A Multi Center Placebo Controlled Double Blind Randomized Study Evaluating the Role of Oral Glutathione on Growth Parameters in Children With Cystic Fibrosis
Phase: PHASE2
Conditions: Cystic Fibrosis
Sponsor: University of Minnesota



Protocol GROW-IP-16                                                                                       Confidential 
 
PROTOCOL AGREEMENT 
 
I have read the protocol specified below. In my formal capacity as Investigator, my duties 
include ensuring the safety of the study subjects enrolled under my supervision and providing the 
Sponsor-Investigator with complete and timely information, as outlined in the protocol.  It is 
understood that all information pertaining to the study will be held strictly confidential and that 
this confidentiality requirement applies to all study staff at this site. Furthermore, on behalf of 
the study staff and myself, I agree to maintain the procedures required to carry out the study in 
accordance with accepted GCP principles and to abide by the terms of this protocol. 
 
Protocol Number:  GROW-IP-16 
 
Protocol Title:  A Multi-Center, Placebo-Controlled, Double-Blind, Randomized Study 
Evaluating the Role of Oral Glutathione on Growth Parameters in Children with Cystic Fibrosis 
 
Protocol Date:   September 12, 2017 
 
 
 
Investigator Signature 
 
Date 
 
 
 
Print Name and Title 
 
 
Site #: 
 
 
Site Name: 
 
 
Address: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Protocol GROW-IP-16                                                                                       Confidential 
 
TABLE OF CONTENTS 
PROTOCOL SYNOPSIS ............................................................................................................................................. 7 
1 
BACKGROUND ............................................................................................................................................ 14 
1.1 
OVERVIEW OF NON-CLINICAL STUDIES ................................................................................................................... 16 
1.2 
OVERVIEW OF CLINICAL STUDIES ........................................................................................................................... 16 
2 
STUDY RATIONALE ...................................................................................................................................... 18 
2.1 
RISK / BENEFIT ASSESSMENT ................................................................................................................................ 18 
3 
STUDY OBJECTIVES ..................................................................................................................................... 19 
3.1 
PRIMARY OBJECTIVE ........................................................................................................................................... 19 
3.2 
SECONDARY OBJECTIVES ...................................................................................................................................... 19 
3.3 
EXPLORATORY OBJECTIVES ................................................................................................................................... 19 
4 
STUDY DESIGN ............................................................................................................................................ 19 
4.1 
STUDY OVERVIEW .............................................................................................................................................. 19 
5 
CRITERIA FOR EVALUATION ........................................................................................................................ 20 
5.1 
PRIMARY ENDPOINT ........................................................................................................................................... 20 
5.2 
SECONDARY ENDPOINTS ...................................................................................................................................... 20 
6 
SUBJECT SELECTION .................................................................................................................................... 21 
6.1 
STUDY POPULATION............................................................................................................................................ 21 
6.2 
INCLUSION CRITERIA ........................................................................................................................................... 21 
6.3 
EXCLUSION CRITERIA ........................................................................................................................................... 22 
6.4 
STUDY SPECIFIC TOLERANCE FOR INCLUSION/EXCLUSION CRITERIA .............................................................................. 22 
6.5 
SCREEN FAIL CRITERIA ......................................................................................................................................... 22 
7 
CONCURRENT MEDICATIONS ...................................................................................................................... 22 
7.1 
ALLOWED MEDICATIONS AND TREATMENTS ............................................................................................................ 23 
7.2 
PROHIBITED MEDICATIONS AND TREATMENTS ......................................................................................................... 23 
8 
STUDY TREATMENTS .................................................................................................................................. 23 
8.1 
METHOD OF ASSIGNING SUBJECTS TO TREATMENT GROUPS ....................................................................................... 23 
8.2 
BLINDING.......................................................................................................................................................... 24 
8.3 
FORMULATION OF TEST AND CONTROL PRODUCTS .................................................................................................... 25 
8.4 
SUPPLY OF STUDY DRUG TO THE SITE ..................................................................................................................... 25 
8.5 
DOSE MODIFICATION .......................................................................................................................................... 26 
8.6 
STUDY DRUG ACCOUNTABILITY ............................................................................................................................. 27 
9 
STUDY PROCEDURES AND GUIDELINES ....................................................................................................... 27 
9.1 
CLINICAL ASSESSMENTS ....................................................................................................................................... 27 
9.2 
CLINICAL LABORATORY MEASUREMENTS ................................................................................................................. 29 
9.3 
RESEARCH LABORATORY MEASUREMENTS ............................................................................................................... 30 
10 
EVALUATIONS BY VISIT ............................................................................................................................... 31 
10.1 
VISIT 1 (DAY – 42 THROUGH– 1) ..................................................................................................................... 31 
10.2 
VISIT 2 (DAY 0) ............................................................................................................................................ 31 
10.3 
COMBINED VISIT 1 AND VISIT 2 (DAY 0) ............................................................................................................ 32 
10.4 
PHONE CALL WEEK 4 (DAY 28 ± 7 DAYS) ....................................................................................................... 33 
 
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10.5 
PHONE CALL WEEK 8 (DAY 56 ± 7 DAYS) ....................................................................................................... 33 
10.6 
VISIT 3 (DAY 84 ± 7 DAYS) ........................................................................................................................... 34 
10.7 
PHONE CALL WEEK 16 (DAY 112 ± 7 DAYS) ................................................................................................... 34 
10.8 
PHONE CALL WEEK 20 (DAY 140 ± 7 DAYS) ................................................................................................... 34 
10.9 
VISIT 4 (DAY 168 ± 14 DAYS) ....................................................................................................................... 35 
10.10 
FOLLOW-UP PHONE CALL OR VISIT 5 (DAY 182 ± 14 DAYS) .................................................................................. 35 
10.11 
EARLY PERMANENT DISCONTINUATION OF STUDY TREATMENT VISIT ....................................................................... 36 
11 
ADVERSE EXPERIENCE REPORTING AND DOCUMENTATION ....................................................................... 37 
11.1 
ADVERSE EVENTS (AE) ................................................................................................................................... 37 
11.2 
SERIOUS ADVERSE EXPERIENCES (SAE) .............................................................................................................. 38 
11.3 
MEDICAL MONITORING .................................................................................................................................. 39 
12 
DISCONTINUATION AND REPLACEMENT OF SUBJECTS ............................................................................... 39 
12.1 
EARLY PERMANENT DISCONTINUATION OF STUDY TREATMENT ............................................................................... 39 
12.2 
EARLY WITHDRAWAL OF SUBJECTS FROM THE STUDY ........................................................................................... 39 
12.3 
REPLACEMENT OF SUBJECTS ............................................................................................................................ 40 
13 
PROTOCOL VIOLATIONS.............................................................................................................................. 40 
14 
DATA SAFETY MONITORING ....................................................................................................................... 40 
15 
STATISTICAL METHODS AND CONSIDERATIONS .......................................................................................... 40 
15.1 
GENERAL CONSIDERATIONS ............................................................................................................................. 40 
15.2 
DEMOGRAPHIC AND BASELINE CHARACTERISTICS ................................................................................................. 41 
15.3 
ANALYSIS OF PRIMARY ENDPOINT ..................................................................................................................... 41 
15.4 
ANALYSIS OF SECONDARY ENDPOINTS ................................................................................................................ 42 
15.5 
ANALYSIS OF SAFETY ENDPOINTS ...................................................................................................................... 43 
15.6 
ANALYSIS OF EXPLORATORY ENDPOINTS ............................................................................................................. 43 
15.7 
ANALYSIS OF STUDY DRUG DISCONTINUATION AND COMPLIANCE ........................................................................... 43 
15.8 
INTERIM ANALYSIS ......................................................................................................................................... 43 
15.9 
SAMPLE SIZE ................................................................................................................................................. 44 
16 
DATA COLLECTION, RETENTION AND CLINICAL MONITORING .................................................................... 45 
16.1 
DATA COLLECTION INSTRUMENTS ..................................................................................................................... 45 
16.2 
DATA MANAGEMENT PROCEDURES .................................................................................................................. 45 
16.3 
SECURITY AND ARCHIVAL OF DATA .................................................................................................................... 46 
16.4 
AVAILABILITY AND RETENTION OF INVESTIGATIONAL RECORDS ................................................................................ 47 
16.5 
MONITORING ............................................................................................................................................... 47 
16.6 
SUBJECT CONFIDENTIALITY .............................................................................................................................. 47 
17 
ADMINISTRATIVE, ETHICAL, REGULATORY CONSIDERATIONS .................................................................... 47 
17.1 
PROTOCOL AMENDMENTS ............................................................................................................................... 47 
17.2 
INSTITUTIONAL REVIEW BOARDS AND INDEPENDENT ETHICS COMMITTEES ............................................................... 48 
17.3 
INFORMED CONSENT FORM ............................................................................................................................. 48 
17.4 
CONSENT FOR COLLECTION AND USE OF CFF REGISTRY ID NUMBER ....................................................................... 49 
17.5 
PUBLICATIONS .............................................................................................................................................. 49 
17.6 
INVESTIGATOR RESPONSIBILITIES....................................................................................................................... 49 
18 
REFERENCES ............................................................................................................................................... 50 
APPENDIX 1. SCHEDULE OF EVENTS ..................................................................................................................... 52 
APPENDIX 2:  DEFINITION OF PULMONARY EXACERBATION ................................................................................ 54 
 
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Protocol GROW-IP-16                                                                                       Confidential 
 
LIST OF ABBREVIATIONS AND ACRONYMS 
AE 
adverse event 
ALT 
alanine aminotransferase 
AST 
aspartate aminotransferase 
BMI 
Body Mass Index 
BUN 
blood urea nitrogen  
CBM 
Center for Biochemical Markers 
CDC 
Center for Disease Control and Prevention 
CFR 
Code of Federal Regulations 
CFTR 
cystic fibrosis transmembrane conductance regulator 
CF 
cystic fibrosis 
CFF 
Cystic Fibrosis Foundation 
CFFT 
Cystic Fibrosis Foundation Therapeutics, Inc. 
CRF 
case report form 
DMC 
Data Monitoring Committee 
DSMB 
Data Safety Monitoring Board 
EDC 
Electronic data capture 
FDA 
Food and Drug Administration 
FEF25%-75% forced expiratory flow 
FEV1 
forced expiratory volume over one second 
FVC 
forced vital capacity 
GCP 
Good Clinical Practice 
GGT 
gamma-glutamyl transferase 
GI 
Gastrointestinal  
GSH 
L-glutathione Reduced 
HIPAA 
Health Insurance Portability and Accountability Act of 1996 
hs-CRP 
high-sensitivity C-Reactive Protein  
ICF 
informed consent form 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
IRB 
Institutional Review Board 
IV 
intravenous 
mEq 
milliequivalent 
mg 
milligram 
 
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Protocol GROW-IP-16                                                                                       Confidential 
 
mL 
milliliter 
NTM 
nontuberculous mycobacteria  
PE 
Pulmonary Exacerbation 
PERT 
pancreatic enzyme replacement therapy  
PFT 
pulmonary function test 
PI 
pancreatic insufficiency 
PPI 
Proton Pump Inhibitor 
QPIT 
Quantitative Pilocarpine Iontophoresis Test  
SAE 
serious adverse experience 
SGOT 
serum glutamic oxaloacetic transaminase 
SGPT 
serum glutamate pyruvate transaminase 
SAP 
Statistical Analysis Plan 
TDNCC 
Therapeutics Development Network Coordinating Center 
tid 
three times a day 
 
 
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Protocol GROW-IP-16                                                                                       Confidential 
 
PROTOCOL SYNOPSIS 
TITLE 
A Multi-Center, Placebo-Controlled, Double-Blind, Randomized 
Study Evaluating the Role of Oral Glutathione on Growth Parameters 
in Children with Cystic Fibrosis 
SPONSOR-
INVESTIGATOR 
Sarah Jane Schwarzenberg, MD and Molly Bozic, MD 
FUNDING 
ORGANIZATION 
Cystic Fibrosis Foundation Therapeutics, Inc. (CFFT) 
NUMBER OF SITES 
Approximately 17 
RATIONALE 
The nutritional status of children with cystic fibrosis (CF) has a 
profound impact on their mortality and morbidity [1, 2].  Optimal 
nutrition in the early years of life has a positive influence on long-
term growth, development and improved pulmonary status later in 
life.  Despite pancreatic enzyme supplementation, high calorie diets, 
and supplementation of fat-soluble vitamins, many children with CF 
fail to achieve optimal growth. In CF, intestinal inflammation and 
dysbiosis contribute to impaired digestion, absorption, and nutrient 
utilization [3]. CF caregivers have emphasized the importance of 
achieving good nutritional status with routine evaluation and 
aggressive nutritional interventions very early in life. Reducing 
intestinal inflammation may be a crucial factor in achieving this goal. 
Among the interventions studied to combat the underlying 
mechanisms of malnutrition are anti-oxidants, including glutathione. 
Early studies have shown that people with CF have decreased 
systemic levels of glutathione [4].  It is not known whether this is the 
result of inflammatory mediators suppressing production or secretion 
of glutathione, or involves loss of a possible function of cystic 
fibrosis transmembrane conductive regulator (CFTR) to transport 
glutathione across the cell membrane. Glutathione has both 
antioxidant and mucolytic properties in patients with CF. In two pilot 
studies, orally administered glutathione improved growth in people 
with CF [5, 6].  One of these studies evaluated the effect of reduced 
glutathione on the growth of 44 patients with CF in a single center 
placebo-controlled, randomized, double blind clinical trial.  Subjects 
receiving supplemental glutathione over a six-month period 
experienced an average increase of 0.67 SD in weight-for-age z-score 
compared to an average of 0.1 SD improvements in weight-for-age z-
score in subjects receiving placebo.  Furthermore, improvements in 
body mass index (BMI) and height as well as reduced fecal 
calprotectin were also observed [6].  These encouraging results 
emphasize the need to study the impact of oral glutathione on growth 
in CF patients in a larger, multi-center study.   
 
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The purpose of this randomized, placebo-controlled (Phase II) study 
will be to further evaluate the effects of oral glutathione on growth in 
children with CF. 
STUDY DESIGN 
This will be a prospective, multi-center, randomized, placebo-
controlled, double-blind, Phase II clinical trial.   Approximately sixty 
pancreatic insufficient (PI) subjects with CF who are ≥ 2 and < 11 
years of age, will be enrolled to receive either L-Glutathione Reduced 
(GSH) or placebo given orally (tid) for 24 weeks.  
Each subject will be seen for four study visits: Visit 1 (Screening), 
Visit 2 (Baseline/Randomization, Day 0), Visit 3 (Week 12) and Visit 
4 (Week 24).  At Visit 2, subjects will be randomized to receive 
either active treatment or placebo.  Visit 1 and Visit 2 may be 
combined if subject meets eligibility requirements and a fecal 
specimen is collected prior to dosing.   
Safety and clinical outcomes will be assessed throughout the study.  
Assessment of inflammatory and other bio-markers in blood and fecal 
specimens will be performed at Visit 2 and Visit 4.   
DURATION OF 
SUBJECT 
PARTICIPATION 
AND DURATION OF 
STUDY  
Subjects will be on study for up to 32 weeks 
Screening: up to 42 days 
Treatment:  24 weeks 
Follow up:  Phone call/visit 2 weeks after end of treatment  
PRIMARY 
OBJECTIVE 
The primary objective of this study is to investigate the effect of 24 
weeks of treatment with oral glutathione on change in weight-for-age 
z-scores. 
SECONDARY 
OBJECTIVES 
The secondary objectives are to: 
 Evaluate changes in other clinical outcomes (growth, lung 
function, gastrointestinal (GI) symptoms, hospitalizations, 
antibiotic utilization and pulmonary exacerbations [PE]) 
 Evaluate changes in blood and fecal inflammatory markers 
 
EXPLORATORY 
OBJECTIVE 
 The exploratory objectives are to examine the potential mechanisms 
of GSH by: 
 Evaluating changes in circulating GSH levels and in levels of 
other redox intermediates which are co-regulated with GSH  
 Evaluating changes occurring in up to 180 metabolites 
including acylcarnitines, amino acids, biogenic amines, 
monosaccharides, sphingolipids, and glycerophospholipids as 
a result of changes in GI function associated with GSH 
administration 
 
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NUMBER OF 
SUBJECTS 
Approximately 60 
SUBJECT 
SELECTION 
CRITERIA:  
Inclusion Criteria 
Inclusion Criteria: 
1. Male or female ≥ 2 and < 11 years of age at Visit 1 
2. Documentation of a CF diagnosis as evidenced by one or more 
clinical features consistent with the CF phenotype and one or 
more of the following criteria: 
• Sweat chloride ≥ 60 mEq/liter by quantitative pilocarpine 
iontophoresis test (QPIT)  
• Two well-characterized mutations in the cystic fibrosis 
transmembrane conductance regulator (CFTR) gene  
3. Weight-for-age between the 10th and 50th percentiles at Screening 
(Visit 1) (using the Center for Disease Control (CDC) reference 
equations)  
4. Current chronic use, greater than 8 weeks before Day 0, of 
pancreatic enzyme replacement therapy (PERT) for management 
of pancreatic insufficiency 
5. Written informed consent (and assent when applicable) obtained 
from subject or subject’s legal representative and ability to 
comply with the requirements of the study 
6. Clinically stable with no significant changes in health status 
within 2 weeks prior to Day 0 
SUBJECT 
SELECTION 
CRITERIA:  
Exclusion Criteria 
Exclusion Criteria: 
1. Intestinal obstruction or gastrointestinal surgery within the 6 
months prior to Day 0 
2. History of diabetes, Crohn’s disease, celiac disease, or bowel 
resection  
3. Use of either oral or inhaled GSH or N-acetyl cysteine within 
the 4 months prior to Screening (Visit 1) 
4. Known hypersensitivity to oral glutathione or lactose 
5. Initiation of any new or dose changes for ongoing chronic 
therapy (e.g., ibuprofen, hypertonic saline, azithromycin, 
Pulmozyme®, Cayston®, TOBI®, Kalydeco™,Orkambi™, Proton 
Pump Inhibitor, Histamine H-2 Blocker [PPI/H2-blocker], 
Miralax®, PERT, dietary supplementation, probiotics) within the 
4 weeks prior to Day 0 
6. Changes in the amount of proprietary dietary supplement 
formulas (e.g., Scandishakes, Boost, Pediasure) given (oral or 
gastrostomy tube) within the 4 weeks prior to Day 0 
7. Use of antibiotics (oral, IV, or inhaled) for acute symptoms 
within the 2 weeks prior to Day 0 
 
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8. Use of oral steroids within the 4 weeks prior to Day 0 
9. Active treatment for nontuberculous mycobacteria (NTM) at 
Day 0 
10. Active treatment for allergic bronchopulmonary aspergillosis 
(ABPA) at Day 0 
11. Administration of any investigational drug within the 4 weeks 
prior to Day 0 
12. Sibling who received study drug as part of this study 
13. Presence of a condition or abnormality that in the opinion of the 
investigator would compromise the safety of the patient or the 
quality of the data  
TEST PRODUCT, 
DOSE, AND ROUTE 
OF 
ADMINISTRATION 
L- glutathione reduced (GSH) approximately 65 mg/kg/day given 
orally divided into three doses daily given with food for 24 weeks.  
Study drug will be provided in a bulk powder to be mixed with syrup. 
CONTROL 
PRODUCT, DOSE 
AND ROUTE OF 
ADMINISTRATION 
Lactose Monohydrate powder approximately 65mg/kg/day given 
orally divided into three doses daily given with food for 24 weeks.  
Control will be provided in a bulk powder to be mixed with syrup. 
CONCOMMITANT 
MEDICATIONS 
Allowed: Standard therapy for CF is allowed except for treatments 
noted in the exclusion criteria described above and as noted in the 
prohibited medications section below. A stable therapeutic regimen 
(including physiotherapy) between Visit 1 and Visit 4 is the goal. 
Subjects should continue protocol-allowed supplements and vitamin 
use throughout the study without change. Ongoing chronic treatment 
(> 4 weeks prior to randomization) with Pulmozyme®, Cayston®, 
TOBI®, Kalydeco™, Orkambi™, nebulized colistin, high dose 
ibuprofen, hypertonic saline, azithromycin, PPIs, H2-blockers, 
Miralax®, dietary supplementation, probiotics, appetite stimulants, 
vitamins, short and long acting bronchodilators and airway clearance 
is allowed. Unless medically indicated, subjects not using these 
therapies at least 4 weeks prior to randomization should not be started 
on them during the study and subjects that have been using them 
chronically should be encouraged to continue them throughout the 
entire treatment period (Visit 4).   
Prohibited: Medications that may have an effect on the primary 
endpoint are prohibited, including the following:  
 
Initiation of acute oral steroids within 4 weeks of Visit 4 
 
The use of N-acetylcysteine, GSH (other than study drug) 
between Visit 1 and Visit 4.  
 
The use of any other investigational therapies from 4 weeks 
 
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prior to Day 0 through Visit 4. 
 
Changes in chronic CF GI treatment and nutritional 
supplementation (e.g., introduction, dose escalation, or 
elimination of chronic therapies) as noted above (e.g., PPIs, 
H2-blockers, Miralax®, dietary supplementation, probiotics, 
appetite stimulants, and vitamins) 4 weeks prior to Day 0 
through Visit 4. 
 
Changes in PERT dose 4 weeks prior to Day 0 through Visit 
4.  
PERT dose changes may impact the primary endpoint.  If the treating 
clinician wishes to adjust a clinically stable patient’s PERT dose 
without altering their LPU/kg/meal it is recommended that this be 
done 4 weeks prior to Day 0 or after the final study visit has occurred 
to prevent any impact on the primary endpoint and a protocol 
violation.  If, during the study, the treating clinician believes that a 
change in PERT dose is warranted due to failure to thrive or weight 
loss, then the dose can be changed, however, because this could 
impact the primary endpoint, it will result in a protocol violation. 
PRIMARY 
ENDPOINT 
Difference between treatment groups in the 24-week change from 
baseline in weight-for-age z-score.   
SECONDARY 
ENDPOINTS 
Clinical Endpoints: 
 Difference between treatment groups in the 24-week change 
from baseline in height (cm, percentile, and height-for-age z-
score) 
 Difference between treatment groups in the 24-week change 
from baseline in BMI (kg/m2, BMI for age z-score, and 
percentile) 
 Difference between treatment groups in FEV1 (liters and % 
predicted), FVC (liters and % predicted) and FEF25-75 
(liters/second and % predicted) absolute change and relative 
change from baseline (among those subjects able to 
reproducibly perform spirometry) 
 Difference between treatment groups in patient reported 
outcomes (Cystic Fibrosis GI parent questionnaire) at 24 
weeks and changes or shifts from baseline 
 Difference between treatment groups in the proportion of 
subjects hospitalized from Visit 2 through Visit 4  
 Difference between treatment groups in the proportion of 
subjects prescribed acute oral, inhaled, and IV antibiotics 
from Visit 2 through Visit 4  
 Difference between treatment groups in the proportion of 
subjects experiencing a pulmonary exacerbation from Visit 2 
 
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through Visit 4 and pulmonary exacerbation rate from Visit 2 
through Visit 4  
Laboratory Measures of Inflammation: 
 Difference between treatment groups in the 24-week change 
from baseline in fecal calprotectin  
 Difference between treatment groups in the 24-week change 
from baseline in neutrophil counts, platelet count, and high-
sensitivity C-Reactive Protein (hs-CRP) 
Safety: 
 Incidence of adverse events (AE) 
 Changes in safety labs 
PLANNED INTERIM 
ANALYSIS 
When approximately 50% of subjects have completed the study 
through Visit 4 (Week 24), an interim analysis will be conducted by 
an independent data monitoring committee (DMC). A priori interim 
stopping rules for futility and efficacy with respect to the primary 
endpoint are outlined in the DMC Charter. Serious adverse events 
(SAE) will be monitored by medical monitors on an ongoing basis 
throughout the study. 
STATISTICS 
Primary Analysis Plan 
A modified intent to treat (m-ITT) analysis will be used for the 
primary analysis, including all subjects who were randomized and 
received at least one dose of study drug.  
The primary endpoint is the difference between treatment groups of 
the change in weight-for-age z-score from Visit 2 to Visit 4 (Week 
24). A linear mixed effects model will be utilized to incorporate the 
Visit 3 (Week 12) weight-for-age z-score measurement and the model 
will adjust for randomization strata: sex, baseline age (< 6 years, ≥ 6 
years), baseline weight-for-age z-score (< -0.52, ≥ -0.52) and 
historical fecal elastase (<200 µg/g, ≥200 µg/g, unavailable). The 
estimated treatment effect and corresponding 95% confidence 
interval will be reported and p-values will be evaluated assuming a 
two-sided 0.05 level of significance. 
Rationale for Number 
of Subjects 
The primary endpoint is the difference between treatment groups of 
the change in weight-for-age z-score from Visit 2 to Visit 4 (Week 
24). Data from prior studies of similar populations and durations are 
available to estimate sample size and power for the study including a 
randomized, placebo-controlled trial of oral GSH in Italian children 
chronically taking pancreatic enzymes, as well as a factorial 
randomized trial comparing antipseudomonal regimens in US 
children with newly acquired Pseudomonas aeruginosa infection. 
These studies suggest a standard deviation of the change in weight-
for-age z-score ranging from 0.20 to 0.29. A query of CF registry 
data of a similar population found the standard deviation of the 6-
 
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Protocol GROW-IP-16                                                                                       Confidential 
 
month change in weight-for-age z-score to be higher (0.37). A 
previous study of oral GSH in children, conducted in Italy, found the 
weight-for-age z-score difference between the GSH arm and the 
placebo arm after 6 months of therapy to be 0.34 [6]. 
Assuming a conservative standard deviation of 0.4, a total sample 
size of 54 provides 90% power to detect a treatment effect of 0.36 or 
greater. It is anticipated from prior CF trials conducted through the 
Therapeutics Development Network Coordinating Center (TDNCC) 
that the attrition rate will be less than 10% and thus it is reasonable to 
expect that a total sample size of 60 will enable at least 54 subjects to 
complete the trial. 
 
 
 
 
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Protocol GROW-IP-16                                                                                       Confidential 
 
1 
BACKGROUND 
Normal growth is critical to survival in CF. In children, normal growth is a marker for 
improved survival, better pulmonary function, and fewer complications of CF [1]. Based on data 
showing that normal weight-for-height percentiles in early life (<2 years) and body mass index 
percentiles from 2-20 years is associated with better pulmonary function later in life, the Cystic 
Fibrosis Foundation Clinical Practice Guidelines recommend that all children reach weight-for-
length or body mass index (BMI) status of  ≥50th percentile [2, 7]. Weight-for-age percentile 
(WAP) >10% at 4 years of age was associated with better lung function from 6-18 years of age. 
At age 18 years, children who had weight-for-age percentile >50% at age 4 years had fewer 
pulmonary exacerbations, fewer hospital days, and lower rates of impaired glucose tolerance 
than children with WAP <50% at age 4 years [1]. BMI is also correlated with perceived quality 
of life [8], with reduction of BMI associated with diminished health-related quality of life 
(HRQoL) across multiple domains, including physical functioning, social functioning, concerns 
for the future, and body image. While cystic fibrosis transmembrane conductance regulator 
(CFTR) dysfunction makes normal growth more challenging, maintaining normal nutritional 
status improves outcomes in CF [1]. 
CF is characterized by intestinal pathology, including inflammation. Several lines of 
evidence demonstrate chronic inflammation is common in CF. Whole gut lavage from 21 PI CF 
patients without gastrointestinal symptoms demonstrated higher levels of inflammatory markers, 
including eosinophilic cationic protein, neutrophil elastase, interleukin (IL) 8 and IL1, compared 
to controls [9].  Duodenal histopathology in 14 PI CF patients, compared to 20 healthy controls 
showed increased lamina propria mononuclear cell infiltration in the biopsies from CF patients, 
with increased expression of inflammatory markers [10].  Wireless capsule endoscopy in 41 CF 
patients found signs of small intestinal inflammation in 60% [11]. In this same study, fecal 
calprotectin, a marker of inflammation, was increased in PI, but not pancreatic sufficient 
patients; similarly increased fecal calprotectin in PI CF was reported by others [12, 13]. The 
factors contributing to increased intestinal inflammation in CF have been explored in the mouse 
model of CF [14]. The absent or reduced CFTR channel results in a poorly hydrated, acidic small 
intestinal mileu. The resulting thick, inspissated mucus alters motility and results in intestinal 
dysbiosis.  
Intestinal inflammation in CF is a factor limiting growth. Intestinal inflammation is one of 
many factors that contribute to the challenge of achieving normal growth in CF [3]. Treatments 
that reverse inflammation in the intestine of CF mice (laxatives, antibiotics) result in improved 
growth [15-17]. A fecal marker of intestinal inflammation, calprotectin, correlated with both 
weight and height z-scores in a group of PI CF children in a small single center study of 
intestinal inflammation and growth [18]. Because fecal content of neutrophil-derived S100A12 
protein was normal, it is unlikely that this finding is related to calprotectin in swallowed sputum. 
Intestinal inflammation is increased in children with CF, and it contributes to reduced weight and 
height 
Oxidative stress may play a role in the intestinal inflammation in CF. In the inflamed CF 
airway, oxidative stress, or redox imbalance, contributes to tissue damage and perpetuation of the 
inflammatory process [19]. Oxidants are elaborated as defense against pathogens, but in tissues 
lacking CFTR, regulation of redox balance is impaired. In particular, CFTR may play a role in 
 
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transporting glutathione to the airway surface [19]. Glutathione is a tripeptide (γ-glutamyl-
cysteinyl-glycine, GSH) that is one of the most important antioxidants in humans [20], 
scavenging oxygen species, clearing some physiologic metabolites and xenobiotics, and 
participating in prostaglandin metabolism, among other functions [20]. In CF, GSH plasma 
levels are 50% of normal and 5-10% of normal in pulmonary epithelial lining fluid [4]. In normal 
intestine, glutathione plays a role in epithelial proliferation, differentiation, and apoptosis [21]. 
Although direct evidence is lacking, it is plausible that reduced levels of glutathione in the 
intestine of children with CF contributes to the redox imbalance in these tissues and, thus, to the 
development of intestinal inflammation. 
Increased glutathione reduces oxidative stress and inflammation in CF. Previous studies 
have attempted to reduce oxidative stress, often with the goal of improved pulmonary function. 
Improvement of growth or BMI has been a secondary aim in some studies. Two strategies have 
been used to increase glutathione and reduce oxidative stress in CF. 
 Oral administration of a cysteine source. Enteral administration of glutathione does not 
increase plasma levels. Cysteine is a component of GSH, and can be a limiting resource 
in its synthesis. While cysteine can be synthesized from methionine, this pathway may 
not be functional in patients with severe illness. Enteral administration of cysteine 
increases plasma glutathione [22]. Oral N-acetylcysteine (NAC) has been administered in 
CF to evaluate its effect on oxidative stress and pulmonary function. A pilot study of 4 
weeks of NAC demonstrated decreased level of oxidized vitamin C without improvement 
in FEV1percent predicted [23]. A multicenter, randomized trial of oral NAC over 24 
weeks in CF patients ≥7 years old showed that decline in FEV1 was halted in those 
receiving NAC compared to controls, but no changes in plasma glutathione, markers of 
lung inflammation, or BMI. The authors speculate that NAC may have increased 
intracellular glutathione, reducing inflammation and oxidation [24].   
 Oral administration of whey protein. Whey is a protein rich in cysteine. Grey and 
colleagues randomized 24 adults with CF, moderate lung disease, and normal weights to 
either whey or casein supplementation for 3 months [25]. Systemic glutathione, measured 
as lymphocyte glutathione, increased significantly in the whey group compare to the 
casein group. No change was seen in percent body fat, weight, or FEV1 percent predicted. 
The authors speculate that whey may be a means of improving tissue glutathione levels to 
reduce oxidative stress. They also speculate that children might respond to whey 
supplementation with more improvement in FEV1, as it might prevent, but not treat, lung 
injury.  
 Oral glutathione. Two studies have examined oral GSH in CF [5, 6]. Both studies 
showed improvement in clinical markers, including lung function and weight gain (see 
Preliminary Data, below). Fecal calprotectin, a measure of intestinal inflammation, 
improved significantly in the GSH compared to placebo group, although baseline fecal 
calprotectin was higher in the GSH group. White blood cell counts and C-reactive protein 
levels decreased in the GSH group, compared to placebo group, as did mean alanine 
aminotransferase levels. Vitamin E levels increased in GSH treated subjects compared to 
placebo, and the authors suggest that this may represent reduced compensatory need for 
vitamin E as an antioxidant in the absence of glutathione. These results suggest a link 
 
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between improvement in intestinal and systemic inflammation and administration of GSH 
in this study [6].  
 
1.1 
Overview of Non-Clinical Studies 
Non-clinical studies of GSH have not been performed as the GSH formulation to be used in this 
study is considered a dietary supplement.  
1.2 
Overview of Clinical Studies 
Two previous studies of glutathione (oral or oral with inhaled) in people with CF have provided 
encouraging results, demonstrating improvements in weight and other clinical parameters.   
Study 1: Visca, et al. published a placebo-controlled, randomized, double blind study 
evaluating the impact of oral glutathione on growth parameters in an Italian pediatric CF 
cohort [6].  In this study, 44 children ages 18 months to 10 years, receiving pancreatic 
enzyme replacement therapy (PERT), were randomized to receive either placebo or oral 
glutathione daily for 6 months. Patients received 65mg/kg/day of oral GSH or placebo of 
calcium citrate at 65mg/kg/day.  This dose was divided into three doses with one being 
given at each meal. The subjects receiving oral glutathione gained an average of 0.67 
weight-for-age z-score over the course of the 6 month trial while the placebo group 
showed an average increase in weight z-score of 0.10. The overall difference between the 
two groups in the 6-month change from baseline was statistically significant with a p 
value of < 0.0001. Similarly, the overall difference between groups in the 6-month 
change from baseline for BMI-for age z-score was statistically significant (glutathione 
mean change: 0.60, placebo mean change: 0.22, p < 0.0001) (See Figure A below) [6].  
  
Noticably, there was a difference between the two treatment groups in both weight-for-
age z-score at baseline  (-0.84 in the treated group versus -0.54 in the placebo group) and 
BMI-for-age z-score at baseline (-0.76 in the treated group versus -0.57 in the placebo 
group). Although these differences were not statistically significant, the treated group had 
greater opportunity for improvement than the group treated with placebo. 
 
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Secondary outcome measures in this study included blood alanine aminotransferase 
(ALT), WBC, Vitamin E, and CRP.  Each of these improved significantly in the 
glutathione treated group compared to placebo (See Table 3 below).   
 
 
The impact of glutathione on gut inflammation measured as fecal calprotectin levels 
before and after the treatment period was also evaluated.  Interestingly, there was 
improvement in fecal calprotectin in subjects treated with glutathione which was found to 
be statistically significant (difference from baseline in the glutathione group -52.0 µg/g 
vs. placebo 0.5 µg/g, p<0.0001), however, treatment groups were significantly different 
at baseline (glutathione group 113.2 µg/g vs. placebo 76.1 µg/g, p = 0.008). This is 
illustrated in the figures below.  
 
A gastrointestinal symptom index was used to evaluate improvement, worsening, or 
development of new gastrointestinal symptoms while subjects received study drug or 
placebo.  In the subjects treated with glutathione, no subject worsened in any of the 11 
subjective measures used in this symptom index.  Furthermore, there was a trend toward 
improvement in several gastrointestinal symptoms such as abdominal pain, flatulence, 
lack of appetite and more than 2 bowel movements per day in the patients treated with 
glutathione.  
Study 2: In an observational study, 13 patients with CF ages 1-27 years who were using 
GSH (either oral or inhaled) were followed for 5.5 months [5]. Data collected included 
FEV1, BMI and weight percentile.  Significant improvement over baseline was noted for 
 
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FEV1 (average improvement of 5.8 percentage points); weight percentile (average 
improvement of 8.6 percentage points); and BMI percentile (average improvement of 
1.22 percentage points).  
Three subjects experienced adverse effects during the study with one case each of fever, 
chest tightness and diarrhea.  All of these symptoms improved without intervention. 
There was an average decline in baseline ALT in patients receiving glutathione 
suggesting no significant hepatotoxic effects with the use of either oral or inhaled 
glutathione.  
2 
STUDY RATIONALE 
Normal childhood growth is crucial to extended survival in CF. Maintaining normal weight gain 
in childhood is often very difficult and a source of significant stress in parents of young children. 
Finding safe and effective strategies to improve growth early in life holds the promise of 
extending life [1, 26]. In addition, the origins of inflammation in CF begin early in childhood 
[27]. Delaying the onset of significant intestinal inflammation may reduce dysbiosis and have a 
separate positive effect on pulmonary function and pulmonary exacerbations (PE). 
The placebo-controlled study reported above (Study 1), while intriguing, was a small single 
center study (44 subjects randomized to 2 treatments). Due to the imbalance between the GSH 
and placebo groups with respect to important baseline characteristics (i.e., weight-for-age z-score 
and fecal calprotectin) we cannot conclusively determine that the observed improvement of 
intestinal inflammation markers and anthropometrics was due solely to the GSH intervention.  
The planned study will achieve better balance at baseline in these important measures (through 
stratification) to better address the impact of treatment with GSH. Additionally, the inclusion of 
extensive testing of redox imbalance and intestinal inflammation may allow some understanding 
of the mechanism of improved weight gain with GSH. Finally, the planned systematic 
measurement of gastrointestinal symptoms will facilitate better assessment of this potential 
outcome. 
2.1 
Risk / Benefit Assessment 
The Italian study of oral glutathione in CF children did not report any significant adverse events 
(AE) associated with GSH administration [6].  Hypothetical concerns regarding alteration of 
levels of GSH, including alterations of immune modulation have been expressed [28], however 
are unlikely to be apparent in this short term study. 
Notably, oral glutathione is readily available as a nutritional supplement.  The reported risks 
associated with these supplements are those associated with taking high concentrations of 
vitamins, primarily gastrointestinal distress.  Additionally, there have been rare anecdotal reports 
of transitory increase of flatulence and hypersensitivity reactions including skin rashes.  
Glutathione has generally been shown to be poorly absorbed from the GI tract in humans, thus 
we anticipate that any adverse events related to the study drug are likely to be GI in nature. The 
planned study will systematically collect information about gastrointestinal symptoms and 
includes regular monitoring of subjects through study visits and phone calls.  
The risks associated with the study procedures (blood draws, fecal specimen collection, and 
spirometry) are minimal. 
 
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The data from the earlier study of oral glutathione in children with CF showing improved growth 
and reduced intestinal inflammation is promising, and the safety profile observed to date 
suggests an appropriate risk/benefit balance for the proposed study. 
3 
STUDY OBJECTIVES 
3.1 
Primary Objective 
The primary objective of this study is to investigate the effect of 24 weeks of treatment with oral 
glutathione on change in weight-for-age z-scores. 
3.2 
Secondary Objectives 
The secondary objectives of this study are to: 
     Evaluate changes on other clinical outcomes (growth, lung function, gastrointestinal 
symptoms, hospitalizations, antibiotic utilization and PEs) 
     Evaluate changes in blood and fecal inflammatory markers  
3.3 
Exploratory Objectives 
The exploratory objectives of this study are to examine the potential mechanisms of GSH by: 
 
Evaluating changes in circulating GSH levels and in levels of other redox 
intermediates which are co-regulated with GSH (GSSH, cysteine, cystine, redox ratios 
and potential for the GSH and cysteine couples)  
 
Evaluating changes occurring in up to 180 metabolites including acylcarnitines, amino 
acids, biogenic amines, monosaccharides, sphingolipids and glycerophospholipids as a 
result of changes in GI function associated with GSH administration. 
4 
STUDY DESIGN 
4.1 
Study Overview 
This will be a multi-center, placebo-controlled, double-blind, randomized, Phase II clinical trial.  
Approximately sixty pancreatic insufficient (PI) subjects with CF, ≥ 2 and < 11 years of age, will 
be enrolled to participate in this study. 
Each subject will come to clinic for four study visits (see Figure 1). Screening: Visit 1 
(Screening, Day -42), Visit 2 (Baseline, Day 0), Visit 3 (Week 12, Day 84) and Visit 4 (Week 
24, Day 168). At Visit 2 (Baseline), subjects will be randomized to receive GSH 65 mg/kg/day 
or placebo (lactose 65mg/kg/day) for 24 weeks. Visit 1 and Visit 2 may be combined if subject 
meets eligibility requirements and a fecal specimen is collected prior to dosing.   
Safety and clinical outcomes will be assessed throughout the study.  Assessment of inflammatory 
markers in blood and fecal samples will be performed at Visit 2 and Visit 4.   
Subjects will be contacted by phone 4 and 8 weeks after Visit 2, as well as 4 and 8 weeks after 
Visit 3 and 2 weeks after Visit 4, to assess safety.  If a subject had a clinically significant 
 
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abnormal lab result or on-going treatment-related AE at Visit 4, the subject will be asked to 
return for a follow-up visit two weeks after Visit 4 instead of the call (Visit 5). 
Subjects will be on study for up to 32 weeks: 
Screening:  up to 42 days  
Treatment:  24 weeks 
Follow-up:  Phone call/visit 2 weeks after end of treatment 
 
Figure 1.  Study Schematic 
 
5 
CRITERIA FOR EVALUATION 
5.1 
Primary Endpoint 
The primary endpoint in the study is the difference between treatment groups in the 24-week 
change from baseline in weight-for-age z-score.   
5.2 
 Secondary Endpoints 
Clinical Endpoints: 
     Difference between treatment groups in the 24-week change from baseline in height 
(cm, percentile, and height-for-age z-score) 
     Difference between treatment groups in the 24-week change from baseline in BMI 
(kg/m2, BMI for age z-score, and percentile) 
     Difference between treatment groups in FEV1 (liters and % predicted), FVC (liters and 
% predicted) and FEF25-75 (liters/second and % predicted) absolute change and relative 
change from baseline (among those subjects able to reproducibly perform spirometry) 
     Difference between treatment groups in patient reported outcomes (Cystic Fibrosis GI 
parent questionnaire) at 24 weeks and changes or shifts from baseline 
 
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     Difference between treatment groups in the proportion of subjects hospitalized from 
Visit 2 through Visit 4  
     Difference between treatment groups in the proportion of subjects prescribed acute 
oral, inhaled, and IV antibiotics from Visit 2 through Visit 4  
     Difference between treatment groups in the proportion of subjects experiencing a 
pulmonary exacerbation from Visit 2 through Visit 4 and pulmonary exacerbation rate 
from Visit 2 through Visit 4  
Laboratory Measures of Inflammation: 
 Difference between treatment groups in the 24-week change from baseline in fecal 
calprotectin  
 Difference between treatment groups in the 24-week change from baseline in 
neutrophil counts, platelet count, and hs-CRP 
Safety: 
 Incidence of adverse events (AE)  
 Changes in safety labs 
6 
SUBJECT SELECTION 
6.1 
Study Population 
Subjects with a diagnosis of CF who meet all of the inclusion and none of the exclusion criteria 
will be eligible for participation in this study.   
6.2 
Inclusion Criteria 
Inclusion Criteria: 
1. Male or female ≥ 2 and < 11 years of age at Visit 1 
2. Documentation of a CF diagnosis as evidenced by one or more clinical features consistent 
with the CF phenotype and one or more of the following criteria: 
• Sweat chloride ≥ 60 mEq/liter by quantitative pilocarpine iontophoresis test (QPIT)  
• Two well-characterized mutations in the cystic fibrosis transmembrane conductance 
regulator (CFTR) gene  
3. Weight-for-age between the 10th and 50th percentiles at Screening (Visit 1) (using the Center 
for Disease Control (CDC) reference equations)  
4. Current chronic use, greater than 8 weeks before Day 0, of pancreatic enzyme replacement 
therapy (PERT) for management of pancreatic insufficiency 
5. Written informed consent (and assent when applicable) obtained from subject or subject’s 
legal representative and ability to comply with the requirements of the study 
6. Clinically stable with no significant changes in health status within 2 weeks prior to Day 0 
 
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6.3 
Exclusion Criteria 
1. Intestinal obstruction or gastrointestinal surgery within the 6 months prior to Day 0 
2. History of diabetes, Crohn’s disease, celiac disease, or bowel resection  
3. Use of either oral or inhaled GSH or N-acetyl cysteine within the 4 months prior to Screening 
(Visit 1) 
4. Known hypersensitivity to oral glutathione or lactose 
5. Initiation of any new or dose changes for ongoing chronic therapy (e.g., ibuprofen, 
hypertonic saline, azithromycin, Pulmozyme®, Cayston®, TOBI®, Kalydeco™,Orkambi™, 
Proton Pump Inhibitor, Histamine H-2 Blocker [PPI/H2-blocker], Miralax®, PERT, dietary 
supplementation, probiotics) within the 4 weeks prior to Day 0 
6. Changes in the amount of proprietary dietary supplement formulas (e.g., Scandishakes, 
Boost, Pediasure) given (oral or gastrostomy tube) within the 4 weeks prior to Day 0 
7. Use of antibiotics (oral, IV, or inhaled) for acute symptoms within the 2 weeks prior to Day 0 
8. Use of oral steroids within the 4 weeks prior to Day 0 
9. Active treatment for nontuberculous mycobacteria (NTM) at Day 0 
10. Active treatment for allergic bronchopulmonary aspergillosis (ABPA) at Day 0 
11. Administration of any investigational drug within the 4 weeks prior to Day 0 
12. Sibling who received study drug as part of this study 
13. Presence of a condition or abnormality that in the opinion of the investigator would 
compromise the safety of the patient or the quality of the data  
 
6.4 
Study Specific Tolerance for Inclusion/Exclusion Criteria 
Subjects who fail to meet one or more of the inclusion criteria or who meet any of the exclusion 
criteria will not be enrolled in this study. Waivers of any of the above study entry criteria will not 
be granted.  
6.5 
Screen Fail Criteria 
Any consented patient who is excluded from the study before randomization is considered a 
screen failure. All screen failures must be documented with the reason for the screen failure 
adequately stated.  If a subject screen fails, s/he can be rescreened two additional times if the site 
staff feels s/he meets eligibility criteria and following confirmation from the study monitor.  
Rescreened subjects will have to complete all screening procedures (i.e., data from previous 
screening cannot be used).   
7 
CONCURRENT MEDICATIONS 
All subjects should be maintained on the same medications throughout the entire study period, as 
medically feasible, with no introduction of new or changes to existing chronic therapies. 
 
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7.1 
Allowed Medications and Treatments 
Standard therapy for CF is allowed except for treatments noted in the exclusion criteria described 
above and as noted in the prohibited medications section below.   
A stable therapeutic regimen (including physiotherapy and PERT) between Visit 1 and Visit 4 is 
the goal. Subjects should continue protocol allowed supplements and vitamin use throughout the 
study without change. Ongoing chronic treatment (> 4 weeks prior to randomization) with 
Pulmozyme®, Cayston®, TOBI®, Kalydeco™, Orkambi™, nebulized colistin, high dose 
ibuprofen, hypertonic saline, azithromycin, PPIs, H2-blockers, Miralax®, dietary 
supplementation, probiotics, appetite stimulants, vitamins, short and long acting bronchodilators 
and airway clearance is allowed.  
 
Unless medically indicated, subjects not using these therapies at least 4 weeks prior to 
randomization should not be started on them during the study and subjects that have been using 
them chronically should be encouraged to continue them throughout the entire treatment period 
(Visit 4).  
7.2 
Prohibited Medications and Treatments 
Medications that may have an effect on the primary endpoint are prohibited, including the 
following:  
 
Initiation of acute oral steroids within 4 weeks of Visit 4.The use of N-
acetylcysteine, GSH (other than study drug) between Visit 1 and Visit 4.  
 
The use of any other investigational therapies from 4 weeks prior to Day 0 through 
Visit 4. 
 
Changes in chronic CF GI treatment and nutritional supplementation (e.g., 
introduction, dose escalation, or elimination of chronic therapies) as noted above 
(e.g., PPIs, H2-blockers, Miralax®, dietary supplementation, probiotics, appetite 
stimulants, and vitamins) 4 weeks prior to Day 0 through Visit 4. 
 
Changes in PERT dose 4 weeks prior to Day 0 through Visit 4.  
 
PERT dose changes may impact the primary endpoint.  If the treating clinician wishes to adjust a 
clinically stable patient’s PERT dose without altering their LPU/kg/meal it is recommended that 
this be done 4 weeks prior to Day 0 or after the final study visit has occurred to prevent any 
impact on the primary endpoint and a protocol violation.  If, during the study, the treating 
clinician believes that a change in PERT dose is warranted due to failure to thrive or weight loss, 
then the dose can be changed, however, because this could impact the primary endpoint, it will 
result in a protocol violation. 
8 
STUDY TREATMENTS 
8.1 
Method of Assigning Subjects to Treatment Groups 
Randomization will occur centrally using a web based randomization system linked to the 
electronic data capture (EDC) system.  Eligible subjects will be randomly assigned to receive 
study drug (GSH or placebo) in equal allocation.  Study personnel at the investigative site will 
 
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use the Medidata® Rave® and Balance® systems to randomize each subject. An adaptive 
randomization scheme (dynamic allocation based on minimization [29] will be employed with 
the goal of ensuring equal representation in each study arm and strata. Subject randomization 
will be stratified by sex, baseline age (< 6 years, ≥ 6 years), baseline weight-for-age z-score (< -
0.52, ≥ -0.52, i.e., the 30th percentile) and historical fecal elastase (<200 µg/g, ≥200 µg/g, 
unavailable). The dynamic allocation algorithm seeks to optimize randomization balance by 
minimizing a weighted average of the marginal imbalance [30] of treatment allocation for each 
factor and for the study overall. A random element is added to the otherwise deterministic 
minimization algorithm to reduce allocation predictability by using a biased coin (32) to include 
a chance of allocation to a treatment arm other than the arm that optimizes balance.  
Only authorized site personnel are given access to the randomization module. Authorized site 
personnel will enter subject eligibility information and whether or not the subject signed 
informed consent. The system will verify that the subject is eligible and has provided signed 
informed consent; the system will then provide the appropriate authorized site personnel with a 
randomization assignment for the subject that matches a specific treatment. 
8.2 
Blinding 
Study treatments will be administered in a double-blind fashion (i.e., subjects and site research 
staff will not know the treatment assigned, with the exception of the dispensing site pharmacist). 
The central pharmacy, designated TDNCC personnel responsible for creating drug assignment 
lists, and those involved in DMC report generation in accordance with the DMC Charter will be 
unblinded.  
The following study procedures will be in place to ensure double-blind administration of study 
treatments:   
 Randomization assignments will be stored in a secure database and appropriately 
protected and backed up   
 Access to the randomization code will be strictly controlled and limited to 
designated TDNCC personnel who are involved in the generation of the interim 
report for the Data Safety Monitoring Board (DSMB) 
 GSH and control treatments will be identical in appearance and taste masked with 
syrup prior to dosing.   
 All dispensed GSH and control treatment bottle packaging and labeling will be 
identical. 
 
During the study, the blind may be broken for individual subjects in emergencies when 
knowledge of the subject’s treatment group is necessary for further patient management or when 
the event meets the Food and Drug Administration (FDA) expedited reporting requirements as a 
suspected adverse reaction that is serious and unexpected (US Code of Federal Regulations 
(CFR) 21 CFR 312.32(c)(1)(i)). In those cases, knowledge of the treatment received is necessary 
for interpreting the event. If the blind is broken and the subject was receiving placebo, an IND 
Safety Report would not be submitted. However, if the blind is broken and the subject is on 
 
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study drug, an IND Safety Report is submitted to the FDA and all participating investigators 
would be notified. Emergency un-blinding procedures are provided in the Study Manual (refer to 
the section on Serious Adverse Experience reporting). 
The study blind will be broken on completion of the clinical study and after the study database 
has been locked and study results released. The site investigators will be provided with each 
subject’s treatment assignment following completion of the statistical report and dissemination 
of top line results to Sponsor-Investigators. 
8.3 
Formulation of Test and Control Products 
8.3.1 Formulation of Test Product 
L-glutathione reduced, USP (GSH) is a dietary supplement manufactured in accordance with 
current GMP standards for dietary supplements (21 CFR Part 111).  GSH is manufactured and 
supplied by Kyowa Hakko Bio Co, Ltd.   GSH is supplied as an odorless white crystalline 
powder with a slightly sour taste.  
8.3.2 Formulation of Control Product 
The placebo is Lactose Monohydrate Powder.  It is an odorless white powder.     
8.3.3 Packaging and Labeling 
Test and control products (study drugs) will be packaged in identical high density polyethylene 
bottles containing 45 grams of GSH or placebo.  Packaging will be done by University of Iowa 
Pharmaceuticals. Each bottle will be labelled ‘L-Glutathione Reduced or Placebo’ so as to 
maintain the blind. Additionally, the label will contain the required FDA warning statement, the 
protocol number, a bottle number, the name of the sponsors, and directions for patient use and 
storage.   
8.4 
Supply of Study Drug to the Site 
The study drugs will be shipped to participating sites from University of Rochester.  The initial 
shipment will occur after site approval (i.e., all required regulatory documentation has been 
received by the TDNCC and a contract has been executed). Subsequent shipments will be made 
when the site requests resupply. 
8.4.1 Dosage/Dosage Regimen 
All subjects will receive study drug for 24 weeks. Each subject will take approximately 
65mg/kg/day of GSH or placebo given orally divided into three doses daily. Each dose should be 
mixed with flavored syrup immediately prior to administration and given with food.   In the 
event subjects are known to spit out flavored syrup, parents/guardians may alternatively mix the 
study drug with a small amount of food (such as a bite or two of applesauce) immediately prior 
to dosing.  See dosing table below (Table 1) for exact dosing based on body weight ranges.  To 
facilitate dosing the correct amount, each subject will be provided with an appropriate scoop 
based on the subject’s weight (see Table 1).  Preferably the doses should be taken with the 
morning, noon, and evening meals.   
 
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Table 1.  
 
 
 
*Approximate 
8.4.2 Study Drug Preparation and Dispensing 
Study drug will be dispensed in original containers.  Only full bottles should be dispensed.  The 
management and dispensation of the study medication to each subject will be under the 
responsibility of the Investigator and the supervision of appropriately trained site personnel.  
(Refer to Pharmacy Manual) 
Study drug will be dispensed to the subject by the site’s investigational pharmacist (or designee).  
The site pharmacist will provide an appropriate scoop based on subject’s weight at Visit 2 and 
Visit 3. The pharmacist or designee will instruct the subject on proper administration of the study 
drug. 
8.4.3 Storage 
Study drug and placebo should be stored by the study site at controlled room temperature, 15 to 
30ºC (59 to 86ºF) in a secure area under restricted access. If the temperature of study drug and 
placebo storage in the clinic/pharmacy exceeds or falls below this range, this should be reported 
to the Sponsor or designee. Subjects will be instructed to store the medication in original 
packaging at room temperature. 
8.5 
Dose Modification 
Not Applicable 
8.5.1 Temporary Discontinuation of Study Drug 
Study drug can be temporarily discontinued at the discretion of the treating clinician. Indications 
for temporary discontinuation include the development of an AE thought to be related to study 
drug that the investigator believes warrants the temporary discontinuation. 
8.5.2 Missed Doses 
Missed doses may be made up as long as they are not taken within 2 hours of the next scheduled 
dose (refer to Study Manual). 
Weight 
Dose* 
Frequency 
Total daily dose (mg)* 
10-11.9 kg 
225 mg 
Three times a day 
675 mg/day 
12–16.9 kg 
310 mg 
Three times a day 
930 mg/day 
17-23.9 kg 
450 mg 
Three times a day 
1350 mg/day 
24-32.9 kg 
600 mg 
Three times a day 
1800 mg/day 
33-40 kg 
830 mg 
Three times a day 
2490 mg/day 
 
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8.6 
Study Drug Accountability 
Subjects will be asked to return all empty and unopened study drug bottles.  An accurate and 
current accounting of the dispensing and return of empty and unopened study drug for each 
subject will be maintained on an ongoing basis by a member of the study site staff.  The amount 
of study drug dispensed and returned bottles by the subject will be recorded on the 
Investigational Drug Accountability Record.  The study monitor will verify these documents 
throughout the course of the study. 
The site will retain all dispensed and un-dispensed study drug and placebo bottles.  Throughout 
the study, all study drug and placebo bottles will be reconciled by the study monitor.  At the end 
of the study, or appropriate timeframe, unused study drug will be destroyed according to 
applicable US regulations.   
9 
STUDY PROCEDURES AND GUIDELINES 
The procedures described below will be performed at the visits noted in the Schedule of Events 
(Appendix 1) and in Section 10. 
Prior to conducting any study-related activities, written informed consent and Health Insurance 
Portability and Accountability Act (HIPAA) authorization must be signed and dated by the 
subject or subject’s legal representative.  If appropriate, assent must also be obtained prior to 
conducting any study-related activities. 
9.1 
Clinical Assessments 
9.1.1 Concomitant Medications 
All concomitant medication and concurrent therapies will be documented as noted in the 
Schedule of Events.  Dose, route, unit, frequency of administration, indication for administration 
and dates of administration will be captured. 
9.1.2 Demographics and CFF Registry ID 
Demographic information (date of birth, sex, race, ethnicity) will be recorded at Visit 1.  Cystic 
Fibrosis Foundation (CFF) Registry ID number will be recorded for participating subjects who 
provide optional consent. 
9.1.3 Medical History 
Relevant medical history, including history of current disease, pancreatic insufficiency, other 
pertinent respiratory history, and information regarding underlying diseases will be recorded at 
Visit 2. 
9.1.4 CF Diagnosis 
CF diagnostic test date(s) and results will be recorded. 
 
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9.1.5 Physical Examination 
A complete or abbreviated physical examination will be performed by a licensed professional per 
institutional requirements (MD, NP, RN, PA), as noted in the Schedule of Events. The 
abbreviated exam includes respiratory, cardiovascular, and abdominal assessments.  After 
randomization, new clinically significant abnormal physical exam findings must be documented 
as AEs and will be followed by a physician or other qualified staff at the next scheduled visit or 
as medically indicated. 
9.1.6 Weight and Height   
Weight will be measured and recorded as noted in the Schedule of Events. For weight 
measurement, children should be weighed in clothes, with a dry diaper (if applicable), and no 
shoes. A standing height will be measured and recorded as noted in the Schedule of Events. 
Height and weight measurements for each subject should be performed using consistent and 
appropriately calibrated equipment (per institutional requirements) for each type of measurement 
across visits. 
9.1.7 Vital Signs 
Resting (minimum of 5 minutes) measurements of body temperature, blood pressure, pulse and 
respirations will be performed and recorded as noted in the Schedule of Events. 
9.1.8 Oximetry 
A resting (minimum of 5 minutes) measurement of oximetry will be measured on room air and 
recorded at as noted in the Schedule of Events. 
9.1.9 Spirometry 
Spirometry will be performed as noted in the Schedule of Events study visits by participants 4 
years of age and older at the time of randomization; who are able to reproducibly perform 
spirometry [31].  Spirometry will be performed in accordance with the current American 
Thoracic Society recommendations for the performance and interpretation of tests.  
The same spirometry equipment should be used for the duration of the study whenever possible. 
Raw lung function measurements will be recorded. Percent of predicted measurements will be 
calculated centrally.   
Bronchodilator use at each visit should be consistent throughout the study for reproducible 
results.    
For subjects that routinely use bronchodilator reference the standard guidelines, as noted below:  
    Subjects who routinely use short acting inhaled bronchodilators should use them 15 
minutes to 2 hours prior to PFTs during study visits. 
    Subjects who routinely use long acting bronchodilator agents should use them 15 
minutes to 6 hours prior to PFTs during study visits. 
If a bronchodilator is not used prior to spirometry at Visit 2 or Combined Visit 1 and Visit 2, 
subjects should not use a bronchodilator prior to spirometry at subsequent visits.    
 
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9.1.10 Subject Questionnaire 
Parent/Guardian will complete a Cystic Fibrosis GI parent questionnaire at the beginning of each 
visit as noted in the Schedule of Events. This questionnaire includes 14 questions and takes less 
than five minutes to complete.  
9.1.11 Subject Diary 
Parent/Guardian will be requested to complete a daily diary to document each dose of study 
treatment from Visit 2 to Visit 4. The diary will be dispensed and reviewed as noted in the 
Schedule of Events. 
9.1.12 Antibiotic Utilization Assessment 
When a subject initiates a new IV, oral, or inhaled antibiotic, the presence of specific signs and 
symptoms will be assessed and documented. These data will be used to determine the incidence 
of a protocol defined PE based on the definition in Appendix 2.    
9.1.13 Adverse Events 
Information regarding occurrence of AE will be captured throughout each subject’s study 
participation, starting after the first dose of study drug.  Duration (start and end dates), grade, 
seriousness, outcome, treatment, and relation to study drug will be recorded on the case report 
form (CRF). 
9.2 
Clinical Laboratory Measurements  
9.2.1 Hematology 
Blood will be obtained as noted in the Schedule of Events and sent to each site’s clinical 
hematology lab for a complete blood count (hemoglobin, hematocrit, red blood cell count, white 
blood cell count, white blood cell differential, and platelet count).  If values are abnormal and 
clinically significant at Visit 4, a sample will be collected and these parameters re-evaluated at a 
follow-up visit two weeks later. 
9.2.2 Blood Chemistry Profile 
Blood will be obtained as noted in the Schedule of Events and sent to each site’s clinical 
chemistry lab for determination of high-sensitivity C-reactive protein (hs-CRP), aspartate 
aminotransferase (AST/SGOT), alanine aminotransferase (ALT/SGPT), gamma-glutamyl 
transferase (GGT), and an electrolyte panel (sodium, potassium, chloride, bicarbonate) and renal 
function (BUN and creatinine). If values are abnormal and clinically significant (with an 
exception of hs-CRP) at Visit 4, a sample will be collected and these parameters re-evaluated at a 
follow-up visit two weeks later. 
 
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9.2.3  Spot Fecal Elastase  
For subjects with no historical documentation of fecal elastase results, a spot fecal elastase test 
will be performed on the fecal specimen obtained at Visit 1 (or Combined Visit 1 and Visit 2) to 
document pancreatic insufficiency.   
9.3 
Research Laboratory Measurements  
9.3.1 Blood Specimens for Metabolomics and REDOX Balance 
Approximately four and half (4.5) mL of blood will be collected as noted in the Schedule of 
Events. The blood will be aliquoted/processed for plasma as detailed in the Study Lab Manual. 
All specimens will be labeled; two cryovials will be batch-shipped for analysis, while the other 
cryovial will be kept on site as a back-up. Required specimens will be batch-shipped frozen 
throughout the study to Tirouvanziam Laboratory Emory University for analysis.  
The specimens will be analyzed for:  
 
Plasma Redox assay: GSH, GSSH, cysteine, cystine, redox ratios and potential for the 
GSH and cysteine couples will be assessed. 
 
Plasma metabolomics assay: acylcarnitines, amino acids, biogenic amines, 
monosaccharides, sphingolipids and glycerophospholipids will be assessed 
 
9.3.2.   Fecal Calprotectin 
Collection supplies and instructions will be provided for fecal collection at home as noted in the 
Schedule of Events. Subjects will be instructed to collect and freeze the samples at home and 
bring to the clinic at their next study visit. The sample will be stored frozen at -70 to -80ºC at the 
site and batch shipped to the CFFT TDN Center for Biochemical Markers (CBM) located at 
Children’s Hospital Colorado (Aurora, CO) for fecal calprotectin analysis. 
 
9.3.3    Specimens for Long-Term Biorepository Storage 
Instructions for specimen collection, processing, storage and shipping of samples will be 
provided in the Study Laboratory Manual.  
For long-term biorepository storage, the following specimens will be collected from participating 
subjects who provide optional consent for the CFF Registry ID and for the CFFT biorepository 
as noted in the Schedule of Events:  
 Plasma: Approximately 4.5 mL of blood will be collected. 
 Fecal: a portion of fecal sample (collected per the instructions noted in Section 9.3.2 
above) will be sent to the CFFT Biorepository for long-term storage. 
The samples will be processed and stored frozen at -70 to -80ºC at the site and batch shipped to 
the CFFT biorepository for long-term biorepository storage.  
 
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10 EVALUATIONS BY VISIT 
10.1 Visit 1 (Day – 42 through– 1)  
1. Review the study with the subject (subject’s legal representative) and obtain written informed 
consent and HIPAA authorization and assent, if appropriate. 
2. Review the optional consent for Specimen Banking (Subjects who elect not to provide 
biorepository specimens are still eligible for this study). 
3. Review the “Consent for Collection and Use of your CFF Registry ID Number” and ensure 
that the subject (or subject’s legal representative) has checked one of the two options 
(Subjects who elect not to provide this information are still eligible for this study). 
4. Assign the subject a unique screening number. 
5. Record demographics data and if consent obtained, the CFF Registry ID. 
6. Record medical history, including a history of CF, diagnosis date, and prior CF treatments. 
7. Record concomitant medications. 
8. Perform a complete physical examination. 
9. Measure and record height and weight. 
10. Dispense site specific fecal elastase collection kit (only for subjects without a historical 
fecal elastase test to document pancreatic insufficiency). 
11. Dispense study fecal collection kit. 
12. Schedule subject for Visit 2 (within 41 days). 
10.2 Visit 2 (Day 0) 
It is suggested to have a pre-visit reminder call at least one day prior to the visit to remind 
subject of key visit information (e.g., date, time, and fecal sample collection).  
Day of Visit: 
1. Review all eligibility criteria to confirm subject’s eligibility for participation. 
2. Obtain subject-collected fecal sample: 
 
TDN CBM laboratory testing (fecal calprotectin) 
 
Long-term bio-repository storage, CFFT biorepository vendor (only for subjects 
with signed optional consent for CFF Registry ID and biorepository) 
3. If applicable (only for subjects without a historical fecal elastase test to document 
pancreatic insufficiency), obtain the site specific fecal elastase kit dispensed at Visit 1 from 
the subject and send to the local laboratory for testing.  
4. Administer Cystic Fibrosis GI parent questionnaire.  
5. Record changes to concomitant medications. Perform an abbreviated physical examination.  
6. Measure and record height and weight. 
 
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7. Obtain and record vital signs and oximetry. 
8. Perform and record spirometry, if ≥4 years old at the time of randomization. 
9. Collect blood for: 
 
On-site clinical laboratory testing (Refer to section 9.2.1 and 9.2.2) 
 
REDOX/Metabolomics testing 
 
Long-term bio-repository storage, CFFT biorepository vendor (only for subjects 
with signed optional consent for CFF Registry ID and biorepository) 
10. For eligible subjects, complete the appropriate data entry in Medidata Rave to complete the 
randomization. (Refer to Study Manual and CRF completion Guidelines)  
11. Dispense fecal collection kit. 
12. Dispense study drug and syrup. 
13. Administer first dose of the study drug. 
14. Instruct subjects/parents on study drug administration and provide written instructions. 
15. Provide subject diary. 
16. Schedule subject for Visit 3 (Day 84± 7 days). 
10.3 Combined Visit 1 and Visit 2 (Day 0) 
 Visit 1 can be combined with Visit 2 if a fecal sample can be obtained prior to dosing. 
1. Review the study with the subject (subject’s legal representative) and obtain written informed 
consent and HIPAA authorization and assent, if appropriate. 
2. Review the optional consent for Specimen Banking (Subjects who elect not to provide 
biorepository specimens are still eligible for this study). 
3. Review the “Consent for Collection and Use of your CFF Registry ID Number” and ensure 
that the subject (or subject’s legal representative) has checked one of the two options 
(Subjects who elect not to provide this information are still eligible for this study). 
4. Assign the subject a unique screening number. 
5. Record demographics data and if consent obtained, the CFF Registry ID. 
6. Record medical history, including a history of CF, diagnosis date, and prior CF treatments. 
7. Record concomitant medications. 
8. Review all eligibility criteria to confirm subject’s eligibility for participation. 
9. Administer Cystic Fibrosis GI parent questionnaire. 
10. Perform a complete physical examination. 
11. Measure and record height and weight. 
12. Obtain and record vital signs and oximetry. 
 
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13. Perform and record spirometry, if ≥4 years old at the time of randomization. 
14. Obtain subject-collected fecal sample: 
 
TDN CBM laboratory testing (fecal calprotectin) 
 
Long-term bio-repository storage, CFFT biorepository vendor (only for subjects 
with signed optional consent for CFF Registry ID and biorepository) 
15. If applicable (only for subjects without a historical fecal elastase test to document 
pancreatic insufficiency), obtain subject-collected fecal sample and send to the local 
laboratory for fecal elastase testing.  
16. Collect blood for: 
 
On-site clinical laboratory testing (Refer to section 9.2.1 and 9.2.2) 
 
REDOX/Metabolomics testing 
 
Long-term bio-repository storage (CFFT biorepository vendor) (only for subjects 
with signed optional consent for CFF Registry ID and biorepository) 
17. For eligible subjects, complete the appropriate data entry in Medidata Rave to complete the 
randomization. (Refer to Study Manual and CRF Completion Guidelines) 
18. Dispense fecal collection kit  
19. Dispense study drug and syrup. 
20. Administer first dose of the study drug. 
21. Instruct subjects/parents on study drug administration and provide written instructions. 
22. Provide subject diary. 
23. Schedule subject for Visit 3 (Day 84 ± 7 days). 
10.4 Phone Call Week 4 (Day 28 ± 7 days) 
1. 
Record any AEs and changes to concomitant medications. If a new IV, oral or inhaled 
antibiotic was prescribed, ensure that the Antibiotic Utilization Assessment form was 
completed. 
2. 
Review adherence to the study treatment. 
10.5 Phone Call Week 8 (Day 56 ± 7 days) 
3. 
Record any AEs and changes to concomitant medications. If a new IV, oral or inhaled 
antibiotic was prescribed, ensure that the Antibiotic Utilization Assessment form was 
completed. 
4. 
Review adherence to the study treatment. 
5. 
Remind the parent/legal guardian to retain empty/or unused drug containers and bring them 
along with the diary to Visit 3. 
 
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10.6 Visit 3 (Day 84 ± 7 days) 
It is suggested to have a pre-visit reminder call at least one day prior to the visit to remind 
subject of key visit information (e.g., date, time, fecal sample collection, bring all used and 
unused study drug bottles and diary to visit).   
Day of Visit: 
1. Administer Cystic Fibrosis GI parent questionnaire.  
2. Perform adverse event review.  
3. Record changes to concomitant medications. If a new IV, oral or inhaled antibiotic was 
prescribed, ensure that the Antibiotic Utilization Assessment form was completed. 
4. Perform an abbreviated physical examination. 
5. Measure and record height and weight. 
6. Obtain and record vital signs and oximetry. 
7. Perform and record spirometry, if ≥4 years old at the time of randomization. 
8. Obtain subject-collected fecal sample for: 
 
TDN CBM laboratory testing (fecal calprotectin) 
 
Long-term bio-repository storage, CFFT biorepository vendor (only for subjects 
with signed optional consent for CFF Registry ID and biorepository) 
9. Review subject diary. 
10. Collect returned study drug containers. 
11. Dispense fecal collection kit. 
12. Dispense study drug and syrup. 
13. Provide subject diary. 
14. Schedule subject for Visit 4 (Day 168 ± 14 days). 
10.7 Phone Call Week 16 (Day 112 ± 7 days) 
1. Record any AEs and changes to concomitant medications. If a new IV, oral or inhaled 
antibiotic was prescribed, ensure that the Antibiotic Utilization Assessment form was 
completed. 
2. Review adherence to the study treatment. 
10.8 Phone Call Week 20 (Day 140 ± 7 days) 
1. Record any AEs and changes to concomitant medications. If a new IV, oral or inhaled 
antibiotic was prescribed, ensure that the Antibiotic Utilization Assessment form was 
completed. 
2. Review adherence to the study treatment. 
 
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3. Remind the parent/legal guardian to retain empty/or unused drug containers and bring them 
along with the diary to Visit 4. 
10.9 Visit 4 (Day 168 ± 14 days) 
It is suggested to have a pre-visit reminder call at least one day prior to the visit to remind 
subject of key visit information (e.g., date, time, fecal sample collection, bring all used and 
unused study drug bottles and diary to visit). 
Day of Visit: 
1. Administer Cystic Fibrosis GI parent questionnaire.  
2. Perform adverse event review.  
3. Record changes to concomitant medications. If a new IV, oral or inhaled antibiotic was 
prescribed, ensure that the Antibiotic Utilization Assessment form was completed. 
4. Perform an abbreviated physical examination.  
5. Measure and record height and weight. 
6. Obtain and record vital signs and oximetry. 
7. Perform and record spirometry, if ≥4 years old at the time of randomization. 
8. Obtain subject-collected fecal sample for: 
 TDN CBM laboratory testing (fecal calprotectin) 
 
Long-term bio-repository storage, CFFT biorepository vendor (only for subjects 
with signed optional consent for CFF Registry ID and biorepository) 
9. Collect blood for: 
 On-site clinical laboratory testing (Refer to section 9.2.1 and 9.2.2) 
 REDOX/Metabolomics testing 
 
Long-term bio-repository storage, CFFT biorepository vendor (only for subjects 
with signed optional consent for CFF Registry ID and biorepository) 
10. Review subject diary. 
11. Collect and count returned study drug containers. 
12. Schedule subject for Follow up Phone Call or Visit 5 (Day 182 ± 14 days). 
10.10 Follow-Up Phone Call or Visit 5 (Day 182 ± 14 days) 
For subjects with normal or abnormal, non-clinically significant lab values at Visit 4 and no 
on-going treatment-related AEs, call the subject’s legal guardian and: 
1. Review AEs and changes in concomitant medications with the subject.  
2. Record in CRF. 
 
 
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For subjects with on-going treatment related AEs at Visit 4, have the subject return to the 
clinic for a follow-up visit. 
1. Review AEs and changes in concomitant medications with the subject.  
2. Record in CRF. 
 
For subjects with abnormal, clinically significant clinical lab values at Visit 4, have the 
subject return to the clinic for a follow-up visit. 
1. Record any AEs. 
2. Record changes to concomitant medications. 
3. Collect blood for laboratory tests that were abnormal and clinically significant at Visit 4 
(e.g., Refer to section 9.2.1 and 9.2.2).  
10.11 Early Permanent Discontinuation of Study Treatment Visit  
1. Administer Cystic Fibrosis GI parent questionnaire.  
2. Perform AEs review.  
3. Record changes to concomitant medications. If a new IV, oral or inhaled antibiotic was 
prescribed, ensure that the Antibiotic Utilization Assessment form was completed. 
4. Perform an abbreviated physical examination. 
5. Measure and record height and weight. 
6. Obtain and record vital signs and oximetry. 
7. Perform and record spirometry, if ≥4 years old at the time of randomization. 
8. Obtain subject-collected fecal sample (if available) for: 
 TDN CBM laboratory testing (fecal calprotectin) 
 
Long-term bio-repository storage, CFFT biorepository vendor (only for subjects 
with signed optional consent for CFF Registry ID and biorepository) 
9. Collect blood for: 
 On-site clinical laboratory testing (Refer to section 9.2.1 and 9.2.2) 
 REDOX/Metabolomics testing 
 
Long-term bio-repository storage, CFFT biorepository vendor (only for subjects 
with signed optional consent for CFF Registry ID and biorepository) 
10. Review subject diary. 
11. Collect and count returned study drug containers. 
12. Encourage the subject to return for any remaining study visits. 
 
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11 ADVERSE EXPERIENCE REPORTING AND DOCUMENTATION 
11.1 Adverse Events (AE) 
An AE is any untoward medical occurrence in a clinical investigation of a patient administered a 
pharmaceutical product and that does not necessarily have a causal relationship with the 
treatment.  An AE is therefore any unfavorable and unintended sign (including an abnormal 
laboratory finding), symptom or disease temporally associated with the administration of an 
investigational product, whether or not related to that investigational product.  An unexpected 
AE is one of a type not identified in nature, severity, or frequency in the current Investigator’s 
Brochure or of greater severity or frequency than expected based on the information in the 
Investigator’s Brochure. 
The Investigator will probe, via discussion with the subject, for the occurrence of AEs during 
each subject visit and record the information in the site’s source documents.  AEs will be 
recorded in the subject CRF.   
AE Severity 
The National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE) 
Version 4.0, as modified for cystic fibrosis, should be used to assess and grade AE severity, 
including laboratory abnormalities judged to be clinically significant. The modified criteria can 
be found in the Study Reference Binder.  If the experience is not covered in the modified criteria, 
the guidelines shown in Table 2 below should be used to grade severity.  It should be pointed out 
that the term “severe” is a measure of intensity and that a severe AE is not necessarily serious. 
Table 2.  AE Severity Grading 
Severity (Toxicity Grade) 
Description 
Mild (1) 
Mild; asymptomatic or mild symptoms; clinical or diagnostic 
observations only; intervention not indicated 
Moderate (2)  
Moderate; minimal, local or noninvasive intervention indicated; 
limiting age-appropriate Instrumental activities of daily living 
(e.g., preparing meals, using the telephone, managing money)  
Severe (3) 
 
Severe or medically significant but not immediately life-
threatening; hospitalization or prolongation of hospitalization 
indicated; disabling; limiting self-care activities of daily living 
(e.g., bathing, dressing, feeding self, using toilet, taking 
medications) 
Life-threatening (4) 
Life-threatening consequences; urgent intervention indicated 
Death (5) 
Death related to AE 
 
AE Relationship to Study Drug 
The relationship of an AE to the study drug should be assessed using the following the guidelines 
in Table 3. 
 
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Table 3.  AE Relationship to Study Drug 
Relationship 
to Drug 
Comment 
Definitely 
Previously known toxicity of agent; or an event that follows a reasonable 
temporal sequence from administration of the drug; that follows a known or 
expected response pattern to the suspected drug; that is confirmed by stopping 
or reducing the dosage of the drug; and that is not explained by any other 
reasonable hypothesis. 
Probably 
An event that follows a reasonable temporal sequence from administration of 
the drug; that follows a known or expected response pattern to the suspected 
drug; that is confirmed by stopping or reducing the dosage of the drug; and that 
is unlikely to be explained by the known characteristics of the subject’s clinical 
state or by other interventions. 
Possibly 
An event that follows a reasonable temporal sequence from administration of 
the drug; that follows a known or expected response pattern to that suspected 
drug; but that could readily have been produced by a number of other factors. 
Unrelated 
An event that can be determined with certainty to have no relationship to the 
study drug. 
 
 
11.2 Serious Adverse Experiences (SAE) 
An SAE is defined as any AE that results in any of the following outcomes: 
 
death 
 
a life-threatening adverse experience 
 
inpatient hospitalization or prolongation of existing hospitalization 
 
a persistent or significant disability/incapacity 
 
a congenital anomaly/birth defect  
Other important medical events may also be considered an SAE when, based on appropriate 
medical judgment, they jeopardize the subject or require intervention to prevent one of the 
outcomes listed.  
11.2.1 Serious Adverse Experience Reporting 
Study sites will document all SAEs that occur (whether or not related to study drug) on an SAE 
Report Form.  The collection period for all SAEs will begin after informed consent is obtained 
and end after procedures for the final study visit/call have been completed. 
All SAE Report Forms will be reviewed by the site investigator and sent to the TDNCC within 
one business day of the site learning of the event.  Sites will send the SAE report by either: 
 
Email (scanned copy) to: cfsaesfacsys@seattlechildrens.org 
 
TDNCC SAE Fax: (206) 985-3278 
 
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The site will notify the TDNCC of additional information or follow-up to an initial SAE Report 
as soon as relevant information is available.  The TDNCC Medical Monitor may request 
additional information related to the SAE. Follow-up information is reported on an SAE Report 
Form. 
In accordance with the standard operating procedures and policies of the local Institutional 
Review Board (IRB)/Independent Ethics Committee (IEC), the site investigator will report SAEs 
to the IRB/IEC.   
11.3 Medical Monitoring 
The TDNCC Medical Monitoring Group should be contacted directly at this number to report 
medical concerns or questions regarding safety: 
 
Pager: (800) 341-0961  
12 DISCONTINUATION AND REPLACEMENT OF SUBJECTS 
12.1 Early Permanent Discontinuation of Study Treatment  
A subject may be permanently discontinued from study treatment at any time if the subject, the 
investigator, or the Sponsor feels that it is not in the subject’s best interest to continue.  The 
following is a list of possible reasons for early permanent discontinuation of study treatment:  
 
Subject or subject’s legal representative decision  
 
Adverse event  
 
Protocol violation  
 
Death  
If a subject is permanently discontinued from treatment due to an adverse event, the subject will 
be followed and treated by the Investigator until the abnormal parameter or symptom has 
resolved or stabilized.   
All subjects who permanently discontinue study treatment early, for any reason, should come in 
for an early permanent discontinuation of study treatment visit as soon as possible and then 
should be encouraged to remain on-study and complete all remaining scheduled visits and 
procedures. 
12.2 Early Withdrawal of Subjects from the Study 
All subjects are free to withdraw from participation at any time, for any reason, specified or 
unspecified, and without prejudice.  This may include subjects who withdraw from study 
treatment early and who decline to continue to come in for remaining follow-up visits.  
Reasonable attempts will be made by the investigator to provide a reason for early subject 
withdrawals.  The reason for the subject’s early withdrawal from the study will be specified in 
the subject’s source documents.  Subjects who withdraw early from the study should be 
encouraged to come in for a final study visit (follow the procedures for Visit 4 Refer to Section 
10.9).  
 
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12.3 Replacement of Subjects 
Subjects who withdraw from the study will not be replaced.   
13 PROTOCOL VIOLATIONS 
A protocol violation occurs when the subject, investigator, or the Sponsor fails to adhere to 
significant protocol requirements affecting the inclusion, exclusion, subject safety and primary 
endpoint criteria.  Protocol violations for this study include, but are not limited to, the following: 
 
Failure to meet inclusion/exclusion criteria 
 
Failure to obtain weight at either Visit 2 (or Combined Visit 1 and Visit 2) or Visit 4 
 
Use of prohibited concomitant medication that impacts the safety of the subject or is 
anticipated to significantly affect the primary endpoint 
 
Inappropriate administration of study drug that impacts the safety of the subject  or 
inappropriate dispensing of study drug (e.g., a subject randomized to the placebo 
arm is given GSH)  
Failure to comply with Good Clinical Practice (GCP) guidelines will also result in a protocol 
violation. The Sponsor will determine if a protocol violation should result in early permanent 
discontinuation of study treatment for a subject. 
When a protocol violation occurs, it will be discussed with the investigator and a Protocol 
Violation Form detailing the violation will be generated. This form will be signed by a Sponsor 
representative and the Investigator. A copy of the form will be filed in the site’s regulatory 
binder and in the Sponsor’s files. The site will report the violation to their IRB in accordance 
with their IRB reporting requirements. 
14 DATA SAFETY MONITORING  
The Cystic Fibrosis Foundation DSMB will establish a Data Monitoring Committee (DMC) to 
review data relating to safety and efficacy, to conduct and review interim analyses, and to ensure 
the continued scientific validity and merit of the study, according to the Cystic Fibrosis 
Foundation DSMB Operations Manual and a DMC Charter created for this protocol. There will 
be one formal interim review conducted by the DMC for the purpose of monitoring study 
conduct, assessing patient safety and assessing pre-specified stopping rules. Additional safety 
reviews will be conducted by the DMC as specified in the DMC Charter. Further details 
regarding the timing and content of the interim reviews (both formal and safety) will be fully 
specified in the DMC charter and approved by the study appointed DMC prior to study initiation. 
15 STATISTICAL METHODS AND CONSIDERATIONS 
15.1 
General Considerations 
Prior to the analysis of the final study data, a detailed Statistical Analysis Plan (SAP) will be 
written, describing all analyses that will be performed.  The SAP will contain any modifications 
to the analysis plan described below. All analyses will be performed using SAS® (SAS Institute, 
Inc., Cary, NC, USA) or R (R Foundation for Statistical Computing, Vienna, Austria). 
 
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For the purposes of analyses, baseline will be defined as Day 0 (Randomization/Visit 2). Except 
where otherwise noted, comparisons of continuous variables between treatment arms will utilize 
two-sample t-tests or multiple linear regression/ANOVA, proportions will be compared using 
Fisher’s exact test, and rate ratios will be compared using Poisson regression. Except where 
otherwise noted, all tests will be two-sided and statistical significance will be determined at the 
0.05 level. Missing data methods for the primary and key secondary endpoints will be described 
in the SAP. No adjustment for multiple comparisons will be made.   
15.1.1 Data Sets Analyzed 
All analyses will be performed using a modified intent-to-treat (m-ITT) population, which is 
defined as all randomized subjects who took at least one dose of the study drug. Subjects who are 
discontinued from study drug temporarily or permanently are encouraged to complete all 
remaining study visits and will remain in the analysis population according to ITT. Subjects will 
be analyzed according to the treatment arm to which they were randomized. The safety 
population will be used to summarize all safety measures and is identical to the m-ITT 
population. The primary efficacy analysis and key secondary analyses will be repeated in the 
per-protocol population, which is defined as subjects having completed >70% of study drug 
doses based on subject diary and having incurred no major protocol violations. The per-protocol 
analyses will analyze subjects according to the treatment they received. 
15.2 
Demographic and Baseline Characteristics 
Treatment groups will be described with respect to baseline demographic and clinical 
characteristics such as age, sex, race/ethnicity, genotype, height, weight, body mass index, fecal 
elastase, use of chronic concomitant medications (e.g., CFTR modulators, hypertonic saline, 
dornase alpha, azithromycin, acid reducing medications), and FEV1 % predicted.  
15.3 
Analysis of Primary Endpoint 
Based on evidence from prior studies, it is hypothesized that six months of oral GSH will be 
associated with an improved weight-for-age z-score as compared to six months of oral placebo. 
Therefore the null hypothesis is that there is no difference between treatment groups in the 6 
month change in weight-for-age z-score. 
The primary endpoint is the difference between the GSH and placebo groups in the change in 
weight-for-age z-score from Visit 2 to Visit 4 (Week 24). The difference between treatment 
groups will be estimated using a linear mixed effects model which will incorporate Visit 3 
(Week 12) weight-for-age z-score measurements. The model will adjust for randomization strata 
and assume, if estimable, an unstructured covariance structure. Least squares means at each visit 
and the estimated treatment effect and corresponding 95% confidence intervals and p-values will 
be reported from the model. The p-value will be evaluated against a two-sided 0.05 level of 
significance. Weight-for-age z-scores will be calculated using CDC reference equations [32]. 
Graphical displays will be used to show both unadjusted and adjusted mean changes in weight-
for-age z-score between visits for the two treatment groups.  
Sensitivity analyses of the primary endpoint will include: 
 
Performing the primary efficacy analysis on the per-protocol population. 
 
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 
Performing the primary efficacy analysis on the sub population of subjects 
determined to be pancreatic insufficient (defined as documented fecal elastase < 200 
µg/g). 
 
Missing data methods.  
Missing data sensitivity analyses of the primary endpoint will include the least favorable 
treatment arm imputation method, which imputes missing values with the mean change from the 
treatment arm with the worst change in the observed case analysis.  Further details regarding 
missing data methods will be provided in the SAP. 
Additional sensitivity analyses of the primary endpoint may be performed to adjust for potential 
baseline confounders.   
15.4 
Analysis of Secondary Endpoints 
Descriptive analyses and graphical displays will be used to summarize all secondary endpoints. 
Endpoints will be compared between the GSH and placebo treatment groups from Visit 2 
through Visit 4. 
 
Continuous secondary endpoints which are collected at Visits 2, 3, and 4, including absolute 
changes and relative changes in weight, weight percentile, height, height-for-age z-score, height 
percentile, BMI, lung function (FEV1 (liters and % predicted), FVC (liters and % predicted) and 
FEF25-75 (liters/second and % predicted)), and fecal calprotectin, will be modeled using a linear 
mixed effects model similarly to the primary endpoint. The estimated treatment effect for the 
change for each secondary endpoint from Visit 2 to Visit 4 will be presented as well as 
corresponding 95% confidence intervals and p-values. Predicted values for spirometry measures 
at each visit will be calculated for those subjects ≥ 4 years of age at baseline using the Global 
Lung Initiative reference equations [33] Height for age z-score and height and weight percentiles 
will be calculated using the CDC reference equations [32]. 
 
Continuous measures collected only at Visit 2 and Visit 4, including neutrophil, platelets, and hs-
CRP will be analyzed using ANOVA. The estimated treatment effect for the change for each 
secondary endpoint from Visit 2 to Visit 4 will be presented as well as corresponding 95% 
confidence intervals and p-values. 
 
Event rates for hospitalization, PEs, intravenous antibiotic usage, inhaled antibiotic usage, and 
oral antibiotic usage from Visit 2 through Visit 4 will be descriptively summarized and 
differences in the proportions of subjects with an event between the treatment groups will be 
estimated with accompanying 95% confidence intervals. Event rates will be compared between 
treatment groups using Poisson regression. 
Descriptive analyses will be used to summarize GI parent questionnaire data collected 
throughout the study.  For each of the 14 gastrointestinal symptoms measured, changes from 
Visit 2 to Visit 4 will be summarized and compared between the GSH and placebo treatment 
groups. 
 
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15.5 
Analysis of Safety Endpoints 
All reported treatment emergent SAEs and AEs will be coded using MedDRA and grouped by 
body system. Treatment emergent AEs are defined as AEs presenting post study treatment 
initiation. SAEs and AEs will be tabulated by treatment group using standard coding terms 
sorted by body system. The incidence of AEs in each treatment arm will be tabulated by severity.  
The number of SAEs and AEs will be summarized for each treatment group as follows: (i) The 
proportion of subjects with at least one (S)AE, (ii) The average number of (S)AEs per patient, 
and (iii) The rate of (S)AEs per patient week of follow-up. Histograms showing the frequency of 
the number of (S)AEs in each treatment group will be included. Rates of (S)AEs by System 
Organ Class (SOC) will be presented by treatment group. Poisson regression modeling will be 
used to derive rate ratios and 95% CIs comparing overall S(AE) rates by treatment group as well 
as within each SOC. The rate ratios will be compared using a two-sided 0.05 level test for 
Poisson count data. 
Safety lab data at Visit 2 and Visit 4 and changes from baseline will be summarized by treatment 
group. In addition, the following clinical laboratory summaries will be presented by treatment 
group: (i) the incidence of clinically significant abnormalities at each study visit; and (ii) tables 
summarizing the frequencies of subjects below, within, and above the normal reference ranges at 
baseline and end of study; and (iii) tables displaying baseline to end of study shifts in each 
laboratory value (shifts between below, within or above normal range). 
15.6 
Analysis of Exploratory Endpoints 
To assess potential mechanisms of action and describe GSH metabolism, changes in circulating 
GSH levels and levels of other redox intermediates which are co-regulated with GSH will be 
analyzed in an exploratory manner. Additionally, changes in up to 180 metabolites including 
acylcarnitines, amino acids, biogenic amines, monosaccharides, sphingolipids and 
glycerophospholipids will be analyzed in an exploratory manner. These exploratory analyses will 
be conducted by Dr. Rabindra Tirouvanziam at Emory University. 
15.7 
Analysis of Study Drug Discontinuation and Compliance  
The proportion of subjects permanently or temporarily discontinuing study drug will also be 
tabulated by treatment group. Drug discontinuation events will be categorized as: (1) 
Permanently discontinued study drug, (2) Permanently discontinued study drug and withdrew 
from study, and (3) Temporarily discontinued study drug. Reason for permanent and temporary 
drug discontinuation will be summarized.  
 
Estimates of study drug compliance will be summarized by treatment group based on subject 
diary information.  If a subject discontinued study drug early for any reason, study drug 
compliance will be based on the intended duration of treatment per protocol. Compliance 
percentage is calculated as: (Number of doses reported taken / Number of expected doses) x 100. 
15.8 
Interim Analysis 
An independent DMC will be appointed by the Cystic Fibrosis Foundation DSMB to monitor 
enrollment, study conduct, efficacy and safety at specified time points and throughout the study 
 
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as needed. A priori stopping rules for efficacy, safety and futility with respect to the primary 
endpoint will be formalized in conjunction with the DMC and will be put in place prior to 
initiating the study. One formal interim review will be conducted when approximately 25 
subjects have completed the study. Details of these pre-defined stopping rules are specified in the 
DMC charter. 
15.9 
Sample Size  
The primary endpoint is the difference between treatment groups of the change in weight-for-age 
z-score from Visit 2 to Visit 4 (Week 24). Data from prior studies of similar populations and 
durations are available to estimate sample size and power for the study including a randomized, 
placebo-controlled trial of oral GSH in Italian children chronically taking pancreatic enzymes, as 
well as a factorial randomized trial comparing antipseudomonal regimens in US children with 
newly acquired Pseudomonas aeruginosa infection. These studies suggest a standard deviation 
of the change in weight-for-age z-score ranging from 0.20 to 0.29. A query of CF registry data of 
a similar population found the standard deviation of the 6-month change in weight-for-age z-
score to be higher (0.37). A previous study of oral GSH in children, conducted in Italy, found the 
weight-for-age z-score difference between the GSH arm and the placebo arm after 6 months of 
therapy to be 0.34. The following table provides example weight changes in kilograms over a 6 
month period for certain patient age and sex combinations, as well as how those gains translate 
into changes in weight-for-age z-score. 
Subject Age 
and Sex  
at Baseline 
Weight 
Baseline (kg) 
Weight  
Visit 4 (kg) 
6-month 
change 
(kg)  
Weight  
at baseline 
(z-score) 
Weight  
at Visit 4 
(z-score) 
6 month 
change  
(z-score) 
9-year old boy 
25 
28 
3 
-0.87 
-0.46 
0.42 
7-year old girl 
19 
20.75 
1.75 
-1.27 
-1 
0.27 
3-year old boy 
14 
15.25 
1.25 
-0.21 
0.01 
0.22 
4-year old girl 
15 
17.5 
2.5 
-0.4 
0.28 
0.68 
 
The figure below displays a range of detectable treatment effect sizes and resulting sample sizes 
for 3 standard deviations (SD = 0.2, 0.3 and 0.4) Assuming a conservative standard deviation of 
0.4, a total sample size of 54 provides 90% power to detect a treatment effect of 0.36 or greater. 
It is anticipated from prior CF trials conducted through the TDNCC that the attrition rate will be 
less than 10% for a study of this duration, thus it is reasonable to expect that a total sample size 
of 60 will enable at least 54 subjects to complete the trial.  
 
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0.2
0.3
0.4
0.5
0.6
0.7
0
20
40
60
80
100
Total sample size needed for 90% pow
Treatment effect (6-month change in weig
Sample size (assuming 10% attrition)
SD = 0.2
SD = 0.3
SD = 0.4
 
16 DATA COLLECTION, RETENTION AND CLINICAL MONITORING 
16.1 Data Collection Instruments 
The Investigator will prepare and maintain adequate and accurate source documents designed to 
record all observations and other pertinent data for each subject who signs informed consent.  
Study personnel at each site will enter data from source documents corresponding to a subject’s 
visit into the protocol-specific electronic CRF when the information corresponding to that visit is 
available.  Subjects will not be identified by name in the study database or on any study 
documents to be collected by the Sponsor (or designee), but will be identified by a site number, 
subject number and initials. 
If a correction is required for a CRF, the time and date stamp tracks the person entering or 
updating CRF data and create an electronic audit trail. 
The Investigator is responsible for all information collected on subjects enrolled in this study.  
All data collected during the course of this study must be reviewed and verified for completeness 
and accuracy by the Investigator.  A CD containing the CRF data will be provided to the site to 
be retained with the essential documents at the Investigator’s site at the completion of the study.  
16.2 Data Management Procedures 
TDNCC utilizes Medidata Solutions, Inc. (Medidata) Rave for their EDC studies. The Medidata 
Rave EDC system is designed to be US Code of Federal Regulations (CFR) 21 Part 11 
compliant, with a robust audit trail system and electronic signature capabilities.  Study personnel 
 
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at each site will enter data from a subject’s visit onto electronic CRF screens via a web browser.  
Study subjects will not be identified by name in the study database or on any data capture 
screens, but will be identified by initials and a unique subject identification number.  Only study 
personnel at the individual sites will be able to link the study ID to the subject’s name.  The 
Biostatistics and Clinical Data Management group of the TDNCC will be responsible for data 
processing, in accordance with procedural documentation.  Database lock will occur once quality 
assurance procedures have been completed.  All procedures for the handling and analysis of data 
will be conducted using good computing practices for the handling and analysis of data for 
clinical trials.   
Data Quality Control and Reporting 
After data have been entered into the study database, data validation checks will be applied on a 
regular basis.  Queries are entered, tracked, and resolved through the EDC system directly.  The 
study database will be updated in accordance with the resolved queries. All changes to the study 
database will be documented in an audit trail.  
16.3 Security and Archival of Data 
The EDC system is hosted by Medidata; the data are stored at Medidata’s primary data center in 
Houston, Texas, with fail-safe data centers in New Jersey.  Data are regularly backed up by 
Medidata. 
Medidata maintains 21 CFR Part 11-compliant electronic systems, with procedures in place to 
safeguard against unauthorized acquisition of data.  Any authorized communication with the 
Medidata servers at the Houston Data Center is conducted via SSL (128-bit) encryption.  Robust 
password procedures, consistent with 21 Part 11, are in place.  Robust physical security 
procedures are in place at the Houston Data Center to prevent unauthorized personnel physical 
access to the server rooms.  EDC account access is maintained and monitored by the Biostatistics 
and Clinical Data Management group of the TDNCC. 
Other databases will be stored on Seattle Children’s servers and are safeguarded against 
unauthorized access by established security procedures.  Network accounts are password 
protected and maintained and monitored by Seattle Children’s.  Data is backed up regularly 
according to the Information Services group’s procedures.  
Note that there is an intention to make biospecimens and associated data available to 
investigators for future exploration. The biospecimens will be collected under IRB approval, 
processed according to a rigorous standard operating procedure and stored at a central facility, 
with appropriate procedures to enable long term, stable storage. Researchers may apply, via a 
standardized process, for use of de-identified data and specimens for research purposes. 
Applications will undergo a scientific review process administered through CFFT. When 
applying for use of data or specimens, the applicant must agree to: (1) use the data and 
specimens only for research purposes and to not make any attempts to try to identify any 
individual subject; (2) securing the data and specimens using appropriate methods; and (3) 
destroy or return the data (and specimens) in accordance with the specimen/data use agreement 
after analyses are completed.  Before data or specimens will be released to an investigator, 
documentation of IRB exemption or approval from their institution must be provided to the 
CFFT. 
 
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16.4 Availability and Retention of Investigational Records 
The Investigator must make study data accessible to the monitor, other authorized 
representatives of the Sponsor (or designee), IRB/IEC, and Regulatory Agency (e.g., FDA) 
inspectors upon request.  A file for each subject must be maintained that includes the signed 
Informed Consent, HIPAA Authorization and Assent Form and copies of all source 
documentation related to that subject.  The Investigator must ensure the reliability and 
availability of source documents from which the information on the CRF was derived. 
All study documents (e.g., patient files, signed informed consent forms (ICF), copies of CRFs, 
Essential Document and Study Reference Binders) must be kept secured for a period of two 
years following marketing of the investigational product or for two years after centers have been 
notified that the IND has been discontinued.  There may be other circumstances for which the 
Sponsor is required to maintain study records and, therefore, the Sponsor should be contacted 
prior to removing study records for any reason. 
16.5 Monitoring 
By signing this protocol, the Investigator grants permission to the Sponsor (or designee), and 
appropriate regulatory authorities to conduct on-site monitoring and/or auditing of all appropriate 
study documentation.  Monitoring visits will be conducted by representatives of the Sponsor 
according to the U.S. CFR 21 Part 312 and International Conference on Harmonisation (ICH) 
Guidelines for GCP (E6) and to ensure investigator compliance to 21 CFR Parts 50, 56 and 312 
and to GCP.   
16.6 Subject Confidentiality 
In order to maintain subject confidentiality, only a site number, subject number and subject 
initials will identify all study subjects on CRFs and other documentation submitted to the 
Sponsor.  If specific consent is given, the subject’s CFF patient registry number will also be 
collected. Additional subject confidentiality issues (if applicable) are covered in the Clinical 
Study Agreement. 
17 ADMINISTRATIVE, ETHICAL, REGULATORY CONSIDERATIONS 
The study will be conducted according to the Declaration of Helsinki, Protection of Human 
Volunteers (21 CFR 50), Institutional Review Boards (21 CFR 56), and Obligations of Clinical 
Investigators (21 CFR 312). 
To maintain confidentiality, all laboratory specimens, evaluation forms, reports and other records 
will be identified by a coded number and initials only.  Clinical information will not be released 
without written permission of the subject, except as necessary for monitoring by the FDA.  The 
Investigator must also comply with all applicable privacy regulations (e.g., Health Insurance 
Portability and Accountability Act of 1996, EU Data Protection Directive 95/46/EC). 
17.1 Protocol Amendments 
Any amendment to the protocol will be written by the Sponsor.  Protocol amendments cannot be 
implemented without prior written IRB/IEC approval except as necessary to eliminate immediate 
safety hazards to patients.  A protocol amendment intended to eliminate an apparent immediate 
 
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hazard to patients may be implemented immediately, provided the IRBs are notified within five 
working days. 
17.2 Institutional Review Boards and Independent Ethics Committees 
The protocol and consent form will be reviewed and approved by the IRB/IEC of each 
participating center prior to study initiation.  SAEs regardless of causality will be reported to the 
IRB/IEC in accordance with the standard operating procedures and policies of the IRB/IEC, and 
the Investigator will keep the IRB/IEC informed as to the progress of the study.  The Investigator 
will obtain assurance of IRB/IEC compliance with regulations. 
Any documents that the IRB/IEC may need to fulfill its responsibilities (such as protocol, 
protocol amendments, Investigator’s Brochure, consent forms, information concerning patient 
recruitment, payment or compensation procedures, or other pertinent information) will be 
submitted to the IRB/IEC.  The IRB/IECs written unconditional approval of the study protocol 
and the informed consent form will be in the possession of the Investigator before the study is 
initiated.  The IRB/IEC’s unconditional approval statement will be transmitted by the 
Investigator to the Sponsor or designee prior to the shipment of study supplies to the site.  This 
approval must refer to the study by exact protocol title and number and should identify the 
documents reviewed and the date of review. 
Protocol and/or informed consent modifications or changes may not be initiated without prior 
written IRB/IEC approval except when necessary to eliminate immediate hazards to the patients 
or when the change(s) involves only logistical or administrative aspects of the study.  Such 
modifications will be submitted to the IRB/IEC and written verification that the modification 
was submitted and subsequently approved should be obtained.   
The IRB/IEC must be informed of revisions to other documents originally submitted for review; 
serious and/or unexpected adverse experiences occurring during the study in accordance with the 
standard operating procedures and policies of the IRB; new information that may affect 
adversely the safety of the patients of the conduct of the study; an annual update and/or request 
for re-approval; and when the study has been completed. 
17.3 Informed Consent Form  
Informed consent will be obtained in accordance with the Declaration of Helsinki, ICH GCP, US 
Code of Federal Regulations for Protection of Human Subjects (21 CFR 50.25[a,b], CFR 50.27, 
and CFR Part 56, Subpart A), the Health Insurance Portability and Accountability Act (HIPAA, 
if applicable), and local regulations. 
The Investigator will prepare the informed consent form, assent and HIPAA authorization and 
provide the documents to the Sponsor or designee for approval prior to submission to the 
IRB/IEC.  The consent form generated by the Investigator must be acceptable to the Sponsor and 
be approved by the IRB/IEC.  The written consent document will embody the elements of 
informed consent as described in the ICH and will also comply with local regulations. The 
Investigator will send an IRB/IEC-approved copy of the Informed Consent Form to the Sponsor 
(or designee) for the study file. 
 
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A properly executed, written, informed consent will be obtained from each subject prior to 
entering the subject into the trial.  Information should be given in both oral and written form and 
subjects (or their legal representatives) must be given ample opportunity to inquire about details 
of the study.  If appropriate and required by the local IRB/IEC, assent from the subject will also 
be obtained.  If a subject is unable to sign the ICF and the HIPAA authorization, a legal 
representative may sign for the subject.   A copy of the signed consent form (and assent) will be 
given to the subject or legal representative of the subject and the original will be maintained with 
the subject’s records. 
During the course of the study, if modifications are made to the consent form that impact the 
subject, the subject will be re-consented as described above.  
17.4 
Consent for Collection and Use of CFF Registry ID Number  
To facilitate possible future evaluation of retrospective and prospective information from all 
patients who screen for this study, consent will also be sought to collect the subject’s CFF 
Registry ID number at the screening visit.  The CFF registry collects data on all CF patients who 
consented to participate in the CFF registry and who are followed at CFF-accredited care centers.  
The registry data includes information from clinical encounters, hospitalizations courses of 
antibiotics, and year-end surveys.  Data also include microbiology results, spirometry results, CF 
genotype and other information. If specific consent is given to collect this number, the patient’s 
CF registry number will be recorded in the CRF. 
17.5 Publications  
The preparation and submittal for publication of manuscripts containing the study results shall be 
in accordance with a process determined by mutual written agreement among the study Sponsor 
and participating institutions.  The publication or presentation of any study results shall comply 
with all applicable privacy laws, including, but not limited to, the Health Insurance Portability 
and Accountability Act of 1996. 
17.6 Investigator Responsibilities 
By signing the Agreement of Investigator form, the Investigator agrees to: 
1. Conduct the study in accordance with the protocol and only make changes after notifying the 
Sponsor (or designee), except when to protect the safety, rights or welfare of subjects. 
2. Personally conduct or supervise the study (or investigation). 
3. Ensure that the requirements relating to obtaining informed consent and IRB review and 
approval meet federal guidelines, as stated in § 21 CFR, parts 50 and 56. 
4. Report to the Sponsor or designee any AEs that occur in the course of the study, in 
accordance with §21 CFR 312.64. 
5. Ensure that all associates, colleagues and employees assisting in the conduct of the study are 
informed about their obligations in meeting the above commitments. 
6. Maintain adequate and accurate records in accordance with §21 CFR 312.62 and to make 
those records available for inspection with the Sponsor (or designee). 
 
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7. Ensure that an IRB that complies with the requirements of §21 CFR part 56 will be 
responsible for initial and continuing review and approval of the clinical study. 
8. Promptly report to the IRB and the Sponsor (or designee) all changes in the research activity 
and all unanticipated problems involving risks to subjects or others (to include amendments 
and IND safety reports). 
9. Seek IRB approval before any changes are made in the research study, except when 
necessary to eliminate hazards to the patients/subjects. 
10. Comply with all other requirements regarding the obligations of clinical investigators and all 
other pertinent requirements listed in § 21 CFR part 312. 
18 REFERENCES 
 
1. 
Yen, E.H., H. Quinton, and D. Borowitz, Better Nutritional Status in Early Childhood Is 
Associated with Improved Clinical Outcomes and Survival in Patients with Cystic Fibrosis. J 
Pediatr, 2012. 
2. 
Stallings, V.A., et al., Evidence-based practice recommendations for nutrition-related 
management of children and adults with cystic fibrosis and pancreatic insufficiency: results of a 
systematic review. J Am Diet Assoc, 2008. 108(5): p. 832-9. 
3. 
Borowitz, D., et al., Gastrointestinal outcomes and confounders in cystic fibrosis. J Pediatr 
Gastroenterol Nutr, 2005. 41(3): p. 273-85. 
4. 
Roum, J.H., et al., Systemic deficiency of glutathione in cystic fibrosis. J Appl Physiol (1985), 
1985. 75(6): p. 2419-24. 
5. 
Visca, A., et al., Improvement in clinical markers in CF patients using a reduced glutathione 
regimen: an uncontrolled, observational study. J Cyst Fibros, 2008. 7(5): p. 433-6. 
6. 
Visca, A., et al., Oral reduced L-glutathione improves growth in pediatric cystic fibrosis patients. 
J Pediatr Gastroenterol Nutr, 2015. 60(6): p. 802-10. 
7. 
Borowitz, D., R.D. Baker, and V. Stallings, Consensus report on nutrition for pediatric patients 
with cystic fibrosis. J Pediatr Gastroenterol Nutr, 2002. 35(3): p. 246-59. 
8. 
Abbott, J., et al., Longitudinal impact of demographic and clinical variables on health-related 
quality of life in cystic fibrosis. BMJ Open, 2015. 5(5): p. e007418. 
9. 
Smyth, R.L., Intestinal inflammation in cystic fibrosis. Archives of Disease in Childhood, 2000. 
82(5): p. 394-399. 
10. 
Raia, V., et al., Evidence of chronic inflammation in morphologically normal small intestine of 
cystic fibrosis patients. Pediatr Res, 2000. 47(3): p. 344-50. 
11. 
Werlin, S.L., et al., Evidence of intestinal inflammation in patients with cystic fibrosis. J Pediatr 
Gastroenterol Nutr, 2010. 51(3): p. 304-8. 
12. 
Bruzzese, E., et al., Intestinal inflammation is a frequent feature of cystic fibrosis and is reduced 
by probiotic administration. Aliment Pharmacol Ther, 2004. 20(7): p. 813-9. 
13. 
Adriaanse, M.P.M., et al., Evidence for a Cystic Fibrosis Enteropathy. PLoS One, 2015. 10(10): 
p. e0138062. 
14. 
De Lisle, R.C. and D. Borowitz, The Cystic Fibrosis Intestine. Cold Spring Harb Perspect Med, 
2013. 
15. 
Norkina, O., et al., Inflammation of the cystic fibrosis mouse small intestine. Am J Physiol 
Gastrointest Liver Physiol, 2004. 286(6): p. G1032-41. 
 
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16. 
De Lisle, R.C., E.A. Roach, and O. Norkina, Eradication of small intestinal bacterial overgrowth 
in the cystic fibrosis mouse reduces mucus accumulation. J Pediatr Gastroenterol Nutr, 2006. 
42(1): p. 46-52. 
17. 
De Lisle, R.C., E. Roach, and K. Jansson, Effects of laxative and N-acetylcysteine on mucus 
accumulation, bacterial load, transit, and inflammation in the cystic fibrosis mouse small 
intestine. Am J Physiol Gastrointest Liver Physiol, 2007. 293(3): p. G577-84. 
18. 
Dhaliwal, J., et al., Intestinal inflammation and impact on growth in children with cystic fibrosis. 
J Pediatr Gastroenterol Nutr, 2015. 60(4): p. 521-6. 
19. 
Nichols, D.P. and J.F. Chmiel, Inflammation and its genesis in cystic fibrosis. Pediatr Pulmonol, 
2015. 50 Suppl 40: p. S39-56. 
20. 
Wu, G., et al., Glutathione metabolism and its implications for health. J Nutr, 2004. 134(3): p. 
489-92. 
21. 
Aw, T.Y., Cellular Redox: A Modulator of Intestinal Epithelial Cell Proliferation. Physiology, 
2003. 18(5): p. 201-204. 
22. 
McPherson, R.A. and G. Hardy, Clinical and nutritional benefits of cysteine-enriched protein 
supplements. Curr Opin Clin Nutr Metab Care, 2011. 14(6): p. 562-8. 
23. 
Skov, M., et al., The effect of short-term, high-dose oral N-acetylcysteine treatment on oxidative 
stress markers in cystic fibrosis patients with chronic P. aeruginosa infection -- a pilot study. J 
Cyst Fibros, 2015. 14(2): p. 211-8. 
24. 
Conrad, C., et al., Long-term treatment with oral N-acetylcysteine: affects lung function but not 
sputum inflammation in cystic fibrosis subjects. A phase II randomized placebo-controlled trial. J 
Cyst Fibros, 2015. 14(2): p. 219-27. 
25. 
Grey, V., et al., Improved glutathione status in young adult patients with cystic fibrosis 
supplemented with whey protein. J Cyst Fibros, 2003. 2(4): p. 195-8. 
26. 
Lai, H.J., et al., Recovery of birth weight z score within 2 years of diagnosis is positively 
associated with pulmonary status at 6 years of age in children with cystic fibrosis. Pediatrics, 
2009. 123(2): p. 714-22. 
27. 
Munck, A., Cystic fibrosis: Evidence for gut inflammation. Int J Biochem Cell Biol, 2014. 
28. 
Cantin, A.M., et al., Antioxidants in cystic fibrosis. Conclusions from the CF antioxidant 
workshop, Bethesda, Maryland, November 11-12, 2003. Free Radic Biol Med, 2007. 42(1): p. 15-
31. 
29. 
Pocock, S.J. and R. Simon, Sequential treatment assignment with balancing for prognostic factors 
in the controlled clinical trial. Biometrics, 1975. 31(1): p. 103-15. 
30. 
Han, B., N.H. Enas, and D. McEntegart, Randomization by minimization for unbalanced 
treatment allocation. Statistics in Medicine, 2009. 28(27): p. 3329-46. 
31. 
Miller, M.R., et al., Standardisation of spirometry. European Respiratory Journal, 2005. 26(2): p. 
319-38. 
32. 
Kuczmarski, R.J., et al., 2000 CDC Growth Charts for the United States: methods and 
development. Vital and Health Statistics. Series 11: Data from the National Health Survey, 
2002(246): p. 1-190. 
33. 
Quanjer, P.H., et al., Multi-ethnic reference values for spirometry for the 3-95-yr age range: the 
global 
lung 
function 
2012 
equations. 
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J, 
2012. 
40(6): 
p. 
1324-43.
 
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APPENDIX 1. SCHEDULE OF EVENTS 
 
VISIT 1  
SCREENING 
DAY           
(-42 THROUGH    
–1)a 
VISIT 2 
DAY 0 
PHONE  
CALL/ 
CONTACT 
WEEK 4 
DAY 28 ±7 
PHONE  
CALL/ 
CONTACT 
WEEK 8 
DAY 56 ±7 
VISIT 3  
WEEK 12  
DAY 84± 7 
DAYS 
PHONE  
CALL/ 
CONTACT 
WEEK 16 
DAY 112 ±7 
PHONE  
CALL/ 
CONTACT 
WEEK 20 
DAY 140 ±7 
 
VISIT 4  
WEEK 24   
DAY 168 ± 
14 DAYS 
 FOLLOW 
UP CALL/ 
CONTACT 
OR VISIT 5 
WEEK 26   
DAY 182 ± 
14 DAYS b 
EARLY 
PERMANENT 
DISCONTINUATION 
OF  STUDY 
TREATMENTc 
Informed Consent d 
Xe 
 
 
 
 
 
 
 
 
 
Review Eligibility 
Xe 
Xf 
 
 
 
 
 
 
 
 
Medical History and 
Demographics 
Xe 
 
 
 
 
 
 
 
 
 
Adverse Events Review 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
Concomitant Medication 
Review 
X 
Xf 
X 
X 
X 
X 
X 
X 
X 
X 
Cystic Fibrosis GI Parent 
Questionnaire  
 
X 
 
 
X 
 
 
X 
 
X 
Height and Weight  
X 
Xf 
 
 
X 
 
 
X 
 
X 
Complete Physical Exam 
Xg 
 
 
 
 
 
 
 
 
 
Abbreviated Physical Exam 
 
Xf 
 
 
X 
 
 
X 
 
X 
Dispense Fecal Collection Kit 
(x2 Vials) 
Xa 
X 
 
 
X 
 
 
 
 
 
Fecal Elastaseh  
X 
 
 
 
 
 
 
 
 
 
Obtain Frozen Fecal Specimen:   
• Fecal calprotectin 
• Banking (Optional)   
 
Xf 
 
 
X 
 
 
X 
 
X 
Vital Signs and Oximetry 
 
Xf 
 
 
X 
 
 
X 
 
X 
Spirometry  (in subjects > 4 years 
of age at the time of 
randomization) 
 
Xf 
 
 
X 
 
 
X 
 
X 
Obtain Blood Specimen: 
• On-site Clinical Laboratory   
    (see protocol section 9.2)  
 
Xf 
 
 
 
 
 
X 
Xb 
X 
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VISIT 1  
SCREENING 
DAY           
(-42 THROUGH    
–1)a 
VISIT 2 
DAY 0 
PHONE  
CALL/ 
CONTACT 
WEEK 4 
DAY 28 ±7 
PHONE  
CALL/ 
CONTACT 
WEEK 8 
DAY 56 ±7 
VISIT 3  
WEEK 12  
DAY 84± 7 
DAYS 
PHONE  
CALL/ 
CONTACT 
WEEK 16 
DAY 112 ±7 
PHONE  
CALL/ 
CONTACT 
WEEK 20 
DAY 140 ±7 
 
VISIT 4  
WEEK 24   
DAY 168 ± 
14 DAYS 
 FOLLOW 
UP CALL/ 
CONTACT 
OR VISIT 5 
WEEK 26   
DAY 182 ± 
14 DAYS b 
EARLY 
PERMANENT 
DISCONTINUATION 
OF  STUDY 
TREATMENTc 
Obtain Blood Specimen:  
• Redox/ Metabolomics  
• Banking (Optional)   
 
Xf 
 
 
 
 
 
X 
 
X 
Randomization 
 
Xf 
 
 
 
 
 
 
 
 
Study Drug Administration 
 
Xi 
 
 
 
 
 
 
 
 
Study Drug Dispensing 
 
X 
 
 
X 
 
 
 
 
 
Study Drug Accountability 
 
 
 
 
X 
 
 
X 
 
X 
Provide Subject Diary 
 
X 
 
 
X 
 
 
 
 
 
Subject Diary Review 
 
 
 
 
X 
 
 
X 
 
X 
Antibiotic Utilization 
Assessment  
 
 
X 
X 
X 
X 
X 
X 
X 
X 
a Visit 1(Screening) and Visit 2 can be combined if a fecal specimen is obtained prior to dosing. 
b Any subject with any clinically significant abnormal lab results or on-going treatment-related AEs at Visit 4 will return for a follow-up visit. All other subjects will receive a phone call follow-
up to document any new adverse events and changes to concomitant medications. Safety labs will only be performed if the subject had clinically significant abnormal labs (with an exception of 
hs-CRP) at Visit 4 (see protocol section 9.2). 
c These visit procedures should be followed for subjects who discontinue study drug treatment early.  
d Informed Consent for the study will be obtained; an optional consent for specimen banking will be obtained to participate in specimen banking and for provision of CFF registry number. 
e Perform procedure at combined Visit 1 and Visit 2. 
f Procedures and collections performed prior to first dose of study drug. 
g If Visit 1 and Visit 2 are combined Complete Physical Exam is performed instead of Abbreviated Physical Exam. 
h Only subjects without a historical fecal elastase test to document pancreatic insufficiency. 
i First dose of study drug should be administered in clinic at Visit 2 (or combined Visit 1 and Visit 2) post blood and fecal specimen collection. Study drug should be administered orally three 
times a day with meal/snack for 168 ± 14 days.                                                                                                                                                                                                                                 
 
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APPENDIX 2:  DEFINITION OF PULMONARY EXACERBATION  
 
The presence of a pulmonary exacerbation is established by the following: 
(1) 
One of the major criteria alone  
             or  
(2) 
Two of the minor signs/symptoms and fulfillment of symptom duration   
 
Major Criteria: (One finding alone establishes the presence of a pulmonary exacerbation) 
(1) Absolute decrease in FEV1 %predicted of ≥10%  
(2) Oxygen saturation <90% on room air or absolute decrease of ≥ 5%  
(3) New lobar infiltrate(s) or atelectasi(e)s on chest radiograph 
(4) Hemoptysis (more than streaks on more than one occasion in past week) 
 
Minor Signs/Symptoms: (Two minor signs/symptoms are required in the absence of major 
criteria. If at least 2 minor signs/symptoms are present, at least one needs to be 3 or more days 
in duration to meet the PE definition) 
(1) Increased work of breathing or respiratory rate 
(2) New or increased adventitial sounds on lung exam 
(3) Weight loss ≥5% of body weight or decrease across 1 major percentile in weight 
percentile for age in past 6 months 
(4) Increased cough 
(5) Decreased exercise tolerance or level of activity 
(6) Increased chest congestion or change in sputum 
 
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