection resulting in meningitis or encephalitis
•
Bleeding 
•
Spinal cord damage or trauma to the spinal cord or nerve roots
•
Post-lumbar puncture, cerebrospinal fluid (CSF) leak, leading to headache, or 
subcutaneous CSF collection
•
Epidural instead of intrathecal placement of catheter
•
Inflammatory mass resulting in neurological impairment, including paralysis
•
Pain on injection
•
Complications of anesthesia
•
Pseudomeningocele
System-Related Complications
•
Improperly positioned access port
•
Erosion of the skin because of the underlying access port or the catheter
•
Wound dehiscence

HGT-1110(recombinant human arylsulfatase A, rhASA)
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•
Access port migration, fracture, breakage or occlusion
•
Catheter damage, dislodgement, migration, disconnection, kinking or occlusion, fibrosis, 
or hygroma, resulting in tissue damage or a loss of or change in therapy, or other 
potentially serious adverse health consequences
•
Catheter breakage and migration of residual catheter fragments, potentially resulting in 
serious adverse health consequences and the need for surgical removal 
•
Local immunological or fibrous reaction to the presence of a foreign body (the device)
•
End of device service life or component failure, requiring surgical replacement
•
Component failure, resulting in loss of therapy
•
Access port inversion (“flipping”), rotation, or extrusion
•
Access port or catheter rejection 
•
Fibrin sheath formation around catheter tip

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Appendix 5
Summary of Changes for Amendment 9
Justification for the Amendment and Summary of Changes
The HGT-MLD-070 protocol is primarily being amended to update the study design prior to 
enrollment start for Cohort 4, which will evaluate the HGT-1110 investigational drug product 
produced with the revised drug substance manufacturing process (referred to as Process B). A 
DSMB meeting will be held after completion of Cohorts 1-3.
Approximately 24 patients, including approximately 6 patients in Cohort 4, will be enrolled in 
the study. The revised study design for Cohort 4 will change the age inclusion criterion (from 
<12 years of age to <8 years of age); enroll patients with GMFM-88 total score (percent) ≥40 at 
screening with eligibility confirmed at baseline with a GMFM-88 score ≥35 and an additional 
inclusion criteria based on the walking dimension of the GMFM-88; permit patients to initiate 
treatment via lumbar puncture, if IDDD implantation is delayed; and allow use of local 
laboratories to confirm MLD diagnosis and eligibility with central laboratory confirmation.
Other changes in this amendment include, but are not limited to, the addition of information 
regarding the new Medical Monitor; an increase in blood volume collected at Screening for 
Cohort 4, updates to information regarding studies with IT treatment, including the list of Shire-
sponsored studies in other intrathecal programs, and clarification regarding statistical 
methodology language.
Changes in grammar, spelling, punctuation, format, minor editorial changes (including changes 
for consistency and clarity), and updates to the list of abbreviations and cross-references are not 
reflected in the list above or in the Detailed Summary of Changes, which follows.
Detailed Summary of Changes from Amendment 9
The changes from the previous protocol version are detailed below and include changes and 
additions to the protocol text. Bold text indicates new text. Strikethrough text indicates deleted 
text. Only those changes that are associated with each purpose are indicated with bold and 
strikethrough text.

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PPD
PPD

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
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Purpose: To update information regarding studies with IT treatment, including the list of 
Shire-sponsored studies in other intrathecal programs
•
a Phase I/II safety and dose escalation study of monthly 
idursulfase-IT intrathecal injection for cognitively impaired 
patients with Hunter syndrome (Study HGT-HIT-045; 
NCT00920647), and the open-label extension to this study 
(HGT-HIT-046; NCT01506141)
•
a Phase II/III controlled, randomized, two-arm open-label, 
assessor-blinded study of idursulfase-IT administered in 
conjunction with Elaprase® in pediatric patients with Hunter 
Syndrome and early cognitive impairment (Study 
HGT-HIT-094)
•
a Phase I/II ascending dose and dose frequency study of 
monthly IT injection of recombinant human heparan N-
sulfatase (rhHNS) in patients with Sanfilippo Syndrome Type A 
(Study HGT-SAN-055; NCT01155778), and the open-label 
extension to this study (HGT-SAN-067; NCT 01299727)
•
a Phase IIb, randomized, controlled, open-label, multicenter, 
safety and efficacy study of HGT-1410 (recombinant heparan 
N-sulfatase) administration via an intrathecal drug delivery 
device in pediatric patients with early stage 
mucopolysaccharidosis Type IIIA disease (Study 
HGT-SAN-093)
…
Now reads
…
Several patients with MPS I have been treated since 2005 with IT 
laronidase (recombinant α-L-iduronidase) in a clinical trial 
(ClinicalTrials.gov identifiers NCT00215527, NCT00786968) studying 
efficacy on spinal cord compression. This study has been 
terminated.21 A study further investigating the effectiveness of IT ERT 
as a treatment for another neurological symptom in MPS I, cognitive 
decline, is ongoing (ClinicalTrials.gov identifier NCT00852358).22
The following describes the 9 Shire Human Genetic Therapies, Inc. 
(Shire)–sponsored IT studies other than HGT-MLD-070:
•
a Phase I/II open-label extension of study HGT-MLD-070 
evaluating long term safety and efficacy of IT administration of 
HGT-1110 in patients with MLD (HGT-MLD-071)
•
a Phase I/II safety and dose escalation study of monthly 
idursulfase-IT intrathecal injection for cognitively impaired 
patients with Hunter syndrome (Study HGT-HIT-045; 

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
Shire
Confidential
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Purpose: To update information regarding studies with IT treatment, including the list of 
Shire-sponsored studies in other intrathecal programs
NCT00920647), and the open-label extension to this study 
(HGT-HIT-046; NCT01506141)
•
a Phase II/III controlled, randomized, two-arm open-label, 
assessor-blinded study of idursulfase-IT administered in 
conjunction with Elaprase® in pediatric patients with Hunter 
Syndrome and early cognitive impairment (Study 
HGT-HIT-094; NCT02055118) and the open-label extension 
to this study (Study SHP-609-302; NCT02412787)
•
a Phase I/II ascending dose and dose frequency study of 
monthly IT injection of recombinant human heparan N-
sulfatase (rhHNS) in patients with Sanfilippo Syndrome Type A 
(Study HGT-SAN-055; NCT01155778), and the open-label 
extension to this study (HGT-SAN-067; NCT 01299727)
•
a Phase IIb, randomized, controlled, open-label, multicenter, 
safety and efficacy study of HGT-1410 (recombinant heparan 
N-sulfatase) administration via an intrathecal drug delivery 
device in pediatric patients with early stage 
mucopolysaccharidosis Type IIIA disease (Study 
HGT-SAN-093; NCT02060526) and the open-label extension 
to this study (Study SHP-610-201; NCT02350816)
…
Other Sections Impacted By This Change:
N/A
Purpose: To update the study design to require GMFM-88 evaluation at screening and 
baseline and to allow for dosing with study medication as soon as possible by allowing 
use of LP and the use of local laboratory results to confirm MLD diagnosis prior to receipt 
of central laboratory results
Primary Section Impacted By This Change: Section 4.1, Overall Study Design and 
Plan
Formerly read
…
This study will have the following 5 phases:  
Phase 1:  Screening:  Day -40 through Day -11
Upon obtaining informed consent, the procedures and assessments 
required for the determination of the patient’s eligibility will be 
completed at the clinical site within 40 days of the baseline visit 
(Week 0). Sample collection for diagnostic testing should take place 
between Day -40 and Day -29 to ensure diagnostic results are 

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
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Purpose: To update the study design to require GMFM-88 evaluation at screening and 
baseline and to allow for dosing with study medication as soon as possible by allowing 
use of LP and the use of local laboratory results to confirm MLD diagnosis prior to receipt 
of central laboratory results
received prior to IDDD implantation in Phase 2 of the study.
Sites will be allowed one opportunity to re-screen any patient who 
fails initial screening or withdraws consent prior to device 
implantation. If the patient subsequently screen fails, the patient will 
no longer be considered for inclusion in the study.
Phase 2:  Surgical Implantation of the IDDD:  Day -10 to Day -1
Patients will undergo surgical implantation of an IDDD and a 
post-surgical assessment.
Phase 3:  Baseline and Treatment Week 0 to Week 38 (±3 days 
for injection of HGT-1110)  
Upon confirmation of study eligibility, baseline assessments (ie, 
those scheduled for Week 0) may be performed at any time prior to 
dosing, including the Phase 2 period of the study, but baseline 
assessments should be performed as close to dosing as possible. 
Patients will undergo pre-dose baseline assessments at Week 0, 
which will include a standard battery of clinical laboratory tests 
(serum chemistry, hematology, and urinalysis), serum assessments 
of anti-HGT-1110 antibodies and CSF assessments (cell counts, 
protein, glucose, albumin, anti-HGT-1110 antibodies, and 
HGT-1110 levels) as well as safety assessments (ie, vital signs, 
physical examination, routine CSF analysis, pregnancy testing [if 
applicable], AEs, and concomitant medication/therapies/procedures 
assessments).
Baseline efficacy outcome assessments including the GMFM-88, 
FEES, ENG studies, VABS-II, COMFORT questionnaire, and brain 
MRI and MRS will be performed as well as sample collection for 
CSF, serum, and urine biomarker assessments. 
Patients will receive their first dose (Week 0) and begin the 
HGT-1110 EOW dosing period (through Week 38). At Week 0, 
blood will also be drawn for a PK assessment at the time points 
specified in the Schedule of Events. 
During the EOW treatment period (Weeks 2 through 38), all 
assessments will be performed prior to IT injection of HGT-1110 
unless otherwise indicated. Safety assessments (ie, vital signs, 
physical examination, routine CSF analysis, pregnancy testing [if 
applicable], AEs, and concomitant medication/therapies/procedures 

HGT-1110(recombinant human arylsulfatase A, rhASA)
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Purpose: To update the study design to require GMFM-88 evaluation at screening and 
baseline and to allow for dosing with study medication as soon as possible by allowing 
use of LP and the use of local laboratory results to confirm MLD diagnosis prior to receipt 
of central laboratory results
assessments) will be performed. Patients will remain under 
observation in the hospital setting for at least 36 hours following 
dosing and will be discharged when deemed clinically stable by the 
Investigator. Additionally, anti-HGT-1110 antibody sampling, the 
standard battery of clinical laboratory tests (serum chemistry, 
hematology, and urinalysis) and sample collection for analysis of 
CSF concentration of HGT-1110, and CSF, serum, and urine 
biomarkers will be performed every 4 weeks. 
In addition to the scheduled assessments performed Weeks 2 
through 38, Weeks 16 and 28 will also include the efficacy outcome 
assessments of the GMFM-88, FEES, ENG studies, VABS-II, 
COMFORT questionnaire, and brain MRI and MRS. For Weeks 16 
and 28, the window for assessments will be -5 days. In addition, at 
Week 38 blood will be drawn for a PK assessment at the time points 
specified in the Schedule of Events.
It is anticipated that the IDDD will be used to obtain CSF samples 
and to deliver all 20 IT injections of HGT-1110. If the IT space is 
not accessible via the IDDD, investigational drug product may be 
administered by LP. Should the IDDD become clogged, undergo 
mechanical complications or otherwise not be accessible, the CSF 
sample may also be obtained by LP. Anesthesia may be required for 
injections of investigational drug product and some evaluations, and 
can be used at the discretion of the Investigator. The IDDD Manual 
provides details on the investigation and management of any IDDD-
related issues. 
…
Now reads
…
This study will have the following 5 phases:  
Cohorts 1-3: Phases 1-3
Phase 1:  Screening:  Day -40 through Day -11
Upon obtaining informed consent, the procedures and assessments 
required for the determination of the patient’s eligibility will be 
completed at the clinical site within 40 days of the baseline visit 
(Week 0). Sample collection for diagnostic testing should take place 
between Day -40 and Day -29 to ensure diagnostic results are 

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
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114
Purpose: To update the study design to require GMFM-88 evaluation at screening and 
baseline and to allow for dosing with study medication as soon as possible by allowing 
use of LP and the use of local laboratory results to confirm MLD diagnosis prior to receipt 
of central laboratory results
received prior to IDDD implantation in Phase 2 of the study.
Sites will be allowed one opportunity to re-screen any patient who 
fails initial screening or withdraws consent prior to device 
implantation. If the patient subsequently screen fails, the patient will 
no longer be considered for inclusion in the study.
Phase 2:  Surgical Implantation of the IDDD:  Day -10 to Day -1
Patients will undergo surgical implantation of an IDDD and a 
post-surgical assessment.
Phase 3:  Baseline and Treatment Week 0 to Week 38 (±3 days 
for injection of HGT-1110)  
Upon confirmation of study eligibility, baseline assessments (ie, 
those scheduled for Week 0) may be performed at any time prior to 
dosing, including the Phase 2 period of the study, but baseline 
assessments should be performed as close to dosing as possible. 
Patients will undergo pre-dose baseline assessments at Week 0, 
which will include a standard battery of clinical laboratory tests 
(serum chemistry, hematology, and urinalysis), serum assessments 
of anti-HGT-1110 antibodies and CSF assessments (cell counts, 
protein, glucose, albumin, anti-HGT-1110 antibodies, and 
HGT-1110 levels) as well as safety assessments (ie, vital signs, 
physical examination, routine CSF analysis, pregnancy testing [if 
applicable], AEs, and concomitant medication/therapies/procedures 
assessments).
Baseline efficacy outcome assessments including the GMFM-88, 
FEES, ENG studies, VABS-II, COMFORT questionnaire, and brain 
MRI and MRS will be performed as well as sample collection for 
CSF, serum, and urine biomarker assessments. 
Patients will receive their first dose (Week 0) and begin the 
HGT-1110 EOW dosing period (through Week 38). At Week 0, 
blood will also be drawn for a PK assessment at the time points 
specified in the Schedule of Events. 
During the EOW treatment period (Weeks 2 through 38), all 
assessments will be performed prior to IT injection of HGT-1110 
unless otherwise indicated. Safety assessments (ie, vital signs, 
physical examination, routine CSF analysis, pregnancy testing [if 
applicable], AEs, and concomitant medication/therapies/procedures 

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
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115
Purpose: To update the study design to require GMFM-88 evaluation at screening and 
baseline and to allow for dosing with study medication as soon as possible by allowing 
use of LP and the use of local laboratory results to confirm MLD diagnosis prior to receipt 
of central laboratory results
assessments) will be performed. Patients will remain under 
observation in the hospital setting for at least 36 hours following 
dosing and will be discharged when deemed clinically stable by the 
Investigator. Additionally, anti-HGT-1110 antibody sampling, the 
standard battery of clinical laboratory tests (serum chemistry, 
hematology, and urinalysis) and sample collection for analysis of 
CSF concentration of HGT-1110, and CSF, serum, and urine 
biomarkers will be performed every 4 weeks. 
In addition to the scheduled assessments performed Weeks 2 
through 38, Weeks 16 and 28 will also include the efficacy outcome 
assessments of the GMFM-88, FEES, ENG studies, VABS-II, 
COMFORT questionnaire, and brain MRI and MRS. For Weeks 16 
and 28, the window for assessments will be -5 days. In addition, at 
Week 38 blood will be drawn for a PK assessment at the time points 
specified in the Schedule of Events.
It is anticipated that the IDDD will be used to obtain CSF samples 
and to deliver all 20 IT injections of HGT-1110. If the IT space is 
not accessible via the IDDD, investigational drug product may be 
administered by LP. Should the IDDD become clogged, undergo 
mechanical complications or otherwise not be accessible, the CSF 
sample may also be obtained by LP. Anesthesia may be required for 
injections of investigational drug product and some evaluations, and 
can be used at the discretion of the Investigator. The IDDD Manual 
provides details on the investigation and management of any IDDD-
related issues. 
Cohort 4: Phases 1-3
Note:  Enrollment may occur prior to IDDD implantation or the 
first dose (baseline); however, implantation of the device should 
occur within 28 days of the first dose.
Phase 1:  Screening:  Day-40 through Day -1
Upon obtaining informed consent, the procedures and 
assessments required for the determination of the patient’s 
eligibility, including GMFM-88, will be completed at the clinical 
site within 40 days prior to the baseline visit (Week 0). Sample 
collection for central diagnostic testing should take place at the 
screening visit to ensure diagnostic results are received 
promptly. Local laboratory results confirming the MLD 

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
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Confidential
116
Purpose: To update the study design to require GMFM-88 evaluation at screening and 
baseline and to allow for dosing with study medication as soon as possible by allowing 
use of LP and the use of local laboratory results to confirm MLD diagnosis prior to receipt 
of central laboratory results
diagnosis (analysis of urine sulfatide, ASA activity in leukocytes) 
will be accepted to confirm the MLD diagnosis enrollment 
criteria while waiting for the central laboratory results so that 
dosing of the study medication can occur as soon as possible.
Sites will be allowed one opportunity to re-screen any patient 
who fails initial screening or withdraws consent prior to device 
implantation or dose administration (if administration to be 
initiated by LP prior to device implantation). If the patient 
subsequently screen fails, the patient will no longer be 
considered for inclusion in the study.
Phase 2:  Surgical Implantation of the IDDD:  Day -10 to 
Day +28
To confirm the patient meets eligibility criteria at baseline, 
specifically the baseline GMFM-88 assessment will be 
performed as close as possible to, but before device implantation 
or prior to first dose administration, whichever occurs first. 
Patients who do not continue to meet eligibility criteria will be 
discontinued from the study prior to device implantation and/or 
initial dosing. If device implantation and/or initial dosing occur 
within 7 days of the screening GMFM-88 assessment, the 
baseline GMFM-88 assessment will not be required. However, if 
more than 7 days has passed since the screening GMFM-88 
assessment, the baseline GMFM-88 assessment will need to be 
completed prior to IDDD implantation or first dose, and prior to 
any other baseline assessments in order to confirm eligibility for 
enrollment (per inclusion criterion 3.1 in Section 5.2).
Upon confirmation of eligibility, patients will undergo surgical 
implantation of an IDDD and a post-surgical assessment. The 
patient may receive study drug by LP until the device is 
implanted. Device implantation should be scheduled within 
28 days of enrollment unless a delay is required due to clinical 
judgment for medical reasons (eg, infection).
Phase 3:  Baseline and Treatment Week 0 to Week 38 (±3 days 
for injection of HGT-1110)  
Upon confirmation of study eligibility,  baseline assessments (ie, 
those scheduled for Week 0) may be performed at any time 
prior to dosing, including the Phase 2 period of the study, but 
baseline assessments should be performed as close to dosing as 

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Purpose: To update the study design to require GMFM-88 evaluation at screening and 
baseline and to allow for dosing with study medication as soon as possible by allowing 
use of LP and the use of local laboratory results to confirm MLD diagnosis prior to receipt 
of central laboratory results
possible. Patients will undergo pre-dose baseline assessments at 
Week 0, which will include a standard battery of clinical 
laboratory tests (serum chemistry, hematology, and urinalysis), 
serum assessments of anti-HGT-1110 antibodies and CSF 
assessments (cell counts, protein, glucose, albumin, 
anti-HGT-1110 antibodies, and HGT-1110 levels) as well as 
safety assessments (ie, vital signs, physical examination, routine 
CSF analysis, pregnancy testing [if applicable], AEs, and
concomitant medication/therapies/procedures assessments).
Baseline efficacy outcome assessments including the GMFM-88,
FEES, ENG studies, VABS-II, COMFORT questionnaire, and 
brain MRI and MRS will be performed as well as sample 
collection for CSF, serum, and urine biomarker assessments. If 
device implantation and/or initial dosing occur within 7 days of 
the screening GMFM-88 assessment, the baseline GMFM-88 
assessment will not be required.
Patients will receive their first dose (Week 0) and begin the 
HGT-1110 EOW dosing period (through Week 38). At Week 0, 
blood will also be drawn for a PK assessment at the time points 
specified in the Schedule of Events. 
During the EOW treatment period (Weeks 2 through 38), all 
assessments will be performed prior to IT injection of 
HGT-1110 unless otherwise indicated. Safety assessments (ie, 
vital signs, physical examination, routine CSF analysis, 
pregnancy testing [if applicable], AEs, and concomitant 
medication/therapies/procedures assessments) will be 
performed. Patients will remain under observation in the 
hospital setting for at least 36 hours following dosing and will be 
discharged when deemed clinically stable by the Investigator. 
Additionally, anti-HGT-1110 antibody sampling, the standard 
battery of clinical laboratory tests (serum chemistry, 
hematology, and urinalysis) and sample collection for analysis of 
CSF concentration of HGT-1110, and CSF, serum, and urine 
biomarkers will be performed every 4 weeks. 
In addition to the scheduled assessments performed Weeks 2 
through 38, Weeks 16 and 28 will also include the efficacy 
outcome assessments of the GMFM-88, FEES, ENG studies, 
VABS-II, COMFORT questionnaire, and brain MRI and MRS. 
For Weeks 16 and 28, the window for assessments will be -5 

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Purpose: To update the study design to require GMFM-88 evaluation at screening and 
baseline and to allow for dosing with study medication as soon as possible by allowing 
use of LP and the use of local laboratory results to confirm MLD diagnosis prior to receipt 
of central laboratory results
days. In addition, at Week 38 blood will be drawn for a PK 
assessment at the time points specified in the Schedule of Events.
It is anticipated that the IDDD will be used to obtain CSF 
samples and to deliver all 20 IT injections of HGT-1110. If 
eligibility has been confirmed, and IDDD implantation cannot 
be scheduled to occur within the Phase 2 window, or it is desired 
to shorten the screening period to promptly initiate first dose 
administration, investigational drug product may be 
administered by means of an LP. 
If the IT space is not accessible via the IDDD, investigational 
drug product may be administered by LP. Should the IDDD 
become clogged, undergo mechanical complications or otherwise 
not be accessible, the CSF sample may also be obtained by LP 
until the device is repaired or replaced. Anesthesia may be 
required for injections of investigational drug product and some 
evaluations, and can be used at the discretion of the 
Investigator. The IDDD Manual provides details on the 
investigation and management of any IDDD-related issues.
All Cohorts (1-4): Phases 4 and 5
…

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Purpose: To update the study design to require GMFM-88 evaluation at screening and 
baseline and to allow for dosing with study medication as soon as possible by allowing 
use of LP and the use of local laboratory results to confirm MLD diagnosis prior to receipt 
of central laboratory results
Other Sections Impacted By This Change:
•
Synopsis
•
Section 6.2, Treatment Administered
•
Section 7.9.4, Intrathecal Drug Delivery Device Removal
•
Section 7.10, Investigational Drug Product Administration
•
Section 7.11, Pharmacokinetic Assessments
•
Section 7.13.2, Vital Signs
•
Section 8, Study Activities
•
Section 8.1, Phase 1:  Screening (Days -40 to -11 for Cohorts 1-3; Days -40 to 
Day -1 for Cohort 4)
•
Section 8.2, Phase 2:  IDDD Implantation (Day -10 to Day -1 for Cohorts 1-3; 
Days -10 to Day +28 for Cohort 4)
•
Section 8.3.1, Baseline:  Week 0 (±3 days for IT injection of HGT-1110)
•
Appendix 1, Study Schedule of Events:  Cohorts 1, 2, and 3
•
Appendix 2, Study Schedule of Events:  Cohort 4
Purpose: To clarify that approximately 24 patients are planned for this study, based on 
the number of patients enrolled in Study HGT-MLD-070
Primary Section Impacted By This Change: Section 5.1, Study Population
Formerly read
Up to 24 patients are planned who are less than 12 years of age with a 
confirmed diagnosis of MLD, 6 per cohort. Patients must be ambulatory 
at the time of screening and untreated with investigational drug products 
for MLD.
Now reads
Approximately 24 patients are planned who are less than 12 years of 
age with a confirmed diagnosis of MLD, approximately 6 per cohort. 
Patients must be ambulatory at the time of screening and untreated with 
investigational drug products for MLD.
Other Sections Impacted By This Change:
•
Synopsis
•
Section 10.2, Determination of Sample Size

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Purpose:  To revise the inclusion criteria to require that patients are less than 8 years of 
age and to revise the GMFM-88 requirements at screening and baseline
Primary Section Impacted By This Change:  Section 5.2, Inclusion Criteria
Formerly read
Patients must meet all of the following criteria to be considered eligible 
for enrollment:
1. Confirmed diagnosis of metachromatic leukodystrophy by both:  
•
Arylsulfatase A (ASA) deficiency by assay in leukocytes 
AND
•
Elevated sulfatide in urine
2. Appearance of the first symptoms of disease at or before 30 months 
of age.
3. Ambulatory at the time of screening. The minimum level of function 
required to meet this criterion is defined as the ability to walk 
forward 10 steps with one hand held.
4. The patient is less than 12 years of age at the time of screening.
5. Neurological signs of MLD must be present at the screening
…
Now reads
Patients must meet all of the following criteria to be considered eligible 
for enrollment:
For Cohorts 1-4:
1. Confirmed diagnosis of metachromatic leukodystrophy by both:  
•
Arylsulfatase A (ASA) deficiency by assay in leukocytes 
AND
•
Elevated sulfatide in urine
2. Appearance of the first symptoms of disease at or before 30 months 
of age.
For Cohorts 1-3 only: 
3. Ambulatory at the time of screening. The minimum level of function 
required to meet this criterion is defined as the ability to walk 
forward 10 steps with one hand held.
4. The patient is less than 12 years of age at the time of screening.
For Cohort 4 only:
3.1 Minimum motor function requirements:
a.
A total GMFM-88 (percent) score ≥40 at the screening 
examination and a total GMFM-88 (percent) score ≥35 at the 
baseline examination, 

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Purpose:  To revise the inclusion criteria to require that patients are less than 8 years of 
age and to revise the GMFM-88 requirements at screening and baseline
AND
b. GMFM-88 Dimension E: Walking, Running & Jumping, 
item 68 ("walk forward 10 steps with one hand held") score 
of at least 1 "initiates" at the screening and baseline 
examinations (if applicable). 
4.1. The patient is less than 8 years of age at the time of screening.
For Cohorts 1-4:
5. Neurological signs of MLD must be present at the screening
…
Other Sections Impacted By This Change:
•
Synopsis
•
Section 4.1, Overall Study Design and Plan 
•
Section 7.4, Study Enrollment
Purpose:  To indicate that no restrictions are made regarding the patient’s symptomatic 
MLD treatment
Primary Section Impacted By This Change:  Section 6.6, Concomitant Medications, 
Therapies, and Medical/Surgical Interventions
Removed text:
…
Every effort should be made to keep the patient’s symptomatic 
MLD treatment constant throughout the study. However, Changes in 
medications are acceptable if necessary according to clinical 
judgment. All changes will be recorded on the appropriate eCRF. 
Concomitant medications will be coded using World Health 
Organization – Drug Dictionary (WHO-DD).
Other Sections Impacted By This Change:
•
NA

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Purpose: To allow for dosing with study drug based on central laboratory results and 
provide clarification regarding what action should be taken if the central and local 
laboratory results are not aligned.
Primary Section Impacted By This Change: Section 7.3, Confirmation of Study 
Eligibility and MLD Diagnosis and Genotype
Formerly read
Patient eligibility according to the study inclusion and exclusion criteria 
will be assessed during the Screening period. Sites will be allowed one 
opportunity to re-screen any patient who fails initial screening or 
withdraws consent prior to device implantation. If the patient 
subsequently screen fails, the patient will no longer be considered for 
inclusion in the study.
Assays for leukocyte arylsulfatase A enzyme activity, urine sulfatide, 
and genotype determination will be performed by specialty 
laboratory(ies) designated by Shire to confirm the diagnosis of MLD.5,30
Biochemical confirmation of MLD diagnosis is required for study 
eligibility, but genotype results are not.
Local leukocyte arylsulfatase A enzyme activity and urine sulfatide 
information will be allowed to confirm the diagnosis of MLD, if 
available and deemed sufficient by the Principal Investigator and 
Medical Monitor. Sample collection for diagnostic testing will still be 
performed if local results are used to confirm the diagnosis of MLD.
Now reads
Cohorts 1-3:  
Patient eligibility according to the study inclusion and exclusion criteria 
will be assessed during the Screening period. Sites will be allowed one 
opportunity to re-screen any patient who fails initial screening or 
withdraws consent prior to device implantation). If the patient 
subsequently screen fails, the patient will no longer be considered for 
inclusion in the study.
Assays for leukocyte arylsulfatase A enzyme activity, urine sulfatide, 
and genotype determination will be performed by specialty 
laboratory(ies) designated by Shire to confirm the diagnosis of MLD.5,30
Biochemical confirmation of MLD diagnosis is required for study 
eligibility, but genotype results are not.
Local leukocyte arylsulfatase A enzyme activity and urine sulfatide will 
be allowed to confirm the diagnosis of MLD, if available and deemed 
sufficient by the Principal Investigator and Medical Monitor. Sample 
collection for diagnostic testing will still be performed if local results 
are used to confirm the diagnosis of MLD.
Cohort 4:

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Patient eligibility according to the study inclusion and exclusion 
criteria will be assessed during the Screening period. Sites will be 
allowed one opportunity to re-screen any patient who fails initial 
screening or withdraws consent prior to device implantation or dose 
administration (if administration to be initiated by LP prior to 
device implantation. If the patient subsequently screen fails, the 
patient will no longer be considered for inclusion in the study.
Assays for leukocyte arylsulfatase A enzyme activity, urine 
sulfatide, and genotype determination will be performed by 
specialty laboratory(ies) designated by Shire to confirm the 
diagnosis of MLD.5,30 Biochemical confirmation of MLD diagnosis 
is required for study eligibility, but genotype results are not.
Local laboratory results for leukocyte arylsulfatase A enzyme 
activity and urine sulfatide will be allowed to confirm the diagnosis 
of MLD, if available and deemed sufficient by the Principal 
Investigator and Medical Monitor, while waiting for the central 
laboratory results so that dosing of the study medication could 
occur as soon as possible. Sample collection for diagnostic testing 
will still be performed at Screening if local results are used to 
confirm the diagnosis of MLD. If local laboratory results are not in 
agreement with central laboratory results and the patient has 
already been dosed with study medication and/or has received 
device implantation, then the central laboratory tests will be
repeated. If repeat central laboratory results confirm a positive 
local laboratory result then the patient will continue in the study. 
However, if the repeat central laboratory results are in discordance 
with the local laboratory results then the Investigator must contact 
the Shire Medical Monitor to evaluate what action should be taken 
regarding this patient. Dosing will be stopped if the Investigator 
and Medical Monitor determine that the patient does not have a 
diagnosis of MLD; however, such a patient would still be followed 
for safety.
To confirm the patient meets eligibility criteria at baseline, the 
baseline GMFM-88 assessment will be performed as close as 
possible to, but before device implantation or prior to first dose 
administration, whichever occurs first. Patients who do not 
continue to meet eligibility criteria will be discontinued from the 
study prior to device implantation and/or initial dosing. If device 
implantation and/or initial dosing occur within 7 days of the 
screening GMFM-88 assessment, the baseline GMFM-88 
assessment will not be required.

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Other Sections Impacted By This Change:
•
Synopsis
•
Appendix 2, Study Schedule of Events:  Cohort 4
Purpose:  To specify that device explantation occur at the main site unless urgent device 
removal requires otherwise
Primary Section Impacted By This Change:  Section 7.9.1, Intrathecal Drug Delivery 
Device Implantation, Replacement, or Revision
Added text:
The IDDD will be surgically implanted at the clinical site. Procedures 
for implantation will be detailed in the device’s IFU Manual. Standard 
hospital procedures for surgery will be followed; the patient may be 
under general anesthesia for this procedure. It is planned that device 
explantation will occur at the main site unless urgent device 
removal is medically required to be performed locally or patient 
travel to the main site is medically inadvisable.
…
Other Sections Impacted By This Change:
•
NA
Purpose:  To clarify the intrathecal drug delivery device removal process
Primary Section Impacted By This Change:  Section7.9.4, Intrathecal Drug Delivery 
Device Removal
Formerly read:
If at the time of a scheduled dosing it is not possible to administer a full 
medication dosage as per the standard administration steps detailed in 
the device’s IFU due to a device related issue, the IDDD will be 
declared a device malfunction. If the device malfunction is irreversible 
and cannot be corrected without a device surgical intervention, the 
IDDD will be declared a device failure, starting from the date of the 
initial malfunction.
…
Now reads
If at the time of a scheduled dosing, due to a device-related issue it is 
not possible to aspirate CSF prior to dose administration, administer 
a full medication dosage using the standard administration steps 
detailed in the device’s IFU, or flush the system following dose 
administration, the IDDD will be declared a device malfunction. If the 
device malfunction is irreversible and cannot be corrected without a 
partial or full device revision or removal, the IDDD will be declared a 

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Purpose:  To clarify the intrathecal drug delivery device removal process
device failure, starting from the date of the initial malfunction.
…
Other Sections Impacted By This Change:
•
NA
Purpose:  Blood collection volume at Screening was increased for patients in Cohort 4 
due to a change in the ASA sample collection and handling process
Primary Section Impacted By This Change:  Section 7.13.4, Clinical Laboratory Tests
Formerly read:
…
The Screening and Baseline visit will require approximately 24 and 20 
mL of blood for all patients, respectively. The remaining visits will 
require approximately 11 mL of blood for the required assessments 
(Weeks 4, 8, 12, 16, 20, 24, 28, 32, 36, 38, and 40). Approximately 7 
mL of CSF will be drawn to approximate the volume of investigational 
drug product and flush to be injected. The CSF will be used for required 
and optional assessments at each treatment visit and the EOS visit.
Now reads
…
The Screening and Baseline visit will require approximately 24 and 20 
mL of blood for all patients in Cohorts 1-3, respectively, and 28 and 
20 mL of blood, respectively, for patients in Cohort 4. The remaining 
visits will require approximately 11 mL of blood for the required 
assessments (Weeks 4, 8, 12, 16, 20, 24, 28, 32, 36, 38, and 40). 
Approximately 7 mL of CSF will be drawn to approximate the volume 
of investigational drug product and flush to be injected. The CSF will be 
used for required and optional assessments at each treatment visit and 
the EOS visit.
Other Sections Impacted By This Change:
•
NA

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Purpose:  To define device adjustment
Primary Section Impacted By This Change:  Section 7.18.2.4, Device Adjustment
Added section:
Surgery of the device which does not result in partial or complete 
device revision or removal (eg, surgical exploration only or 
placement of additional sutures, tissue glue, and/or fascial repair).
Other Sections Impacted By This Change:
•
NA
Purpose: Clarification of device-related adverse events
Primary Section Impacted By This Change:  Section 7.18.5.1, Adverse Events with 
Respect to Investigational Drug Product, Investigational Drug Product Administration, 
Device, and Associated Procedures
Formerly read:
DEVICE SURGICAL PROCEDURE–RELATED ADVERSE EVENTS
Examples of AEs related to device surgical procedures include, but are 
not limited to, the following:  events that occur during or shortly 
following IDDD implant/explant, IDDD adjustment, full revision, 
partial revision, IDDD removal, and delayed re-implantation after 
previous IDDD removal (such as complications of anesthesia, excessive 
bleeding, wound hematoma), and post-operative complications (such as 
post-operative infection). These events are related to the surgical 
procedure itself.
INTRATHECAL DRUG DELIVERY DEVICE–RELATED ADVERSE EVENTS
Examples of AEs related to use of the IDDD include, but are not limited 
to, the following:  device failure, device malfunction, incorrect 
connection of IDDD components, erosion of the portal/catheter through 
the skin, fibrin sheath formation around the catheter tip, hematoma, 
implant rejection, migration of the portal/catheter, and occlusion of the 
portal/catheter, portal site or subcutaneous tract infection. 
A malfunction of the device (defined in Section 7.18.2.2) should not be 
entered as an AE unless it has physiological consequences. In the event 
of a device failure (defined in Section 7.18.2.3), the device may need to 
be replaced or repaired. If overnight hospitalization is required for such 
a procedure (or the device failure meets any other serious criteria, eg, 
medically important), the device failure will be reported as an SAE. 
Details of the cause of the IDDD malfunction or failure will be recorded 
on the device malfunction and failure eCRF, and the SAE form (where 
applicable).
A list of the most common IDDD AEs is included in Appendix 2.

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Purpose: Clarification of device-related adverse events
…
Now reads
DEVICE SURGICAL PROCEDURE–RELATED ADVERSE EVENTS
Examples of AEs related to device surgical procedures include, but are 
not limited to, the physiologic consequences of the following:  events 
that occur during or shortly following IDDD implant/explant, IDDD 
adjustment, full revision, partial revision, IDDD removal, and delayed 
re-implantation after previous IDDD removal (such as complications of 
anesthesia, excessive bleeding, wound hematoma), and post-operative 
complications (such as post-operative infection). These events are 
related to the surgical procedure itself.
INTRATHECAL DRUG DELIVERY DEVICE–RELATED ADVERSE EVENTS
Examples of AEs related to use of the IDDD include, but are not limited 
to, the physiologic consequences (noxious, pathologic, or unintended 
change in anatomical, physiologic, or metabolic function as 
indicated by physical signs, symptoms, or laboratory changes) of the 
following:  device failure, device malfunction, incorrect connection of 
IDDD components, erosion of the portal/catheter through the skin, 
fibrin sheath formation around the catheter tip, hematoma, implant 
rejection, migration of the portal/catheter, and occlusion of the 
portal/catheter, portal site or subcutaneous tract infection. 
A malfunction of the device (defined in Section 7.18.2.2) should not be 
entered as an AE unless it has physiological consequences. In the event 
of a device failure (defined in Section 7.18.2.3), the device will need to 
be replaced or repaired by removal and replacement of a component 
or removed in its entirety. “Device failure” will be reported as the 
SAE term. Details of the cause of the IDDD malfunction or failure will 
be recorded on the device malfunction and failure eCRF, and the SAE 
form (where applicable).
A list of the most common IDDD AEs is included in the list of 
complications in Appendix 3
…
Other Sections Impacted By This Change:
•
NA

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Purpose: To clarify the statistical methodology language
Primary Section Impacted By This Change: Section 10.1, General Methodology
Formerly read
All statistical analyses will be performed by the Shire Biometrics 
department (with the exception of the PK analysis, which will be 
performed by the Shire Clinical Pharmacology and Pharmacokinetics 
department). Statistical analyses will be performed using SAS® software
Version 9.3 or higher. Data will be summarized by cohort and overall, if 
appropriate. Summary statistics for continuous variables will include the 
number of patients, mean, standard deviation (SD), median, minimum, 
and maximum. Categorical variables will be summarized in a 
contingency table by the number and percentage of patients in each 
category (including a missing category, if applicable). Any statistical 
tests comparing cohorts will be 2-sided with a significance level of 0.05 
and considered hypothesis generating. The mean change, mean
difference in the change between cohorts, and the corresponding 95% 
confidence intervals, may also be presented as appropriate.
Safety summaries will be based on all post-baseline assessments 
including the frequency of TEAEs and the frequency of clinically 
notable abnormal vital signs and laboratory values. Any analyses of 
safety and PK summarizing Cohort 3 and Cohort 4 (Process A and 
Process B) will be descriptive.
Now reads
All statistical analyses will be performed by the Shire Biometrics 
department (with the exception of the PK analysis, which will be 
performed by the Shire Clinical Pharmacology and Pharmacokinetics 
department). Statistical analyses will be performed using SAS® software
Version 9.3 or higher. Data will be summarized by cohort and overall, if 
appropriate. Summary statistics for continuous variables will include the 
number of patients, mean, standard deviation (SD), median, minimum, 
and maximum. Categorical variables will be summarized in a 
contingency table by the number and percentage of patients in each 
category (including a missing category, if applicable). Any statistical 
tests comparing cohorts will be 2-sided with a significance level of 0.05 
and considered exploratory or hypothesis generating. The mean 
change, mean difference in the change between cohorts, and the 
corresponding 95% confidence intervals, may also be presented as 
appropriate.
Safety summaries will be based on all post-baseline assessments 
including the frequency of TEAEs and the frequency of clinically 
notable abnormal vital signs and laboratory values. Any analyses of 
safety and PK summarizing Cohort 3 and Cohort 4 (Process A and 
Process B) will be descriptive.

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Other Sections Impacted By This Change:
•
Synopsis
•
Section 10.13, Secondary Analyses
Purpose:  To remove detailed statistical methodology language, which will be added to 
the Statistical Analysis Plan
Primary Section Impacted By This Change:  Section 10.14, Exploratory Analyses
Formerly read
The exploratory endpoints listed in Section 10.9 will be summarized 
descriptively at each study visit. For each endpoint of the change, the 
analysis will be performed using the same methodology used in the 
secondary analysis. 
…
Now reads
The exploratory endpoints listed in Section 10.9 will be summarized 
descriptively at each study visit. 
…
Other Sections Impacted By This Change:
•
NA
Purpose:  To clarify the statistical methodology language
Primary Section Impacted By This Change:  Section 10.15, Intrathecal Drug Delivery 
Device Analyses
Formerly read
…
The proportion of patients for whom a successful first injection of 
investigational drug product occurred will be reported among those for 
whom a first injection was attempted (ie, those who had an apparently 
successful implantation and did not suffer a device removal or revision 
prior to first scheduled injection). The proportion of patients who had no 
failed injection attempts during the study will also be summarized. The 
corresponding 95% CIs of the proportion of interest will be estimated, 
where appropriate. Injections that are not administered for patient
related reasons (eg, patient uncooperative or competing medical issue) 
will not be included in the determination of the success of injection rate.  
…
Now reads
…
The rate of successful IDDD injections will be calculated for each 
patient and summarized descriptively. The success rate will be 
calculated as the number of IDDD injections given as a percentage 
of IDDD injections given plus any malfunctions reported for 

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inability to dose. The corresponding 95% confidence interval for 
the mean rate will be estimated, where appropriate. Injections that 
are not administered for patient-related reasons (e.g. patient 
uncooperative, competing medical issue, etc) will not be included in 
the determination of the injection success rate.
…
Other Sections Impacted By This Change:
•
NA
Purpose:  To clarify the statistical methodology language
Primary Section Impacted By This Change:  Section 10.16, Interim Analysis
Formerly read
An interim analysis of all data will be performed after all enrolled 
patients in Cohorts 1-3 have completed the study. All data from Cohorts 
1-3 will be entered into the database, reviewed, and discrepancies 
resolved for this analysis. Because any hypothesis testing is considered 
exploratory, no adjustment for multiplicity will be made. The analysis 
methods will be detailed in an interim statistical analysis plan, and a full
interim study report based on these data will be completed. Other 
descriptive analyses of the data before trial completion may be 
performed for additional safety monitoring, regulatory reporting, or 
general planning (Section 11.8).
Now reads
An interim analysis of all data will be performed after all enrolled 
patients in Cohorts 1-3 have completed the study. All data from Cohorts 
1-3 will be entered into the database, reviewed, and discrepancies 
resolved for this analysis. Because any hypothesis testing is considered 
exploratory, no adjustment for multiplicity will be made. The analysis 
methods will be detailed in an interim statistical analysis plan, and an
interim study report based on these data will be completed. Other 
descriptive analyses of the data before trial completion may be 
performed for additional safety monitoring, regulatory reporting, or 
general planning (Section 11.8).
Other Sections Impacted By This Change:
•
Synopsis

HGT-1110(recombinant human arylsulfatase A, rhASA)
Clinical Trial Protocol: HGT-MLD-070 Amendment 9
26 August 2015
Shire
Confidential
131
Purpose:  To clarify that a DSMB meeting will be held after completion of Cohorts 1-3
Primary Section Impacted By This Change:  Section 11.8, Data Safety Monitoring 
Board
Formerly read
…
Planned DSMB meetings will occur prior to each dose escalation (see 
Section 6.5) and prior to the start of Cohort 4. In addition, an ad hoc 
DSMB meeting will be convened if the safety-related study stopping 
rules are met (see Section 7.22).
…
Now reads
…
Planned DSMB meetings will occur prior to each dose escalation (see 
Section 6.5). A DSMB meeting will be held after completion of 
Cohorts 1-3. In addition, an ad hoc DSMB meeting will be convened if 
the safety-related study stopping rules are met (see Section 7.22).
…
Other Sections Impacted By This Change:
•
Synopsis
•
Section 4.1, Overall Study Design and Plan
•
Section 6.3.1, Dose Selection
•
Section 6.5, Staggered Enrollment/Dose Escalation