A Phase 2, Randomized, Placebo-controlled, Double-blind, Open-label Extension Multicenter Study to Evaluate the Efficacy and Safety of Belumosudil (KD025) in Subjects With Diffuse Cutaneous Systemic Sclerosis
Phase: PHASE2
Conditions: System; Sclerosis, Diffuse Cutaneous Systemic Sclerosis
Sponsor: Kadmon, a Sanofi Company

Confidentiality Statement 
The information contained herein is confidential and the proprietary property of Kadmon 
Corporation and any unauthorized use or disclosure of such information without the prior 
written authorization of Kadmon Corporation is expressly prohibited. 
 
 
CLINICAL STUDY PROTOCOL  
 
 
Title: A Phase 2, Randomized, Placebo-controlled, Double-blind, Open-label 
Extension Multicenter Study to Evaluate the Efficacy and Safety of Belumosudil 
(KD025) in Subjects with Diffuse Cutaneous Systemic Sclerosis  
 
Protocol Number: 
KD025-209 
Study Drug: 
Belumosudil (KD025) 
IND Number: 
140383  
Phase: 
2 
 
Sponsor: 
Kadmon Corporation, LLC 
 
450 East 29th Street 
 
New York, NY 10016 
 
 
Date of Protocol: 
Original, Final, 19 September 2018 
 
Amendment #1, Final, 18 January 2019 
 
Amendment #2, Final, 03 April 2019 
  
Amendment #3, Final, 02 November 2020 
 
Amendment #4, Final, 27 May 2021 
Version: 
5.0 
 
 
 
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Belumosudil (KD025) 
 
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Final 
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Procedures in Case of Emergency 
 
Serious Adverse Events  
Any serious adverse event (SAE)* occurring in a subject while receiving study drug or 
within 28 days of receiving their last dose of study drug, even though the event may not 
appear to be study drug related, must be promptly reported (within 24 hours) by 
telephone, e-mail, or telefax to the sponsor (or designee).   
Emergency Contact Information  
For medical questions contact the Kadmon Medical Monitor: 
E-mail:  
  
Phone:  
 
 
For SAE Reporting send the SAE form, pregnancy form or follow-up within 24 
hours of becoming aware to: 
Kadmon Pharmacovigilance 
Email:
 
or 
Fax:  
 
 
SAE CRITERIA 
* A SAE is any untoward medical occurrence that at any dose results in any of the following outcomes, 
regardless of relationship to study drug (see Section 9.3.1 Serious Adverse Events, for additional 
information): 
• Death 
• Life-threatening adverse drug event 
• Inpatient hospitalization or prolongation of existing hospitalization 
• A persistent or significant disability/incapacity 
• A congenital anomaly/birth defect 
• An important medical event that may jeopardize the subject and may require medical or surgical 
intervention to prevent one of the outcomes listed above. 
 
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INVESTIGATOR SIGNATURE PAGE  
 
I have read and approve this protocol. My signature, in conjunction with the signature of 
the sponsor, confirms the agreement of both parties that the clinical study will be 
conducted in accordance with the protocol and all applicable laws and regulations 
including, but not limited to, the International Conference on Harmonization Guideline 
for Good Clinical Practice (GCP) R2, the Code of Federal Regulations (CFR), and the 
ethical principles that have their origins in the Declaration of Helsinki. 
Nothing in this document is intended to limit the authority of a physician to provide 
emergency medical care under applicable regulations.  
 
 
 
 
 
Investigator Signature 
 
Date of Signature 
 
 
(DD MMM YYYY) 
 
 
 
 
 
 
Name of Investigator (please print) 
 
 
 
 
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PROTOCOL SYNOPSIS  
Study Title 
A Phase 2, Randomized, Placebo-controlled, Double-blind, Open-label 
Extension Multicenter Study to Evaluate the Efficacy and Safety of 
Belumosudil (KD025) in Subjects with Diffuse Cutaneous Systemic 
Sclerosis 
Clinical Phase 
2 
Number of Study Centers 
Approximately 25 
Study Background 
Systemic sclerosis, also known as scleroderma, is a chronic autoimmune 
disease primarily affecting the skin, but with systemic manifestations.  
Diffuse cutaneous systemic sclerosis (dcSSc) is a more serious form of 
the disease and is often rapidly progressive, involving not only the skin, 
but also internal organs including kidney, heart, and lungs.  
The estimated yearly incidence of all types of systemic sclerosis in the 
United States is 20 cases per million with a prevalence of 240 cases per 
million population.  Racial disparities exist and there is an increased 
incidence and severity in African-Americans.  Women are far more likely 
to acquire the disease and make up 80%˗90% of the systemic sclerosis 
population. 
It has been estimated that up to 60% of systemic sclerosis patients will 
develop interstitial lung disease (ILD).  This interstitial disease begins 
with an inflammatory alveolitis suggesting that anti-inflammatory 
therapy be of benefit at early stages. 
Systemic sclerosis has the highest case-specific mortality among all 
systemic autoimmune diseases.  Pulmonary hypertension, pulmonary 
fibrosis, and cardiac complications are among the most frequent causes 
of death.  The single most common cause of mortality is pulmonary 
fibrosis from ILD. 
There remains a substantial unmet medical need for therapies with 
improved tolerability and effectiveness for patients with systematic 
sclerosis. 
The pathogenesis of dcSSc involves a variety of abnormalities, including 
immunological/inflammatory activation and vascular injury.  The 
important role of T lymphocytes is well established and involves both 
IL-17-producing helper T cells (Th17) and regulatory T cell (Treg) 
subsets.  Generally, Th17 cells upregulate inflammation and fibrosis 
while Treg cells provide an immunosuppressive opposing function.  An 
imbalance of these immunomodulatory cell types may contribute to the 
pathogenesis of dcSSc. 
Several signaling pathways are activated and converge to create the 
pro-fibrotic state commonly seen in dcSSc.  Importantly, extracellular 
mediators such as transforming growth factor-beta (TGF-β) and Wnt10b 
cause fibroblast activation and differentiation into myofibroblasts 
resulting in increased extracellular matrix deposition, collagen 
cross-linking, matrix remodeling, and tissue stiffness.  Thus, fibrotic 
mechanisms appear to play a central role in the pathogenesis of systemic 
sclerosis. 
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Study Rationale 
Rho-associated coiled-coil containing protein kinases (ROCK) are 
members of the serine/threonine kinase family, often studied for their 
role in cell morphology, motility, and shape through effects on the 
cytoskeleton. Two ROCK isoforms have been identified: ROCK1 and 
ROCK2. While both are involved in Rho-mediated changes in the 
actin/myosin cytoskeletal network, ROCK1 and ROCK2 are not 
redundant signaling molecules and may serve different functions within 
cells. Recent research has uncovered additional roles for ROCK 
signaling, in conditions including autoimmune disease aggravated or 
caused by a Th17-polarized T cell response and pulmonary fibrosis. Rho 
GTPase-mediated signaling pathways play a central role in coordinating 
and balancing T cell mediated immune responses, including T cell 
receptor-mediated signaling, cytoskeletal reorganization, and the 
acquisition of the appropriate T cell effector program. 
Studies have demonstrated that aberrant activation of ROCK2 leads to 
induction of interleukin (IL)-17 and IL-21 via interferon regulatory 
factor 4-dependent mechanism. In addition, ROCK activity was found to 
be up-regulated in patients with rheumatoid arthritis and systemic lupus 
erythematosus and inhibition of ROCK2 effectively decreased IL-17 
production in vivo and demonstrated efficacy in arthritis and lupus 
mouse models. Autoimmunity also involves alterations to regulatory 
T cells that suppress activation of the immune system and play a critical 
role in maintaining immunological tolerance to self-antigens and 
inhibiting autoimmune responses. ROCK2 inhibition may increase the 
suppressive function of regulatory T cells. 
ROCK is also downstream of several major pro-fibrotic mediators, 
including TGF-β, connective tissue growth factor (CTGF), and 
lysophosphatidic acid. A defining feature of pathologic fibrosis is the 
differentiation of fibroblasts to myofibroblasts, a process mediated by 
ROCK. In addition, ROCK mediates stress fiber formation and regulates 
the transcription of pro-fibrotic genes, including CTGF and alpha-smooth 
muscle actin (α-SMA). Further, ROCK inhibition has demonstrated 
anti-fibrotic activity in murine models. 
Study Objective(s) 
Primary Objectives 
The primary objective of this study is to evaluate the efficacy of 
belumosudil compared to placebo for the Combined Response Index in 
diffuse cutaneous Systemic Sclerosis (CRISS) at Week 24  
Secondary Objectives  
• 
To assess the CRISS for each group at Week 52 
• 
To evaluate the efficacy of belumosudil compared to placebo at 
Week 24 for: 
o 
Modified Rodnan Skin Score (mRSS) 
o 
Forced Vital Capacity (FVC) 
o 
Physician global assessment 
o 
Patient global assessment 
o 
Scleroderma Health Assessment Questionnaire–
Disability Index (SHAQ-DI) 
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• 
To evaluate the efficacy of belumosudil at Week 52 compared 
to baseline for subjects randomized to belumosudil for the 
parameters in the bullet above 
• 
To assess changes in lung fibrosis, via high resolution 
computerized tomography (HRCT), performed at baseline, 
Weeks 24 and Week 52 only in subjects with ILD at screening 
• 
To assess pharmacokinetics (PK) of belumosudil by sparse 
sampling of belumosudil on Weeks 4 and 8 (i.e., Days 29 and 
57) immediately prior to belumosudil dosing and 3 hours post-
dose 
• 
To assess the safety of belumosudil compared to placebo in 
subjects with dcSSc by examining the percentage of subjects 
with treatment-emergent adverse events (CTCAE v5.0) in 
subjects with diffuse cutaneous systemic sclerosis  
Exploratory Objectives 
• 
To evaluate changes in biomarkers of endothelial cell 
dysfunction, fibrosis, immune system function, and cytokine 
alterations from subjects receiving belumosudil or placebo 
• 
To assess histology and gene expression from skin biopsies 
taken from subjects at baseline, Week 24, and optionally at 
Week 52 
Study Design 
Phase 2, double-blind, placebo-controlled, randomized, multicenter trial 
in subjects with dcSSc with open-label extension. 
Methodology 
Subjects who have signed an IRB/IEC-approved informed consent form 
and met all of the inclusion/exclusion criteria will be enrolled.  A total of 
60 subjects will be randomized into 3 groups (1:1:1) to receive orally 
administered belumosudil 200 mg once daily (QD; n = 20), belumosudil 
200 mg twice daily (BID; n = 20), or matched placebo (n = 20) for 
28 weeks. The study will be double-blinded for the first 28 weeks 
followed by an open-label extension of 24 weeks.  After unblinding, the 
subjects in Group 1 and 2 will continue on the same belumosudil dose 
whereas the subjects in the placebo group will be re-randomized to one 
of the belumosudil doses (200 mg QD or 200 mg BID) in 1:1 fashion.   
The primary endpoint will be analyzed using Week 24 data. 
Efficacy will be assessed at baseline and throughout the 52 weeks of 
dosing period using CRISS, mRSS, PFTs, Physician Global Assessment, 
and Patient Global Assessment. Safety will be assessed throughout the 
study. 
Subjects will undergo evaluations as outlined in the Study Assessment 
table. A 4-Week Follow-Up visit will occur 28 days (± 3 days) after the 
last dose of study drug.  
 
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Approximate Number of 
Subjects 
Sixty male and female subjects will be enrolled (20 randomized to each 
of the 2 belumosudil dose groups and the placebo group). 
Approximate Duration of 
Subject Participation 
Approximately 14 months of study duration (4-week Screening Period, 
52-week Dosing Period, and 4-week Follow-up). The study will be 
double-blinded for the first 28 weeks followed by an open-label 
extension of 24 weeks. 
Diagnosis and Main 
Criteria for Inclusion and 
Exclusion 
Inclusion Criteria: 
1. Male and female subjects ≥ 18 years old with the diagnosis of 
dcSSc according to the 2013 American College of 
Rheumatology and European League Against Rheumatism 
criteria  
2. Must have disease duration (defined as interval from first 
non-Raynaud disease manifestation) of ≤ 5 years 
3. Must have mRSS of ≥ 15 but ≤ 35  
4. Active disease defined as any of the following within the 
6 months prior to screening: 
a. 
Increase in mRSS by ≥ 3 units  
b. Increase in mRSS by ≥ 2 units with involvement of 1 new 
body area  
c. 
Involvement of 2 new body areas 
d. Symptoms indicative of skin activity such as severe 
cutaneous itching or burning 
5. Subjects receiving concomitant immunosuppression must be on 
a stable dose for at least 3 months prior to screening 
6. Adequate organ and bone marrow functions evaluated during 
the 28 days prior to enrollment as follows: 
a. 
Absolute neutrophil count ≥ 1.5 × 109/L  
b. Platelet count ≥ 100 × 109/L  
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c. 
Total bilirubin ≤ 1.0 × upper limit of normal (ULN) 
d. Alanine aminotransferase, (ALT), aspartate 
aminotransferase (AST), and serum creatinine 
≤ 1.5 × ULN. 
7. Female subjects of childbearing potential have a negative 
pregnancy test at screening.  Females of childbearing potential 
are defined as sexually mature women without prior 
hysterectomy or who have had any evidence of menses in the 
past 12 months. However, women who have been amenorrheic 
for 12 or more months are still considered to be of childbearing 
potential if the amenorrhea is possibly due to prior 
chemotherapy, anti-estrogens, or ovarian suppression. 
a. 
Women of childbearing potential (i.e., menstruating 
women) must have a negative urine pregnancy test 
(positive urine tests are to be confirmed by serum test) 
documented within the 24-hour period prior to the first 
dose of study drug.  
b. Sexually active women of childbearing potential 
enrolled in the study must agree to use two forms of 
accepted methods of contraception during the course 
of the study and for 3 months after their last dose of 
study drug.  Effective birth control includes (i) IUD 
plus one barrier method; (ii) on stable doses of 
hormonal contraception for at least 3 months (e.g., 
oral, injectable, implant, transdermal) plus one barrier 
method; or (iii) 2 barrier methods.  Effective barrier 
methods are male or female condoms, diaphragms, and 
spermicides (creams or gels that contain a chemical to 
kill sperm), or a vasectomized partner. 
8. For male patients who are sexually active and who are partners 
of premenopausal women: agreement to use 2 forms of 
contraception as in criterion number 7 above during the 
treatment period and for at least 3 months after the last dose of 
study drug. 
9. Male subjects must not donate sperm for 3 months after last 
dose of study drug. 
10. Able to provide written informed consent prior to the 
performance of any study-specific procedures. 
 
Exclusion Criteria: 
1. Subject has corrected QT interval using Fredericia’s formula 
(QTcF) > 450 ms 
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2. Ongoing use or current use of concomitant medication known 
to have the potential for QTc prolongation 
3. Female subject who is pregnant or breastfeeding 
4. Participated in another study with an investigational drug 
within 28 days of study entry (for studies involving biologics, 
within three half-lives of the biologic) 
5. History or other evidence of severe illness or any other 
conditions that would make the subject, in the opinion of the 
Investigator, unsuitable for the study 
6. Chronic heart failure with New York Heart Association 
Classes II, III, or IV 
7. Acute or chronic liver disease (e.g., cirrhosis) 
8. Positive human immunodeficiency virus (HIV) test 
9. Active hepatitis C virus (HCV), hepatitis B virus (HBV), or 
positive whole blood tuberculin test 
10. Diagnosed with any malignancy within 3 years of enrollment, 
with the exception of basal cell or completely resected 
squamous cell carcinoma of the skin, resected in situ cervical 
malignancy, resected breast ductal carcinoma in situ, or 
low-risk prostate cancer after curative resection 
11. Has had previous exposure to belumosudil or known 
allergy/sensitivity to belumosudil, or any other ROCK2 
inhibitor 
12. Scleroderma renal crisis within 4 months prior to enrollment 
13. FVC ≤ 50% Predicted. 
Test Article(s)  
Belumosudil will be provided as 200 mg tablets. 
Matching placebo will be provided during the initial double-blind period 
as appropriate for subjects in Group 1 and Group 3. 
Dosage and Administration  
Subjects will be randomized to receive belumosudil 200 mg QD 
(Group 1), belumosudil 200 mg BID (Group 2), or matched placebo 
(Group 3) in the blinded 28 weeks as follows:   
Group 1:  Belumosudil 200 mg QD (one 200 mg belumosudil tablet 
AM and one matched placebo PM) will be administered orally daily.   
Group 2:  Belumosudil 200 mg BID (one 200 mg belumosudil tablet 
AM and one 200 mg belumosudil tablet PM) will be administered 
orally daily.    
Group 3:  Matched placebo (one placebo tablet AM and one placebo 
tablet PM) will be administered orally daily.   
After unblinding, the subjects in Group 1 and 2 will continue on the same 
belumosudil dose whereas the subjects in the placebo group will be 
re-randomized to one of the belumosudil doses (200 mg QD or 200 mg 
BID) in 1:1 fashion.  
Reference Therapy 
Not applicable.   
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Duration of Treatment 
Study drug dosing will be for 52 weeks: double-blinded for the first 28 
weeks followed by an open-label extension of 24 weeks ). 
Concomitant Treatment 
 
Ongoing immunosuppressive therapy with steroids ≤ 10 mg per day is 
permitted. 
All medications a subject receives from the signing of informed consent 
through the 28-Day Follow-Up visit will be documented. 
• 
CYP3A4 inhibitors/inducers should be used with caution.  
• 
Subjects on concomitant medication known to have potential for 
QTc prolongation will be excluded. 
Safety Evaluation 
Safety data will be collected from the time the subject signs the informed 
consent form until 28 days after their last dose of study drug (the adverse 
event [AE] reporting period). The primary safety outcome will be the 
percentage of subjects experiencing treatment-emergent AEs (TEAEs) in 
each group.   
Safety assessments will include AEs, serious adverse events (SAEs), 
PEs, vital sign measurements (blood pressure, pulse rate, respiratory rate, 
and temperature), clinical laboratory evaluations (hematology, chemistry 
and urinalysis), and electrocardiograms (ECGs).  Reasons for treatment 
discontinuation because of toxicity will be documented.   
As this is the first study of belumosudil in subjects with dcSSc, careful 
monitoring of all toxicities will be carried out.  
Efficacy/Activity 
Evaluation 
Primary Efficacy Endpoint 
The primary efficacy endpoint is the effect of belumosudil compared to 
placebo for CRISS, an exponential algorithm determining the predicted 
probability of improvement from baseline, incorporating changes in 
mRSS, FVC % predicted, and physician and patient global assessments.  
The outcome is a continuous variable between 0.0 and 1.0 (0-100%).  A 
higher score indicates greater probability of improvement.  A CRISS 
score ≥ 20% is considered a clinically meaningful improvement. 
 
Secondary Efficacy Endpoints 
Secondary efficacy outcomes include the change from baseline in mRSS, 
FVC, SHAQ-DI, physician global assessment, and patient global 
assessment for belumosudil-treated and placebo-treated subjects.   
Onset/progression of ILD will be evaluated by the effect of belumosudil 
compared to placebo in the change in predicted FVC  
In addition, changes in lung fibrosis on HRCT performed at baseline, 
Week 24 and Week 52 will be assessed only in subjects who have SSc 
lung disease at screening. 
 
Exploratory Endpoints 
Exploratory outcome assessments include changes in PD parameters 
measured in plasma and/or skin biopsy sample (discussed below).   
Pharmacokinetics 
Sparse PK sampling will be performed on Weeks 4 and 8 (i.e., Days 29 
and 57) immediately prior to belumosudil dosing and 3 hours post-dose 
Pharmacodynamics 
All subjects will have PD blood samples drawn at the following time 
points prior to dosing:  Week 1 (Day 1, baseline), Week 8 (Day 57), 
Week 24 (Day 169), and Week 52 (Day 365).  These samples will be 
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analyzed to evaluate autoantibody levels at baseline and biomarkers of 
extracellular matrix turnover which could correlate with both SSc disease 
activity and disease modification by belumosudil.   
All subjects will be required to provide skin biopsies obtained from the 
dorsal mid-forearm at the Week 1 (Day 1) and Week 24 (Day 169) visits.  
An optional skin biopsy may be obtained at the Week 52 (Day 365) visit.  
Biopsy sections will be assessed for histology including fibrosis and 
inflammation. In addition, gene expression profiling will be performed 
on skin biopsies. 
Statistical Analysis  
This proof of concept study will inform future development of 
belumosudil in dcSSc. The sample size is not driven by hypothesis 
testing. Two populations will be employed in the analysis of study data:  
• 
The Modified Intent-to-Treat Population (mITT) will consist of 
all subjects who receive at least one dose of study drug.   
• 
The Evaluable for Efficacy/Activity population will consist of 
subjects who have received at least 80% of expected study drug 
and have post-baseline efficacy data.   
The primary endpoint will be analyzed on the mITT Population. 
Demographics, subject disposition, and baseline characteristics will be 
summarized in each population and by group. 
Efficacy will be evaluated by comparing Week 24 CRISS scores for 
subjects treated with belumosudil and placebo.  Secondary endpoints will 
include changes in mRSS, FVC, SHAQ-DI, Physician Global 
Assessment, and Patient Global Assessment from baseline to Week 24 in 
subjects treated with belumosudil compared to placebo and the change 
from baseline for subjects with belumosudil at Week 52. No formal 
comparison will be conducted between the belumosudil QD and 
belumosudil BID dosing cohorts. 
Treatment-emergent AEs will be evaluated using the Common 
Terminology Criteria for Adverse Events (CTCAE) v 5.0. The total 
sample size of 20 subjects per belumosudil dose group will provide 
> 90% probability of one or more belumosudil subjects experiencing an 
AE that has an underlying rate of ≥ 14% and > 80% probability of one or 
more subjects in the study experiencing an AE that has an underlying rate 
of ≥ 10%. 
The TEAEs will be summarized overall and by group using MedDRA 
(Version 21.0 or higher) System Organ Class (SOC) and preferred term 
(PT), classified from verbatim terms. The incidence and percentage of 
subjects with at least one occurrence of a preferred term will be included, 
according to the most severe grade using a 5-point scale (mild, moderate, 
severe, life threatening, or death). The number of events per preferred 
term will also be summarized.  Causality (relationship to study treatment) 
will be summarized separately. 
Adverse events, SAEs, related AEs, related SAEs, ≥ Grade 3 AEs, 
related Grade ≥ 3 AEs, and AEs leading to withdrawal, or treatment 
discontinuation will be summarized overall and by group according to 
SOC and PTs. Adverse events will also be presented in listings. Duration 
of AEs will be determined and included in listings, along with action 
taken and outcome. 
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Laboratory results will be graded using the CTCAE v5.0. Incidence of 
laboratory abnormalities will be summarized.  The worst on-study grade 
after the first dose of study drug will be summarized.  The incidence of 
Grade ≥ 3 laboratory abnormalities under treatment and shifts in toxicity 
grading from baseline to highest-grade post-baseline will be displayed.   
Vital sign measurements and ECGs will be summarized by group at each 
scheduled time point using descriptive statistics and included in data 
listings. 
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Table of Contents  
CLINICAL STUDY PROTOCOL ..................................................................................... 1 
SPONSOR APPROVAL SIGNATURE PAGE ........................................................... 3 
INVESTIGATOR SIGNATURE PAGE ...................................................................... 4 
PROTOCOL SYNOPSIS ................................................................................................ 5 
1. 
Introduction ............................................................................................................... 20 
1.1 
Background ..................................................................................................... 20 
1.2 
Rho-Associated Protein Kinase ...................................................................... 20 
1.3 
Belumosudil Nonclinical Experience ............................................................. 21 
1.4 
Clinical Experience ......................................................................................... 22 
1.4.1 
Clinical Pharmacokinetics .......................................................................... 22 
1.4.2 
Clinical Summary ....................................................................................... 28 
1.5 
Study Rationale............................................................................................... 28 
1.6 
Dose Rationale ................................................................................................ 29 
2. 
Study Objectives ....................................................................................................... 31 
2.1 
Primary Objective ........................................................................................... 31 
2.2 
Secondary Objectives ..................................................................................... 31 
2.3 
Exploratory Objectives ................................................................................... 31 
3. 
Investigational Plan ................................................................................................... 32 
3.1 
Study Design................................................................................................... 32 
3.2 
Number of Subjects ........................................................................................ 33 
3.3 
Study Centers .................................................................................................. 33 
3.4 
Inclusion Criteria ............................................................................................ 33 
3.5 
Exclusion Criteria ........................................................................................... 35 
3.6 
Screening ........................................................................................................ 35 
3.7 
Withdrawal Criteria ........................................................................................ 36 
3.8 
Replacements .................................................................................................. 36 
3.9 
Treatment Discontinuation ............................................................................. 36 
4. 
Study Treatment ........................................................................................................ 38 
4.1 
Investigational Product ................................................................................... 38 
4.2 
Dosage and Administration ............................................................................ 38 
4.3 
Treatment Assignment .................................................................................... 38 
4.4 
Blinding .......................................................................................................... 38 
4.5 
Treatment Compliance ................................................................................... 39 
4.6 
Missed Doses .................................................................................................. 39 
4.7 
Product Accountability ................................................................................... 40 
4.8 
Concomitant Medication and Therapies ......................................................... 40 
4.9 
CYP3A4 Inhibitors/Inducers .......................................................................... 40 
4.10 
Drugs Prolonging the QTc Interval ................................................................ 40 
4.11 
Overdose ......................................................................................................... 41 
4.12 
Dose Modification Guidelines ........................................................................ 41 
5. 
Study Assessments and Procedures .......................................................................... 43 
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5.1 
Screening Period (Day -29 to -1) .................................................................... 43 
5.2 
Double-Blinded Treatment Period.................................................................. 43 
5.2.1 
Week 1, Day 1 Visit (Baseline) .................................................................. 44 
5.2.2 
Day 15 (± 3 Days) Visit .............................................................................. 44 
5.2.3 
End of Week 4, Day 29 (± 3 Days) Visit .................................................... 45 
5.2.4 
End of Week 8, Day 57 (± 3 Days) Visit .................................................... 45 
5.2.5 
End of Week 12, Day 85 (± 3 Days) Visit .................................................. 46 
5.2.6 
End of Week 16, Day 113 (± 3 Days) ......................................................... 46 
5.2.7 
End of Week 20, Day 141 (± 3 Days) ......................................................... 47 
5.2.8 
End of Week 24, Day 169 (± 3 Days) ......................................................... 47 
5.2.9 
End of Double-Blinded Treatment Visit (End of Week 28, Day 197 
[± 3 Days]) ................................................................................................................ 48 
5.3 
Open-label Visits Every 4 Weeks (± 3 Days) Until Week 52 ........................ 49 
5.4 
End of Treatment OR Week 52, (Day 365 [± 3 Days]) .................................. 50 
5.5 
28-day Follow-up Visit ................................................................................... 51 
5.6 
Unscheduled Visit........................................................................................... 51 
6. 
Efficacy and Safety Assessments.............................................................................. 53 
6.1 
Efficacy Endpoints ......................................................................................... 53 
6.1.1 
Primary Endpoint ........................................................................................ 54 
6.1.2 
Secondary Endpoints .................................................................................. 54 
6.1.3 
Exploratory Endpoints ................................................................................ 54 
6.2 
Safety .............................................................................................................. 54 
6.2.1 
Safety Endpoints ......................................................................................... 54 
6.2.2 
Vital Signs ................................................................................................... 55 
6.2.3 
12-Lead ECG .............................................................................................. 55 
6.2.4 
Clinical Laboratory Parameters .................................................................. 55 
6.2.5 
Pregnancy Testing ....................................................................................... 57 
7. 
Pharmacokinetics ...................................................................................................... 58 
8. 
Pharmacodynamics ................................................................................................... 59 
9. 
Safety ........................................................................................................................ 60 
9.1 
Safety Parameters ........................................................................................... 60 
9.2 
Adverse Event Definition ............................................................................... 60 
9.3 
Evaluating Adverse Events ............................................................................. 61 
9.3.1 
Serious Adverse Events .............................................................................. 61 
9.3.2 
Protocol-related Adverse Events ................................................................. 62 
9.3.3 
Relationship to Study Drug ......................................................................... 62 
9.3.4 
Recording Adverse Events .......................................................................... 62 
9.3.5 
Hospitalization ............................................................................................ 63 
9.3.6 
Serious Adverse Event Reporting ............................................................... 63 
9.4 
Follow-up for Adverse Events ........................................................................ 66 
9.5 
Other Safety Considerations ........................................................................... 67 
9.5.1 
Laboratory Data .......................................................................................... 67 
9.5.2 
Medication Errors ....................................................................................... 67 
9.6 
Study  Stopping  Rules ................................................................................... 67 
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9.6.1 
Stopping Rules for Study ............................................................................ 67 
9.6.2 
Stopping Criteria for Subjects ..................................................................... 67 
9.7 
Statistical Considerations ............................................................................... 68 
9.7.1 
Hypothesis................................................................................................... 68 
9.7.2 
Sample Size ................................................................................................. 68 
9.7.3 
Analysis Populations ................................................................................... 68 
9.7.4 
Data Analysis .............................................................................................. 68 
9.7.5 
Interim Analysis .......................................................................................... 68 
9.8 
Efficacy Analysis ............................................................................................ 69 
9.8.1 
Primary Efficacy Endpoint ......................................................................... 69 
9.8.2 
Secondary Efficacy Endpoints .................................................................... 69 
9.8.3 
Exploratory Efficacy Endpoints .................................................................. 69 
9.8.4 
Analysis Method ......................................................................................... 70 
9.9 
Safety Analyses .............................................................................................. 70 
9.10 
Pharmacokinetic Analyses .............................................................................. 71 
9.11 
Data Quality Assurance .................................................................................. 71 
10. 
Regulatory Obligations .......................................................................................... 72 
11. 
Ethical Aspects....................................................................................................... 73 
11.1 
Local regulations ............................................................................................ 73 
11.2 
Informed Consent ........................................................................................... 73 
11.3 
Institutional Review Board ............................................................................. 74 
11.4 
Future Use of Subject Samples ....................................................................... 74 
12. 
Conditions for Modifying the Protocol .................................................................. 75 
13. 
Conditions for Terminating the Study ................................................................... 76 
14. 
Study Documentation, CRFs and Record Keeping................................................ 77 
14.1 
Investigator’s Files and Retention of Documents........................................... 77 
14.2 
Source Documents and Background Data ...................................................... 77 
14.3 
Audits and Inspections.................................................................................... 78 
14.4 
Electronic Case Report Forms ........................................................................ 78 
15. 
Monitoring of the Study ......................................................................................... 79 
16. 
Confidentiality of Trial Documents and Subject Records ..................................... 80 
17. 
Publication of Data and Protection of Trade Secrets ............................................. 81 
18. 
References .............................................................................................................. 82 
19. 
Appendix A:  Schedule of Assessments ................................................................ 85 
20. 
Appendix B:  Calculation of Modified Rodnan Skin Score .................................. 88 
21. 
Appendix C:  Scleroderma Health Assessment Questionnaire .............................. 89 
22. 
Appendix D:  Physician Global Assessment ......................................................... 92 
23. 
Appendix E:  Patient Global Assessment .............................................................. 93 
24. 
Appendix F: Determining Relationship of Adverse Events to Study Drug ........... 94 
25. 
Appendix G: Drugs that Induce and Inhibit CYP3A4 ........................................... 96 
26. 
Appendix H: Drugs Known to have the potential for qtc prolongation ................. 98 
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List of Tables and Figures 
Table 1 
Cohorts in Design of Study KD025-211 ........................................................ 25 
Figure 1 
Schematic of Study KD025-209 ..................................................................... 33 
Table 2 
Dosing of Treatment Groups for Double-blind Period of Study .................... 38 
Table 3 
Guidelines for Management of Treatment-emergent Toxicities (Double-
blinded Phase) ................................................................................................................... 41 
Table 4 
Clinical Laboratory Panels ............................................................................. 55 
 
 
 
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List of Abbreviations 
AE 
Adverse event 
ALT 
Alanine aminotransferase 
AST 
Aspartate aminotransferase 
AUC 
Area under the curve 
BID 
Twice daily 
BSC 
Best supportive care 
BUN 
Blood urea nitrogen 
CFR 
Code of Federal Regulations 
CPK 
Creatinine phosphokinase 
CRISS 
Combined Response Index in Diffuse Cutaneous Systemic Sclerosis 
cGVHD 
Chronic graft versus host disease 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTGF 
Connective tissue growth factor 
dcSSc 
Diffuse cutaneous systemic sclerosis 
DLCO 
Diffusing capacity of the lungs for carbon monoxide 
ECG 
Electrocardiogram 
ECM 
Extracellular matrix 
eCRF 
Electronic case report form 
EOT 
End-of-Treatment 
FDA 
Food and Drug Administration 
FEV1 
Forced expiratory volume (in the first second) 
FVC 
Forced vital capacity 
GCP 
Good Clinical Practice 
GFR 
Glomerular filtration rate 
GGT 
Gamma-glutamyl transferase 
HBV 
Hepatitis B virus 
HCV 
Hepatitis C virus 
HIV 
Human immunodeficiency virus 
HRCT 
High-resolution computerized tomography 
ICF 
Informed consent form 
IEC 
Independent Ethics Committee 
ILD 
Interstitial lung disease 
IND 
Investigational New Drug 
IP 
Investigational Product 
IPF 
Idiopathic pulmonary fibrosis 
IRB 
Institutional review board 
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IUD 
Intrauterine device 
LFT 
Liver function tests 
MCV 
Mean corpuscular volume 
MedDRA 
Medical Dictionary for Regulatory Activities 
mITT 
Modified intent-to-treat 
mRSS 
Modified Rodnan Skin Score 
PASI 
Psoriasis Area and Severity Index 
PE 
Physical examination 
PFT 
Pulmonary function test 
PK 
Pharmacokinetic 
QD 
Once daily 
QOD 
Once every other day 
QTc(F) 
Corrected QT interval using Fridericia's formula 
ROCK 
Rho-associated protein kinase 
SAE 
Serious adverse event 
SAP 
Statistical Analysis Plan 
SHAQ-DI 
Scleroderma Health Assessment Questionnaire—Disability Index 
SOC 
System organ class 
SSc 
Systemic sclerosis 
SUSAR 
Suspected unexpected serious adverse reaction 
TEAE 
Treatment-emergent adverse event 
TGF-β 
Transforming growth factor-beta 
TLC 
Total lung capacity 
Treg 
Regulatory T-cells 
ULN 
Upper limit of normal 
VAS 
Visual Analog Scale 
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1. INTRODUCTION  
1.1 
BACKGROUND  
Systemic sclerosis, also known as scleroderma, is a chronic autoimmune disease primarily 
affecting the skin, but with systemic manifestations. Diffuse cutaneous systemic sclerosis is a 
more serious form of the disease and is often rapidly progressive, involving not only the skin but 
also internal organs including kidney, heart, and lungs.(1) 
The estimated annual incidence of systemic sclerosis in the United States is 20 cases per million 
with a prevalence of 240 cases per million population.(2,3,4) Racial disparities exist and there is an 
increased incidence and severity in African-Americans. Women are far more likely to acquire the 
disease and make up 80%˗90% of the systemic sclerosis population.(5) 
It has been estimated that up to 60% of systemic sclerosis patients will develop interstitial lung 
disease. This interstitial disease begins with an inflammatory alveolitis suggesting that 
anti-inflammatory therapy may be of benefit at early stages.(6,7) 
Systemic sclerosis has the highest case-specific mortality among all systemic autoimmune 
diseases. Pulmonary hypertension, pulmonary fibrosis, and cardiac complications are the most 
frequent causes of death. The single most common cause of mortality is pulmonary fibrosis from 
interstitial lung disease.(8) 
There remains substantial unmet need for therapies with improved tolerability and effectiveness 
for patients with dcSSc.  
1.2 
RHO-ASSOCIATED PROTEIN KINASE  
Rho-associated coiled-coil containing protein kinases (ROCK) are members of the 
serine/threonine kinase family, often studied for their role in cell morphology, motility, and 
shape through effects on the cytoskeleton.  Two ROCK isoforms have been identified, ROCK1 
and ROCK2.(9,10,11,12)  While both are involved in Rho-mediated changes in the actin/myosin 
cytoskeletal network, ROCK1 and ROCK2 are not redundant signaling molecules and may serve 
different functions within cells.(13,14,15)  Recent research has uncovered additional roles for 
ROCK signaling, in conditions including autoimmune disease aggravated or caused by a 
T-cell helper 17- (Th17)-polarized T-cell response(16) and pulmonary fibrosis.(17)  Rho 
GTPase-mediated signaling pathways play a central role in coordinating and balancing 
T cell-mediated immune responses, including T cell receptor-mediated signaling, cytoskeletal 
reorganization, and the acquisition of the appropriate T-cell effector program.(18) 
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Studies have demonstrated that aberrant activation of ROCK2 leads to induction of interleukin 
(IL)-17 and IL-21 via interferon regulatory factor 4-dependent mechanism.(19) In addition, 
ROCK activity was found to be up-regulated in patients with rheumatoid arthritis and systemic 
lupus erythematosus(20) (and inhibition of ROCK2 effectively decreased IL-17 production in 
vivo) and demonstrated efficacy in arthritis and lupus mouse models.  Autoimmunity also 
involves alterations to regulatory T-cells (Tregs) that suppress activation of the immune system 
and play a critical role in maintaining immunological tolerance to self-antigens and inhibiting 
autoimmune responses.(21)  ROCK2 inhibition may increase the suppressive function of Tregs. 
ROCK is also downstream of several major pro-fibrotic mediators, including transforming 
growth factor beta (TGF-β), connective tissue growth factor (CTGF), and lysophosphatidic acid.  
A defining feature of pathologic fibrosis is the differentiation of fibroblasts to myofibroblasts, a 
process mediated by ROCK.  In addition, ROCK mediates stress fiber formation and regulates 
the transcription of pro-fibrotic genes, including CTGF and alpha-smooth muscle actin.  
Further, ROCK inhibition has demonstrated anti-fibrotic activity in murine models. 
1.3 
BELUMOSUDIL NONCLINICAL EXPERIENCE  
In vitro, belumosudil has demonstrated an impact on the T-helper 17 (Th17) and regulatory 
T cells (Treg)-immune responses as well as on the actin/myosin cytoskeletal network and 
collagen formation. In vivo, belumosudil has demonstrated efficacy in a variety of clinically 
relevant animal models of disease including chronic graft versus host disease (cGVHD), 
scleroderma, idiopathic pulmonary fibrosis (IPF), and other autoimmune diseases. 
Good Laboratory Practice (GLP) compliant rat and dog general toxicology/toxicokinetic studies 
of acute, sub-chronic (1-and 3-month), and chronic (6-month rat and 9-month dog) duration have 
been completed. In addition, safety pharmacology (human ether-à-go go related gene [in vitro], 
central nervous system [rat], respiratory [rat], and cardiovascular [dog]), embryo-fetal toxicology 
[rat and rabbit], male/female fertility [rat]), genotoxicity, and phototoxicity studies have also 
been completed. The primary nonclinical toxicology finding at/near clinically relevant exposures 
were limited to changes in the cardiovascular (blood pressure lowering), hepatic (transaminitis, 
hypertrophy/increased organ weight, and cholestasis/inflammation), renal (increased blood urea 
nitrogen [BUN], tubular changes, pigmentation, intracellular protein droplets in the epithelium), 
gastrointestinal (decreased appetite), and hematopoietic/immunologic (anemia with regeneration 
and thymic/splenic lymphoid depletion) systems. 
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Belumosudil demonstrated embryo-fetal toxicity/teratogenicity as well as reduced male fertility 
(reduced fertility index/sperm concentration/motility and increased abnormal sperm percentage), 
and changes in the testes/epididymis (decreased organ weights and degenerative histopathology). 
Male fertility findings were generally at higher than clinically relevant exposures. 
All pivotal non-clinical safety studies (i.e., those studies identified in International Conference 
on Harmonization guidelines as needing to be conducted in accordance with GLP) were 
conducted in a country that is a member of the Organisation for Economic Cooperation and 
Development (OECD) Mutual Acceptance of Data program in accordance with the OECD Test 
Guidelines and Principles of GLP. Study details and potential clinically relevant findings from 
these studies are summarized in the Belumosudil Investigator’s Brochure. 
1.4 
CLINICAL EXPERIENCE  
1.4.1 Clinical Pharmacokinetics  
Following a single oral dose of belumosudil 200 mg in the fed state, the mean absolute 
bioavailability (%F) was 64%. Systemic exposure of belumosudil was increased when 
administered in the fed state, and in ongoing and planned clinical studies, belumosudil should be 
taken with food or within 5 minutes of eating. 
Across all clinical studies, observed time to reach maximum concentration for belumosudil, 
metabolites KD025m1 and KD025m2 has ranged from 2-4 hours, and the belumosudil terminal 
elimination half-life averages ~7 hours following single or multiple dose administration. 
Exposure of belumosudil (maximum concentration observed and area under concentration curve) 
in healthy subjects appears to be slightly greater than dose proportional over the 20 to 500 mg 
once daily (QD) dose range, but less than dose proportional for doses above 500 mg. Little to no 
accumulation of belumosudil or metabolites, KD025m1 or KD025m2, was observed following 
multiple dose administration. KD025m1 and KD025m2 exposures are < 5% and ≤ 20%, 
respectively, of belumosudil exposure. 
A [14C]-belumosudil human absorption, metabolism, and excretion study confirmed that the 
majority of radioactivity was recovered in feces (85%), with < 5% recovered in urine. This 
indicates minimal renal elimination and that the predominant route of clearance of belumosudil 
and associated metabolites is biliary and/or intestinal. 
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CYP34A likely plays a predominant role in the metabolism of belumosudil, and in a clinical 
drug-drug interaction study in healthy volunteers, co-administration with itraconazole (CYP3A4 
inhibitor) resulted in a modest 20-25% increase in belumosudil exposure, while 
co-administration with rifampicin (CYP3A4 inducer) led to a 60-70% reduction in belumosudil 
exposure. 
A delay in absorption and a reduction in belumosudil exposure were observed when belumosudil 
was co-administered with proton pump inhibitors (PPI) rabeprazole (80-90% decrease) or 
omeprazole (50-70% decrease), consistent with the finding that increased pH leads to decreased 
solubility of belumosudil. The clinical relevance of this interaction with PPIs is being evaluated 
in ongoing studies. 
1.4.1.1 Chronic Graft Versus Host Disease  
Study KD025-208 is an ongoing phase 2a, dose-escalation, open-label study to evaluate the 
safety, tolerability, and activity of belumosudil in subjects with cGVHD who have previously 
received 1-3 prior lines of treatment.  The majority of subjects enrolled had cGVHD affecting at 
least 4 organs.  Preliminary data from Cohort 1 (belumosudil 200 mg QD, n = 17), Cohort 2 
(belumosudil 200 mg  BID, n = 16) and Cohort 3 (belumosudil 400 mg QD, n = 18) show 
encouraging activity of belumosudil with response rates of 65%, 69% and 33% respectively.  
Responses have been durable.  Among responders in Cohort 1, 8/11 (73%) subjects have 
sustained the response for ≥ 20 weeks.  Data continue to mature in this ongoing study.  Fifty-nine 
percent of subjects have achieved reductions in corticosteroid doses, with 10% discontinuing 
systemic corticosteroid therapy completely.  Across the 3 cohorts, 61% of responders and 26% of 
non-responders have reported improvements in the Lee Symptom Scale score. 
Study KD025-213 is another study in cGVHD which is currently ongoing at multiple sites in the 
U.S. Over 100 subjects have been enrolled and this study will be submitted as a potential 
registration study for cGVHD in 2020. 
1.4.1.2 Idiopathic Pulmonary Fibrosis  
Study KD025-207 is an ongoing, randomized, phase 2, open-label, multicenter study to evaluate 
the safety, tolerability, and activity of belumosudil in subjects with idiopathic pulmonary fibrosis 
(IPF) who have received pirfenidone and/or nintedanib or been offered both prior to enrollment.  
Subjects are randomized 2:1 to receive 400 mg belumosudil QD or best supportive care (BSC). 
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Forty subjects have been enrolled: 26 to the belumosudil arm and 14 subjects to the BSC arm.  
Nine BSC subjects have crossed over to the belumosudil arm.  This study has been extended to 
enroll an additional 40 subjects. 
Preliminary results demonstrate clinical activity of belumosudil in the treatment of IPF.  In the 
modified Intent-to-Treat (mITT) population, there was an absolute median change in forced vital 
capacity (FVC) of 50 mL at Week 24 in subjects treated with belumosudil, compared to -175 mL 
in subjects treated with BSC.  The decline in percentage predicted FVC was 1% with 
belumosudil versus 5% with BSC. 
Overall, at Week 24, 29% of belumosudil patients had experienced an FVC decline ≥ 5% 
compared to 55% of BSC patients.  
1.4.1.3  Psoriasis  
In Study KD025-205, a study of 8 subjects with moderately severe psoriasis who had failed at 
least 1 line of systemic therapy, the mean Psoriasis Area and Severity Index (PASI) score 
decreased with 28 days of treatment by 1.1 (not statistically significant) from a mean baseline of 
17.5.  Some subjects experienced slight improvement in scaling and softening of plaques. 
Study KD025-206 was a phase 2, open-label, safety and tolerability study of belumosudil dosing 
in 38 subjects with psoriasis vulgaris who had disease progression after at least 1 systemic 
therapy.  The mean baseline PASI score was 19.8.  The changes from baseline PASI scores 
were -8.8 (belumosudil 200 mg), -6.0 (belumosudil 400 mg QD) and -4.8 (belumosudil 400 mg 
BID) and were statistically significant for each treatment group and overall.  Reductions of 
50% in PASI scores were observed in 42% (belumosudil 200 mg BID), 50% (belumosudil 
400 mg QD) and 18% (belumosudil 400 mg BID) of subjects. 
Study KD025-211 was a Phase 2, two-period, dose-finding study of the safety, tolerability, and 
efficacy of belumosudil for the treatment of adult male and female subjects with moderate to 
severe chronic plaque psoriasis who were candidates for systemic therapy or phototherapy. 
The first period (Week 1 through Week 16) was double-blind and placebo-controlled: the 
Double-blind Treatment Period.  Approximately 110 subjects were randomly assigned to each of 
5 dose cohorts in a 1:1:1:1:1 manner and were treated for up to 16 weeks (Table 1). 
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Table 1 
Cohorts in Design of Study KD025-211  
Cohort 
Number of Subjects 
Dose 
1 
22 
200 mg belumosudil QD 
2 
22 
200 mg belumosudil BID 
3 
22 
400 mg belumosudil QD 
4 
22 
600 mg belumosudil (400 mg in the morning; 200 mg in the evening) 
5 
22 
Matching placebo BID 
BID = twice daily; QD = once daily 
Study drug was administered orally (PO), with a meal or within 5 minutes of finishing a meal, in 
a double-blind fashion. 
The second period (Week 16 through Week 52) was an open-label study of belumosudil:  the 
Open-label Treatment Period.  All subjects were given the option to receive belumosudil for an 
additional 32 weeks.  All subjects in the Open-label Period received belumosudil at 400 mg QD, 
regardless of initial randomization. 
Subject status was collected at screening, Week 1 Day 1 (baseline), and for the evaluation of 
primary and secondary study endpoints.  Response was assessed by PASI, PGA, and DLQI 
scores at scheduled time points throughout the study. 
Subjects underwent medical history evaluations; physical examinations ([PEs] including weight, 
skeletal, and neurological measurements); vital sign measurements; adverse event (AE) 
assessments; concomitant medication assessments; blood sample collection for hematology, 
chemistry, coagulation, lipid panel, and thyroid-stimulating hormone; urinalysis; pregnancy 
testing for females of childbearing potential; photography (optional); punch biopsy (optional); 
and electrocardiogram (ECGs).  
If a subject discontinued from the study prior to 16 weeks, an Early Termination Visit was 
performed, and procedures were conducted immediately upon discontinuation.  For all subjects, 
including those who discontinued from the study prematurely, a Follow-Up visit occurred 
30 days (± 3 days) after the last dose of study drug. 
A placebo control was used in the Double-blind Period of this study.  No control was used for 
the Open-label Continuation Period of the study. 
A total of 110 subjects were randomized and included in the mITT Population: 23 subjects in the 
belumosudil 200 mg QD cohort, 22 in the belumosudil 200 mg BID cohort, 21 in the 
belumosudil 400 mg QD cohort, 26 in the belumosudil 600 mg/day cohort, and 18 in the placebo 
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cohort.  The Safety Population had the same number of subjects as the mITT Population.  Of the 
110 subjects in the study, 27.3% (n = 30 subjects) completed treatment: 39.1% (n = 9) in the 
belumosudil 200 mg QD cohort; 27.3% (n = 6) in the 200 mg BID cohort; 42.9% (n = 9) in the 
400 mg QD cohort; 15.4% (n = 4) in the 600 mg/day cohort; and 11.1% (n = 2) in the placebo 
cohort.  Overall, the most frequent reasons for early study termination were withdrawal by 
subject (40.9%; n = 45 subjects), followed by loss to follow-up (12.7%; n = 14 subjects), and 
elevated liver enzymes (5.5%; n = 6 subjects). 
The primary efficacy end point was the number (%) of subjects with a 75% decrease in PASI 
(PASI 75) by Week 16.  When including subjects who completed 16 weeks of treatment and 
carrying forward the last results of subjects who did not complete 16 weeks of treatment, all 
belumosudil-treated subjects and all belumosudil cohorts had a proportion of subjects with 
PASI 75.  Among all 92 belumosudil-treated subjects, 10.9% (95% confidence interval [CI]: 
5.3%, 19.1%; n = 10 subjects) had a PASI 75 at Week 16.  Of the 18 subjects in the placebo 
cohort, 16.7% (95% CI: 3.6%, 41.4%; n = 3 subjects) had a PASI 75.  Each belumosudil cohort 
had a proportion of subjects with PASI 75:  8.7% (95% CI: 1.1%, 28.0%; 2/23 subjects) in the 
200 mg QD cohort; 9.1% (95% CI: 1.1%, 29.2%; 2/22 subjects) in the 200 mg BID cohort; 
19.0% (95% CI: 5.4%, 41.9%; 4/21 subjects) in the 400 mg QD cohort; and 7.7% (95% CI: 
0.9%, 25.1%; 2/26 subjects) in the 600 mg/day cohort.  The proportion of subjects who had a 
PASI 75 among all belumosudil-treated subjects was less than for placebo (-5.8% [95% 
CI: -24.2%, 12.6%]) but the difference was not statistically significantly different (p = 0.4435).  
None of the belumosudil-treated cohorts had a statistically significant difference compared to the 
placebo cohort: p = 0.6384 for the 200 mg QD cohort; p = 0.6419 for the 200 mg BID cohort; 
p > 0.9999 for the 400 mg QD cohort; and p = 0.3859 for the 600 mg/day cohort. 
During the Entire Treatment Period, 92 subjects received belumosudil and 18 subjects received 
placebo.  The proportions of TEAEs among all 92 belumosudil-treated subjects were comparable 
to or less than those occurring among the 18 subjects in the placebo cohort and were as follows: 
• Severe TEAE:  belumosudil = 8.7% (n = 8 subjects); placebo = 11.1% (n = 2 subjects) 
• Grade ≥ 3 TEAEs:  belumosudil = 10.9% (n = 10); placebo = 11.1% (n = 2) 
• TEAEs related to study drug:  belumosudil = 30.4% (n = 28) ; placebo = 33.3% (n = 6) 
• Grade ≥ 3 TEAEs considered related to study drug:  belumosudil = 5.4% (n = 5); 
placebo = 5.6% (n = 1) 
• Grade 4:  belumosudil = 1.1% (n = 1); placebo = 0 
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• SAEs:  belumosudil = 4.3% (n = 4); placebo = 5.6% (n = 1) 
• SAEs related to study drug:  belumosudil = 0; placebo = 0 
• TEAEs leading to discontinuation:  belumosudil = 16.3% (n = 15; includes SAE); 
placebo = 16.7% (n = 3) 
• Deaths:  belumosudil = 1.1% (n = 1); placebo = 0 
• Deaths related to study drug = 0 
The conclusions of the study were that PO administration of belumosudil improves the clinical 
symptoms of subjects with psoriasis as demonstrated by: 
• Improvement in PASI 75 score at 16 weeks, regardless of dosing regimen 
• Improvement in PASI 75 score at 48 weeks 
• Improvement in DLQI score at 16 weeks 
• Improvement in DLQI score at 48 weeks 
• Generally well-tolerated with no deaths or SAEs considered related to study drug 
1.4.1.4 Other Potential Indicators  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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1.4.2 Clinical Summary  
As of 19 February 2020, more than 600 individuals have been dosed with belumosudil as 
participants of Phase 1 and Phase 2 Kadmon-sponsored studies. 
Single and multiple doses of belumosudil up to 1000 mg appear to be safe and well-tolerated in 
Phase 1 studies conducted in healthy volunteers. There were few SAEs, all unrelated to 
belumosudil. The most common AEs seen in Phase 1 studies were transient increases in 
transaminases which resolved after cessation of dosing. 
Analysis of Phase 2 safety data from subjects with cGVHD, IPF, and psoriasis suggests an 
acceptable, manageable safety profile for belumosudil. Overall, TEAEs have generally been 
consistent with those expected in the populations enrolled in each of the studies. 
Development of belumosudil is most advanced in the indication of cGVHD. Data from an early 
Phase 2 study, KD025-208, served as the basis for a Breakthrough Therapy Designation for 
belumosudil for the treatment of adult patients with cGVHD. These results were also the basis 
for a subsequent study, KD025-213 (the ROCKstar Study). Subjects who had received 2 to 
5 prior lines of systemic therapy for cGVHD were enrolled into the ROCKstar study, a 
population with significant unmet medical need. Overall, 132 subjects were randomized to 
receive either belumosudil 200 mg QD (Arm A, n = 66) or belumosudil 200 mg BID (Arm B, 
n = 66). Subjects enrolled reflected a real-world population of complex, advanced cGVHD 
patients: median age 56 years; male 57%; 49% had received at least 4 prior lines of systemic 
therapy; median time from transplant to study 29 months; severe cGVHD at baseline 67%; prior 
treatment with ibrutinib 35%. The primary endpoint was met in both dosing arms at the primary 
analysis (6 months after last patient enrolled): overall response rate was 73.5% (95% CI: 65%, 
81%). 
Taken together, the totality of the data support the continued development of belumosudil. 
1.5 
STUDY RATIONALE  
Belumosudil is an inhibitor of the ROCK2 isoform.  This family of kinases has been shown to 
have profound activity on cell morphology, motility, and shape through effects on the 
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cytoskeleton.  Data show that ROCK2 inhibition has an anti-inflammatory effect predominantly 
through the down-regulation of signal transducer and activator of transcription 3 (STAT3) and 
the Th17 axis.  Thus IL-17, IL-21, and IL-22 are downregulated. 
Chronic fibrosis is characterized by myofibroblast resistance to apoptosis.  Inhibition of the 
ROCK pathway has demonstrated a beneficial effect on bleomycin induced fibrosis acting 
through the inhibition of activation of myofibroblasts.  Anti-inflammatory activity, coupled with 
anti-fibrotic activity, suggests that inhibiting the ROCK2 pathway may be an effective therapy 
for inflammatory fibrotic diseases such as lung disease, which is associated with the majority of 
subjects with systemic sclerosis (SSc).  Belumosudil has been shown to increase STAT5, which 
leads to an increase in the Treg population of lymphocytes and helps balance the immune system 
during inflammation. 
Nonclinical pharmacology studies have demonstrated the potential of belumosudil to have a 
therapeutic benefit in a number of indications, particularly in autoimmune and fibrotic diseases.  
In vitro, belumosudil has demonstrated an impact on the Th17-type immune responses as well as 
on the actin/myosin cytoskeletal network and collagen formation.  In vivo, belumosudil has 
demonstrated efficacy in a variety of clinically relevant animal models of disease including 
cGVHD, scleroderma, IPF, and other autoimmune diseases at clinically relevant drug exposures.  
Belumosudil has also been shown to significantly decrease the GVHD score in the 
sclerodermatous GVHD mouse model. 
In a 3-month study in patients with moderate-to-severe psoriasis, belumosudil demonstrated both 
clinical and pharmacodynamic activity.  Similarly, in an open-label study of belumosudil in the 
treatment of IPF, belumosudil slowed the decrease in lung function in IPF patients over 24 weeks 
of treatment when compared to best supportive care.  Finally, in a study of patients with steroid 
refractory or dependent cGVHD, approximately two-thirds of patients achieved a clinical 
response with belumosudil.  In this study, patients were able to reduce doses of steroids and 
immunosuppressant drugs during treatment with belumosudil.  It is noteworthy that cGVHD 
represents a paradigm for immune-inflammatory triggering of chronic fibrosis that shares 
important similarities with SSc. 
1.6 
DOSE RATIONALE  
Belumosudil was well-tolerated in Phase 1 studies of healthy volunteers at single doses up to 
1000 mg, and with repeat doses up to 500 mg BID for 28 days. 
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Phase 2 studies of belumosudil have been initiated, enrolling patients with IPF 
(Study KD025-207), cGVHD (Study KD025-208 and Study KD025-215) and psoriasis (Study 
KD025-205, Study KD025-206, and Study KD025-211). More than 600 subjects have been 
dosed with belumosudil for inflammatory or fibrotic diseases or as healthy volunteers at doses 
ranging from 20 mg to 1000 mg QD and 500 mg BID.   
Preliminary data from Phase 2 studies of belumosudil indicate that the dose of 200 mg QD is 
associated with clinical efficacy and are well-tolerated in indications with immune and fibrotic 
manifestations (e.g., cGVHD and IPF). 
This study will evaluate belumosudil at doses of 200 mg QD and belumosudil 200 mg BID 
(400 mg/day) for the treatment of dcSSc. 
Refer to the Belumosudil IB for more detailed information. 
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2. STUDY OBJECTIVES  
2.1 
PRIMARY OBJECTIVE  
To evaluate the efficacy of belumosudil compared to placebo for the Combined Response 
Index in diffuse cutaneous Systemic Sclerosis (CRISS) at Week 24  
2.2 
SECONDARY OBJECTIVES  
• To assess the CRISS for each group at Week 52 
• To evaluate the efficacy of belumosudil compared to placebo at Week 24 for: 
o mRSS 
o FVC 
o Physician Global Assessment 
o Patient Global Assessment 
o Scleroderma Health Assessment Questionnaire–Disability Index 
(SHAQ-DI) 
• To evaluate the efficacy of belumosudil at Week 52 compared to baseline for 
subjects randomized to belumosudil for the parameters in the bullet above 
• To assess changes in lung fibrosis, via high resolution computerized tomography 
(HRCT), performed at baseline, Weeks 24 and Week 52 only in subjects with ILD 
at screening 
• To assess pharmacokinetics (PK) of belumosudil by sparse sampling of 
belumosudil on  of Weeks 4 and 8 (i.e., Days 29 and 57) immediately prior to 
belumosudil dosing and 3 hours post-dose 
• To assess the safety of belumosudil compared to placebo in subjects with dcSSc 
by examining the percentage of subjects with TEAEs (CTCAE v5.0) in subjects 
with dcSSc 
2.3 
EXPLORATORY OBJECTIVES  
• To evaluate changes in biomarkers of endothelial cell dysfunction, fibrosis, 
immune system function, and cytokine alterations from subjects receiving 
belumosudil or placebo 
• To assess histology and gene expression from skin biopsies taken from subjects at 
baseline, Week 24 and optionally at Week 52 
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3. INVESTIGATIONAL PLAN  
3.1 
STUDY DESIGN  
This is a phase 2, placebo-controlled, double-blinded, randomized, multicenter trial in 
subjects with dcSSc with an open-label extension. 
The duration of the study will be approximately 14 months (4 weeks for screening, 
52 weeks of dosing period, and 4 weeks of Follow-up). The study will be double-blinded 
for the first 28 weeks followed by an open-label extension of 24 weeks.   
Subjects who have signed an IRB/IEC-approved informed consent form (ICF) and met all 
of the inclusion/exclusion criteria will be enrolled.  A total of 60 subjects will be 
randomized into 3 groups (1:1:1) to receive orally administered belumosudil 200 mg QD 
(n = 20), belumosudil 200 mg BID (n = 20), or matched placebo (n = 20) for 28 weeks.  
The study will be double-blinded for the first 28 weeks followed by an open-label 
extension of 24 weeks.  After unblinding, the subjects in Group 1 and 2 will continue on 
the same belumosudil dose whereas the subjects in the placebo group will be 
re-randomized to one of the belumosudil doses (200 mg QD or 200 BID) in 1:1 fashion.   
Subjects will undergo evaluations as outlined in the Study Assessment Tables in 
Appendix A. 
Efficacy will be assessed throughout the 52-week dosing period using CRISS, mRSS, 
PFTs, physician global assessment, and patient global assessments. 
Follow-up Period 
A 4-Week Safety Follow-Up visit will occur 28 (± 3) days after the last dose of study 
drug. Subjects will undergo PEs; vital sign measurements; weight measurement; blood 
sample collection for hematology and chemistry; thyroid function: urinalysis; ECGs; AE 
assessments; concomitant medication assessments; and pregnancy testing for females of 
childbearing potential. In addition, patients will also have efficacy assessments done as 
per Appendix A. 
 
 
 
 
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Figure 1 
Schematic of Study KD025-209  
 
 
 
 
3.2 
NUMBER OF SUBJECTS  
Sixty male and female subjects will be enrolled (20 randomized to each of the 
2 belumosudil dose groups and the placebo group). 
3.3 
STUDY CENTERS  
Approximately 25 centers will participate in this study. 
3.4 
INCLUSION CRITERIA  
1. Male and female subjects ≥ 18 years old with the diagnosis of dcSSc according to 
the 2013 American College of Rheumatology and European League Against 
Rheumatism criteria  
2. Must have disease duration (defined as interval from first non-Raynaud disease 
manifestation) of ≤ 5 years 
3. Must have mRSS of ≥ 15 but ≤ 35  
4. Active disease defined as any of the following within the 6 months prior to 
screening: 
a. Increase in mRSS by ≥ 3 units  
b. Increase in mRSS by ≥ 2 units with involvement of 1 new body area  
c. Involvement of 2 new body areas 
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d. Symptoms indicative of skin activity such as severe cutaneous itching or 
burning 
5. Subjects receiving concomitant immunosuppression must be on a stable dose for 
at least 3 months prior to screening 
6. Adequate organ and bone marrow functions evaluated during the 28 days prior to 
enrollment as follows: 
a. Absolute neutrophil count ≥ 1.5 × 109/L  
b. Platelet count ≥ 100 × 109/L  
c. Total bilirubin ≤ 1.0 × upper limit of normal (ULN) 
d. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and 
serum creatinine ≤ 1.5 × ULN 
7. Female subjects of childbearing potential have a negative pregnancy test at 
screening.  Females of childbearing potential are defined as sexually mature 
women without prior hysterectomy or who have had any evidence of menses in 
the past 12 months. However, women who have been amenorrheic for 12 or more 
months are still considered to be of childbearing potential if the amenorrhea is 
possibly due to prior chemotherapy, anti-estrogens, or ovarian suppression. 
a. Women of childbearing potential (i.e., menstruating women) must have a 
negative urine pregnancy test (positive urine tests are to be confirmed by 
serum test) documented within the 24-hour period prior to the first dose of 
study drug.  
b. Sexually active women of childbearing potential enrolled in the study 
must agree to use 2 forms of accepted methods of contraception during 
the course of the study and for 3 months after their last dose of study 
drug.  Effective birth control includes (i) IUD plus 1 barrier method; 
(ii) on stable doses of hormonal contraception for at least 3 months (e.g., 
oral, injectable, implant, transdermal) plus 1 barrier method; or (iii) two 
barrier methods.  Effective barrier methods are male or female condoms, 
diaphragms, and spermicides (creams or gels that contain a chemical to 
kill sperm), or a vasectomized partner. 
8. For male patients who are sexually active and who are partners of premenopausal 
women: agreement to use 2 forms of contraception as in Criterion 
Number 7 above during the treatment period and for at least 3 months after the 
last dose of study drug. 
9. Male subjects must not donate sperm for 3 months after last dose of study drug. 
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10. Able to provide written informed consent prior to the performance of any 
study-specific procedures. 
3.5 
EXCLUSION CRITERIA  
1. Subject has corrected QT interval using Fredericia’s formula (QTcF) > 450 ms 
2. Ongoing use or current use of concomitant medication known to have the 
potential for QTc prolongation; 
3. Female subject who is pregnant or breastfeeding 
4. Participated in another study with an investigational drug within 28 days of study 
entry (for studies involving biologics, within 3 half-lives of the biologic) 
5. History or other evidence of severe illness or any other conditions that would 
make the subject, in the opinion of the Investigator, unsuitable for the study 
6. Chronic heart failure with New York Heart Association Classes II, III, and IV 
7. Acute or chronic liver disease (e.g., cirrhosis) 
8. Positive human immunodeficiency virus (HIV) test 
9. Active hepatitis C virus (HCV), hepatitis B virus (HBV), or positive whole blood 
tuberculin test 
10. Diagnosed with any malignancy within 3 years of enrollment, with the exception 
of basal cell or completely resected squamous cell carcinoma of the skin, resected 
in situ cervical malignancy, resected breast ductal carcinoma in situ, or low-risk 
prostate cancer after curative resection 
11. Has had previous exposure to belumosudil or known allergy/sensitivity to 
belumosudil or any other ROCK2 inhibitor 
12. Scleroderma renal crisis within 4 months prior to enrollment 
13. FVC ≤ 50% Predicted 
3.6 
SCREENING  
The screening period commences once the ICF is signed.  Adequate time must be 
allowed for the subject to ask questions and make a voluntary decision. The ICF must be 
signed before any study-specific samples are taken or study -specific tests or evaluations 
are conducted.   
Data regarding screen-failures will be captured in the electronic data capture (EDC) 
system. 
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Screening assessments as summarized in the Schedule of Assessments (Appendix A) will 
be performed within 29 days of first dose of study drug (Week 1, Day 1 visit).   
Study eligibility will be based on satisfying all of the study inclusion and exclusion 
criteria.   
Re-screening of subjects will be allowed only upon approval of the Medical Monitor. 
3.7 
WITHDRAWAL CRITERIA  
Subjects may be withdrawn from study treatment at any time by the Investigator if it is 
considered detrimental for the subject to continue in the study.  The reason for 
withdrawal must be captured in the eCRF. 
Subjects have the right to withdraw from the study at any time and for any reason without 
prejudice to their future medical care by the physician or at the institution.  Every effort 
should be made to have such subjects attend End-of-Treatment (EOT) and 28-day 
Follow-Up visits.  In the instances where a reason for withdrawal of consent is given, this 
will be captured in the electronic case report form (eCRF).  Subject data up to withdrawal 
of consent will be included in the analysis of the study, and where permitted, publicly 
available data can be included after withdrawal of consent.  
3.8 
REPLACEMENTS  
Subjects withdrawn from the study before receiving any study drug will be replaced by 
enrolling additional subjects into the study. 
3.9 
TREATMENT DISCONTINUATION  
Treatment discontinuation reasons include the following: 
• An AE requiring permanent discontinuation of study drug  
• Investigator decision 
• Clinically significant disease progression.  For example: 
o mRSS increase ≥ 5 units 
o Absolute decrease in FVC (% predicted) ≥10% or absolute decrease in diffuse 
capacity of the lungs for carbon monoxide (DLco) (corrected for Hb) of 
≥ 15% 
o Renal crisis 
• Study stopping rules for the sponsor (Section 9.6.1) 
• Subjects meeting criteria for discontinuation from the study (Section 9.6.2) 
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• Voluntary withdrawal by subject 
• Noncompliance to protocol 
• Subject lost to follow-up 
• Termination of the study by sponsor 
• 
Subject death 
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4. STUDY TREATMENT  
4.1 
INVESTIGATIONAL PRODUCT  
Belumosudil (2-(3-(4-(1H-indazol-5-ylamino) quinazolin-2-yl) phenoxy)-N-
isopropylacetamide-methane sulfonic acid salt) is an orally available ROCK2 selective 
inhibitor.  Belumosudil will be provided as 200 mg tablets.  Placebo oral medication will 
match belumosudil oral medication. 
4.2 
DOSAGE AND ADMINISTRATION  
Subjects will be randomized to receive belumosudil 200 mg QD (Group 1), belumosudil 
200 mg BID (Group 2), or matched placebo (Group 3) in the double-blinded 28 weeks as 
follows:    
Table 2 
Dosing of Treatment Groups for Double-blind Period of Study  
Belumosudil Group 
AM 
PM 
Group 1 (200 mg QD) 
One 200 mg belumosudil tablet 
One matched placebo 
Group 2 (200 mg BID) One 200 mg belumosudil tablet 
One 200 mg belumosudil tablet 
Group 3 (Placebo) 
One matched placebo 
One matched placebo 
BID = twice daily; QD = once daily 
 
After unblinding, the subjects in Group 1 and 2 will continue on the same belumosudil 
dose whereas the subjects in the placebo group will be re-randomized to one of the 
belumosudil doses (200 mg QD or 200 mg BID) in 1:1 fashion.   
4.3 
TREATMENT ASSIGNMENT  
All subjects in the study will be double-blinded for the first 28 weeks and open-label for 
another 24 weeks.   
Subjects will be randomized 1:1:1 to receive belumosudil 200 mg QD (Group 1), 
belumosudil 200 mg BID (Group 2), and matched placebo (Group 3) for the first 
28 weeks.  After unblinding, the subjects in Group 1 and 2 will continue on the same 
belumosudil dose whereas the subjects in the placebo group will be re-randomized to one 
of the belumosudil doses (200 mg QD or 200 mg BID) in 1:1 fashion.  This unblinding 
will be done as each subject reaches 28 weeks.   
4.4 
BLINDING  
Study will be double-blinded for the first 28 weeks and open-label for another 24 weeks. 
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4.5 
TREATMENT COMPLIANCE  
Subjects will be given a study drug diary to record the details of each dose of study drug. 
Diaries will be dispensed/collected on each visit. Compliance with oral dosing will be 
confirmed using patient diaries, which will be examined at each visit by site staff to 
determine if dosing is as instructed per protocol and follow-up with the subject 
accordingly. If the subject skips more than 7 consecutive days of drug dosing (other than 
those specified in the Dose Modification Guideline for Toxicity), the subject should be 
discontinued from the study unless approved by the Medical Monitor and Investigator. 
4.6 
MISSED DOSES  
Subjects should make every effort to take the study drug at the same scheduled time 
daily. In the event that the subject misses the planned dose of study drug, the following 
protocol should be followed: 
For subjects during the 28 weeks of double-blinding:  
• If less than 6 hours of time have elapsed after the scheduled dose, the drug should 
be taken. The subject should then resume the regular planned daily dosing 
schedule the following day. 
• If ≥ 6 hours of time have elapsed after the scheduled dose, the drug should be 
skipped for that day. The subject should then resume the regular planned dosing 
schedule the following day. 
For subjects during the 24 weeks of open-label:  
For subjects receiving study drug on a QD dosing schedule: 
• If < 12 hours of time have elapsed after the scheduled dose, the drug should be 
taken. The subject should then resume the regular planned daily dosing schedule 
the following day. 
• If ≥ 12 hours of time have elapsed after the scheduled dose, the drug should be 
skipped for that day. The subject should then resume the regular planned dosing 
schedule the following day. 
For subjects receiving study drug on a BID dosing schedule: 
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• If < 6 hours of time have elapsed after the scheduled dose, the drug should be 
taken. The subject should then resume the regular planned dosing schedule.  
• If ≥ 6 hours of time have elapsed after the scheduled dose, the dose should be 
skipped and the subject should resume dosing with the next regular planned dose. 
4.7 
PRODUCT ACCOUNTABILITY  
In accordance with regulatory requirements, study sites must document the amount of 
investigational product (IP) received from and returned to the sponsor, and the amounts 
of IP dispensed to study subjects, and the amount returned by study subjects.  Product 
accountability records must be maintained throughout the course of the study.  
4.8 
CONCOMITANT MEDICATION AND THERAPIES  
All concomitant medications taken during the study and relevant procedures will be 
recorded on the eCRF. 
Ongoing immunosuppressive therapy with steroids ≤ 10 mg/day is permitted and must be 
documented in the source documentation and eCRFs. 
Subjects will be counseled to avoid non-prescribed medicines or complementary 
alternative medicines excluded by the study.  All medications a subject receives from the 
signing of the ICF through the 28-Day Follow-Up visit will be documented. 
After discontinuation of study drug, any medication used in response to an AE is to be 
recorded on the appropriate eCRF. 
The concomitant medication names will be coded by the sponsor according to the World 
Health Organization Drug Dictionary and classified by anatomical therapeutic chemical 
categories 
4.9 
CYP3A4 INHIBITORS/INDUCERS  
CYP3A4 inhibitors/inducers should be used with caution. 
4.10 DRUGS PROLONGING THE QTC INTERVAL  
Subjects on concomitant medications known to have the potential for QTc prolongation 
will be excluded.  
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4.11 OVERDOSE  
Doses of belumosudil considered to represent an overdose have not been defined.  In 
clinical studies of belumosudil, repeat dosing of 500 mg BID for 28 days was generally 
well tolerated in healthy volunteers.  There are no known antidotes to belumosudil, and 
no specific treatment is recommended in the event of a suspected overdose.  The treating 
Investigator should employ clinical judgment in managing subjects with suspected 
overdose.  Overdose should be reported as an AE. 
4.12 DOSE MODIFICATION GUIDELINES  
Any clinically significant toxicity will necessitate consideration of either a pause or 
cessation of therapy. Dose modification of therapy is permitted in the open label phase as 
outlined in Table 5.Guidelines for management of treatment-emergent toxicities in 
subjects receiving belumosudil are outlined in Table 3Error! Reference source not 
found..   
Table 3 
Guidelines for Management of Treatment-emergent Toxicities 
(Double-blinded Phase)  
Toxicity 
Recommended Action 
Grade ≥ 3 LFTs (AST, 
ALT or total bilirubin) 
• 
Complete the “Treatment-emergent LFT elevations” eCRF 
• 
Discontinue belumosudil 
Other Grade ≥ 3 
clinically significant 
toxicities considered 
related to belumosudil 
• 
Discontinue belumosudil 
Grade 2 clinically 
significant toxicities  
• 
Consider pause or cessation of therapy 
• 
Dose interruption for toxicity will be permitted up to 14 days.  
• 
If toxicity does not resolve to Grade 1 or below for 14 days, subjects 
will be discontinued from treatment 
ALT = alanine aminotransaminase; AST = aspartate aminotransaminase; eCRF = electronic case report form; LFT = 
liver function tests 
 
 
 
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Table 4 
Guidelines for Management of Treatment-emergent Toxicities 
(Open-Label Phase) 
Toxicity 
Recommended Action 
Grade ≥ 3 LFTs (AST, 
ALT or total bilirubin) 
• 
Complete the “Treatment-emergent LFT elevations” eCRF 
• 
Discontinue belumosudil 
Other Grade ≥ 3 
clinically significant 
toxicities considered 
related to belumosudil 
• 
Discontinue belumosudil 
Grade 2 clinically 
significant toxicities  
• 
Consider pause or dose modification(table 5) of therapy 
• 
Dose interruption for toxicity will be permitted up to 14 days. If 
toxicity resolves to grade 1 or below then consider resuming 
belumosudil at current dose or one dose decrement as outlined in 
Table 5 below 
• 
If toxicity recurs, hold dose as above then consider resuming 
belumosudil at one dose decrement 
• 
If toxicity does not resolve to Grade 1 or below for 14 days, subjects 
will be discontinued from treatment 
ALT = alanine aminotransaminase; AST = aspartate aminotransaminase; eCRF = electronic case report form; LFT = 
liver function tests 
 
Dose interruption for toxicity management for 14 days is permitted. Subjects 
requiring pauses of more than 14 days will be discontinued from the study 
unless approved by the Medical Monitor. 
 
Table 5. 
Belumosudil Dose Decrements 
 
Belumosudil Dose 
Dose Reduction 
200 mg BID 
200 mg QD  
200 mg QD 
200 mg QOD 
 BID = twice daily; QD = once daily; QOD = once every other day 
 
If the reduced dose is tolerated for 1 complete cycle, the dose may be escalated to the 
previous dose. 
 
 
 
 
 
 
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5. STUDY ASSESSMENTS AND PROCEDURES  
The schedule of assessments is outlined in Error! Reference source not found.   
CRISS assessments will not be performed on site in either the Double-blind or 
Open-label Periods, but rather will be calculated outside of EDC. 
5.1 
SCREENING PERIOD (DAY -29 TO -1)  
Informed consent must be obtained before any study-specific samples are taken or 
study-specific tests or evaluations are conducted.  The following assessments at the 
screening visit are to occur within 29 days of first dose of study drug (Week 1, Day 1 
visit).  Study eligibility will be based on satisfying all the study inclusion and exclusion 
criteria.   
At the screening visit, information will be collected and subjects will have clinical 
evaluations as follows: 
• Informed consent 
• Subject demography 
• Medical history 
• Inclusion/exclusion criteria 
• mRSS 
• FVC 
• Complete PE 
• Vital signs 
• Weight 
• Hematology and chemistry 
• 12-lead ECG 
• Pregnancy test 
• Concomitant medication assessment 
• AE assessment 
 
5.2 
DOUBLE-BLINDED TREATMENT PERIOD  
After completion of screening procedures and confirmation of subject eligibility, the 
subject will be randomized and enrolled into the study.  Subjects who are enrolled into 
the study are to undergo all subsequent evaluations required by the protocol. 
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5.2.1 Week 1, Day 1 Visit (Baseline)  
At the Week 1 Day 1 visit, subjects will come to the clinic to have the following 
procedures: 
• Confirmation of inclusion/exclusion criteria 
• Randomization 
• mRSS 
• SHAQ-DI 
• Physician Global Assessment 
• Patient Global Assessment 
• Pulmonary function test (PFT)* 
• HRCT (± 7 days; for subjects with ILD at screening only) 
• Skin biopsies 
• Sampling for PD 
• Complete PE 
• Vital signs 
• Weight 
• Hematology and chemistry* 
• Urinalysis* 
• 12-lead ECG 
• Pregnancy test 
• Dispense study diary 
• Study drug administration - review with patient 
• Dispense study drug 
• Concomitant medication assessment 
• AE assessment 
*If these assessments were conducted within seven (7) days of baseline, they do 
not need to be repeated. 
5.2.2 Day 15 (± 3 Days) Visit  
Subjects will come to the clinic to have the following procedures: 
• Symptom-directed PE 
• Vital signs 
• Weight 
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• Hematology and chemistry 
• Urinalysis 
• 12-lead ECG 
• Pregnancy test 
• Study drug administration 
• Concomitant medication assessment 
• AE assessment 
5.2.3 End of Week 4, Day 29 (± 3 Days) Visit  
Subjects will come to the clinic to have the following procedures: 
• Sampling for PK 
• Symptom-directed PE 
• Vital signs 
• Weight 
• Hematology and chemistry 
• Urinalysis 
• 12-lead ECG 
• Pregnancy test 
• Dispense and collect study diary  
• Study drug administration  
• Dispense & collect study drug 
• Concomitant medication assessment 
• AE assessment 
5.2.4 End of Week 8, Day 57 (± 3 Days) Visit  
Subjects will come to the clinic to have the following procedures: 
• CRISS 
• mRSS 
• FVC 
• SHAQ-DI 
• Physician Global Assessment 
• Patient Global Assessment 
• Sampling for PK 
• Sampling for PD 
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• Symptom-directed PE 
• Vital signs 
• Weight 
• Hematology and chemistry 
• Urinalysis 
• 12-lead ECG 
• Pregnancy test 
• Dispense and collect study diary  
• Study drug administration 
• Dispense and collect study drug 
• Concomitant medication assessment 
• AE assessment 
5.2.5 End of Week 12, Day 85 (± 3 Days) Visit  
Subjects will come to the clinic to have the following procedures: 
• Symptom-directed PE 
• Vital signs 
• Weight 
• Hematology and chemistry 
• Urinalysis 
• 12-lead ECG 
• Pregnancy test 
• Collect and dispense study diary 
• Study drug administration 
• Collect and dispense study drug 
• Concomitant medication assessment 
• AE assessment 
5.2.6 End of Week 16, Day 113 (± 3 Days)  
Subjects will come to the clinic to have the following procedures: 
• CRISS 
• mRSS 
• FVC 
• SHAQ-DI 
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• Physician Global Assessment 
• Patient Global Assessment 
• Symptom-directed PE 
• Vital signs 
• Weight 
• Hematology and chemistry 
• Urinalysis 
• 12-lead ECG 
• Pregnancy test 
• Collect and dispense study diary  
• Study drug administration 
• Collect and dispense study drug 
• Concomitant medication assessment 
• AE assessment 
5.2.7 End of Week 20, Day 141 (± 3 Days)  
Subjects will come to the clinic to have the following procedures: 
• Symptom-directed PE 
• Vital signs 
• Weight 
• Hematology and chemistry 
• Urinalysis 
• 12-lead ECG 
• Pregnancy test 
• Collect and dispense study diary  
• Study drug administration 
• Collect and dispense study drug 
• Concomitant medication assessment 
• AE assessment 
5.2.8 End of Week 24, Day 169 (± 3 Days)  
Subjects will come to the clinic to have the following procedures:   
• CRISS 
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• mRSS 
• FVC (if PFT not performed at visit) 
• SHAQ-DI 
• Physician Global Assessment 
• Patient Global Assessment 
• PFTs (± 7 days) 
• HRCTs (± 7 days) 
• Skin biopsies 
• Sampling for PD 
• Complete PE 
• Vital signs 
• Weight 
• Hematology and chemistry 
• Urinalysis 
• 12-lead ECG 
• Pregnancy test 
• Collect and dispense study diary  
• Study drug administration 
• Collection and dispense study drug 
• Concomitant medication assessment 
• AE assessment 
 
5.2.9 End of Double-Blinded Treatment Visit (End of Week 28, Day 197 
[± 3 Days])  
Subjects will come to the clinic to have the following procedures completed:   
• Randomization (for subjects who had been receiving placebo [Group 3] to 1 of 
2 treatments with belumosudil) 
• CRISS 
• mRSS 
• FVC 
• SHAQ-DI 
• Physician Global Assessment 
• Patient Global Assessment 
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• Complete PE 
• Vital signs 
• Weight 
• Hematology and chemistry 
• Urinalysis 
• 12-lead ECG 
• Pregnancy test 
• Dispense and collect study diary  
• Study drug administration 
• Collect and dispense study drug 
• Concomitant medication assessment 
• AE assessment 
5.3 
OPEN-LABEL VISITS EVERY 4 WEEKS (± 3 DAYS) UNTIL WEEK 52  
After 28 weeks of blinded treatment, subjects will continue on open-label treatment for 
24 weeks.  All subjects will return to the clinic every 4 weeks.  Until Week 52, subjects 
will have safety assessments every 4 weeks and efficacy assessments every (8 weeks) as 
follows: 
Every 4 weeks, subjects will have the following safety assessments, i.e., End of Week 32, 
Week 36, Week 40, Week 44, and Week 48. 
• Symptom-directed PE (at Week 32, Week 36, Week 40, Week 44, and Week 48 
visits) 
• Vital signs 
• Weight 
• Hematology and chemistry 
• Urinalysis 
• 12-lead ECG 
• Pregnancy test 
• Collect and dispense study diary 
• Study drug administration 
• Collect and dispense study drug 
• Concomitant medication assessment 
• AE assessment 
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Every 8 weeks, subjects will have the following efficacy assessments, i.e., End of 
Week 36 (Day 253 ± 3 days) and Week 44 (Day 309 ± 3 days): 
• CRISS 
• mRSS 
• FVC 
• SHAQ-DI 
• Physician Global Assessment 
• Patient Global Assessment 
5.4 
END OF TREATMENT OR WEEK 52, (DAY 365 [± 3 DAYS])  
Subjects who complete Week 52 the study will have the following procedures: 
 
• CRISS 
• mRSS 
• FVC (if PFT not performed at visit) 
• SHAQ-DI 
• Physician Global Assessment 
• Patient Global Assessment 
• PFTs (± 7 days) 
• HRCT (± 7 days) 
• Skin biopsies (optional) 
• Sampling for PD 
• Complete PE 
• Vital signs 
• Weight 
• Hematology and chemistry 
• Urinalysis 
• 12-lead ECG 
• Pregnancy test 
• Collect study diary 
• Collect study drug 
• Concomitant medication assessment 
• AE assessment 
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Subjects who discontinue from the study prior to Week 52 will have the same 
assessments performed as subjects who complete Week 52. 
5.5 
28-DAY FOLLOW-UP VISIT  
Subjects will return to the clinic twenty-eight (28) days (± 3 days) after their last dose of 
study drug.  At this visit, the following procedures will be completed: 
• CRISS 
• mRSS 
• SHAQ-DI 
• Physician Global Assessment 
• Patient Global Assessment 
• PFT 
• Complete PE 
• Vital signs 
• Weight 
• Hematology and chemistry 
• Urinalysis 
• 12-lead ECG 
• Pregnancy test 
• Concomitant medication assessment 
• AE assessment 
5.6 
UNSCHEDULED VISIT  
For subjects requiring an unscheduled visit, the following procedures may be performed 
at the Investigator’s discretion: 
• CRISS 
• mRSS 
• FVC (if PFT not performed at visit) 
• SHAQ-DI 
• Physician Global Assessment 
• Patient Global Assessment 
• PFTs 
• Complete PE 
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• Vital signs 
• Weight 
• Hematology and chemistry 
• Urinalysis 
• 12-lead ECG 
• Pregnancy test 
• Collect and dispense study diary 
• Study drug administration 
• Collect study drug 
• Concomitant medication assessment 
• AE assessment 
 
 
 
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6. EFFICACY AND SAFETY ASSESSMENTS  
6.1 
EFFICACY ENDPOINTS  
Efficacy measurements will be performed as outlined in Appendix A. 
The primary efficacy endpoint is the effect of belumosudil compared to placebo for the 
CRISS at the end of Week 24 in the mITT Population.  The CRISS exponential algorithm 
determines the predicted probability of improvement from baseline, incorporating 
changes in mRSS, FVC% predicted, and Physician and Patient Global Assessments.  The 
outcome is a continuous variable between 0.0 and 1.0 (0-100%).  A higher score indicates 
greater probability of improvement.  A CRISS score ≥ 20% is considered a clinically 
meaningful improvement. 
Other efficacy outcomes include the change from baseline in mRSS for 
belumosudil-treated and placebo-treated subjects.  The mRSS is a measure of skin 
thickness rated with scores ranging from 0 (normal) to 3 (severe skin thickening) across 
17 different sites.  The total score is the sum of the individual skin scores in the 17 body 
areas (i.e., face, hands, fingers; proximal area of the arms, distal area of the arms, thorax, 
abdomen; proximal area of the legs, and distal area of the legs, feet), giving a range of 
0-51 units.  The mRSS has been validated for patients with SSc.  A negative change from 
baseline demonstrates improvement. 
The effect of belumosudil compared to placebo will be explored for the change in 
baseline for SHAQ-DI, which assesses 5 scleroderma-specific Visual Analog Scale 
(VAS) items to explore the impact of participant's disease. Each VAS item will be rated 
separately in scale of a 0−100 mm, with higher scores indicating more severe disease. 
The 5 items are: (1) intestinal disease, (2) breathing problem, (3) Raynaud syndrome, 
(4) finger ulcers, and (5) overall disease. 
Onset/progression of ILD will be evaluated by the effect of belumosudil compared to 
placebo in the change in predicted FVC, which is based on institutional standards and 
will be measured as part of PFTs, including FEV1, FVC, DLCO, and total lung capacity 
(TLC).  The same equipment and tester should be used during the course of the study to 
the extent possible. The person responsible for conducting the PFTs will be required to 
comply with the study guidelines and the American Thoracic Society/European 
Respiratory Society joint criteria on lung function testing. 
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6.1.1 Primary Endpoint  
The primary endpoint of this study is to evaluate the efficacy of belumosudil compared to 
placebo for the CRISS at Week 24  
6.1.2 Secondary Endpoints  
• To assess the CRISS for each group at Week 52 
• To evaluate the efficacy of belumosudil compared to placebo at Week 24 for: 
o mRSS 
o FVC 
o Physician Global Assessment 
o Patient Global Assessment 
o SHAQ-DI 
• To evaluate the efficacy of belumosudil at Week 52 compared to baseline for 
subjects randomized to belumosudil for the parameters in the bullet above 
• To assess changes in lung fibrosis, via HRCT, performed at baseline, Week 24, 
and Week 52 only in subjects with ILD at screening 
• To assess PK of belumosudil by sparse sampling of belumosudil on Weeks 4 and 
8 (i.e., Days 29 and 57) immediately prior to belumosudil dosing and 3 hours 
post-dose 
• To assess the safety of belumosudil compared to placebo in subjects with dcSSc 
by examining the percentage of subjects with TEAEs (CTCAE v5.0) in subjects 
with dcSSc 
 
6.1.3 Exploratory Endpoints  
• To evaluate changes in biomarkers of endothelial cell dysfunction, fibrosis, 
immune system function, and cytokine alterations from subjects receiving 
belumosudil or placebo 
• To assess histology and gene expression from skin biopsies taken from subjects at 
baseline, Week 24, and optionally at Week 52 
6.2 
SAFETY  
6.2.1 Safety Endpoints  
Also see Section 9 for additional detail on AEs. 
 
• AEs and SAEs 
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• Hematological and clinical chemistry parameters 
• Vital signs:  change from baseline in systolic blood pressure, diastolic blood 
pressure and heart rate  
• 12-lead ECG:  mean and maximum change from baseline in QTcF  
6.2.2 Vital Signs  
Seated pulse rate and blood pressure measurements will be performed as outlined in the 
Schedule of Assessments (Appendix A).  Measurements will be taken with the subject 
sitting, having rested in this position for at least 5 minutes.  Vital signs should be taken 
before ECGs and other scheduled assessments. 
6.2.3 12-Lead ECG  
Twelve-lead ECGs will be performed as outlined in the Schedule of Assessments 
(Appendix A).  ECGs will be recorded after the subject has rested in the supine position 
for at least 5 minutes and should be performed prior to any blood sample collections. 
The following ECG parameters will be collected:  PR interval, QRS interval, and QTc or 
QTcF.  The ECG findings will be evaluated by a qualified physician for the presence of 
abnormalities (qualitative assessment).  The physician will assess each ECG as normal, 
abnormal/not clinically significant, or abnormal/clinically significant.   
Abnormalities in the ECG that lead to a change in subject management or result in 
clinical signs and symptoms are considered clinically significant for the purposes of this 
study and will be recorded in the AE eCRF. If ECG abnormalities meet criteria defining 
them as serious, they must be reported as an SAE (Section Error! Reference source not 
found.). 
6.2.4 Clinical Laboratory Parameters  
Clinical laboratory tests will be performed as outlined in the Schedule of Assessments 
(Appendix A).  Samples should be taken pre-dose and will be sent to a central laboratory 
for analysis (Table 4).  Full details for collection and shipping of samples are provided in 
the Laboratory Manual. 
Table 4 
Clinical Laboratory Panels  
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Hematology 
Serum Chemistry 
Other 
• 
White blood cell count with 
differential (including at 
minimum: neutrophils, 
basophils, eosinophils, 
lymphocytes, monocytes) 
• 
Red blood cell count 
• 
Hemoglobin 
• 
Hematocrit 
• 
Platelet count 
• 
MCV 
• 
Albumin 
• 
Alkaline phosphatase 
• 
ALT 
• 
AST 
• 
BUN 
• 
Calcium 
• 
Chloride 
• 
CO2 
• 
Creatinine 
• 
CPK 
• 
Total and direct 
bilirubin 
• 
GGT 
• 
Globulin 
• 
Glucose 
• 
HBV (screening only) 
• 
HCV (screening only) 
• 
HIV (screening only) 
• 
Lactate dehydrogenase 
• 
Magnesium 
• 
Phosphorus 
• 
Potassium 
• 
Sodium 
• 
Total protein 
• 
Uric acid 
• 
Whole blood tuberculin 
test (screening only) 
ALT = alanine aminotransferase; AST = aspartate aminotransferase; BUN = blood urea nitrogen; GGT = 
gamma-glutamyl transferase; HBV = hepatitis B virus; HCV = hepatitis C virus; HIV = human 
immunodeficiency virus; MCV = mean corpuscular volume 
 
Abnormalities in clinical laboratory tests that lead to a change in subject management 
(e.g., dose delay, requirement for additional medication or monitoring) are considered 
clinically significant for the purposes of this study and will be recorded on the AE eCRF 
page. Laboratory results will be classified using the CTCAE v5.0. If laboratory values 
constitute part of an event that meets criteria defining it as serious, the event (and 
associated laboratory values) must be reported as an SAE (see Section Error! Reference 
source not found.). 
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6.2.5 Pregnancy Testing  
Pregnancy tests (urine) will be done in women of childbearing potential. Positive urine 
results are to be confirmed with serum testing. In the event of a positive urine test at 
baseline, serum testing results should be acquired within 48 hours prior to study start. 
In the event that a subject or subject’s partner becomes pregnant while on study, they will 
be monitored until the outcome of the pregnancy is known. The baby will continue to be 
monitored to 30 days after delivery. The data are reported on a pregnancy form within 24 
hours of becoming aware. 
 
 
 
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7. PHARMACOKINETICS  
Evaluation of the PK of belumosudil is a secondary objective of this study. 
Sparse PK sampling will be performed at Week 4 and Week 8 (i.e., Day 29 and Day 57) 
immediately prior to dosing and 3 hours post-dose. Each PK blood sample should be 
approximately 6 mL.  A total of up to 4 samples will be collected from each subject.  
Subjects should be instructed to withhold taking study drug on PK sampling days as 
dosing will be performed at the clinic.  The pre-dose and all post-dose PK collection time 
points are to be precisely documented on the appropriate eCRF.  Additionally, the time of 
a subject’s dose of study drug is to be documented.  Detailed instructions for sample 
collection and preparation will be provided in the Central Laboratory Manual. 
 
 
 
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8. PHARMACODYNAMICS  
All subjects will have PD blood samples, up to 20 mL, drawn within 60 minutes prior to 
dosing at the following time points:  Day 1, Week 8 (Day 57), Week 24 (Day 169), and 
EOT/Week 52 (Day 365).  Study medication should be taken in the clinic after PD 
samples are taken.  These samples will be analyzed to evaluate autoantibody levels at 
baseline and biomarkers of extracellular matrix turnover which could correlate with both 
SSc disease activity and disease modification by belumosudil.   
All subjects will provide mandatory skin biopsies obtained from the dorsal mid-forearm 
at the baseline (Week 1 Day 1), Week 24 (Day 169), and optional at End of 
Treatment/Week 52 (Day 365).  Biopsy sections will be assessed for histology including 
myofibroblast (fibrosis) and hyalinized collagen (inflammation) content. In addition, 
gene expression profiling will also be performed on skin biopsies. 
 
 
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9. SAFETY  
9.1 
SAFETY PARAMETERS  
Safety data will be collected from the time the subject signs the ICF form until 28 days 
after their last dose of study drug (the AE reporting period).  The primary safety outcome 
will be the percentage of subjects experiencing AEs in each group.  
Safety assessments will include AEs, SAEs, PEs, vital sign measurements, clinical 
laboratory evaluations (hematology, chemistry, and urinalysis), and ECGs.  Reasons for 
treatment discontinuation because of toxicity will be documented.   
All AEs that occur in enrolled subjects during the AE reporting period must be recorded, 
regardless of the relationship of the AE to study drug.  Any known untoward event that 
occurs beyond the AE reporting period that the Investigator assesses as possibly related 
to study drug also should be reported to Kadmon. 
As this is the first study in subjects with dcSSc, careful monitoring of all toxicities will be 
carried out.   Vital sign measurements, including blood pressure, pulse rate, respiratory 
rate, and temperature will be monitored throughout the study. 
9.2 
ADVERSE EVENT DEFINITION  
An AE is defined as any untoward medical occurrence in a clinical trial subject 
associated with the use of a drug, whether or not considered drug related.  An AE can be 
an unfavorable and unintended sign (e.g., an abnormal laboratory value finding), a 
symptom, or a disease temporally associated with the use of a drug, without judgment as 
to causality.  An AE can arise from use of the drug (e.g., use in combination with another 
drug) and from any route of administration, formulation, or dose, including an overdose. 
An AE also includes, but is not limited to, any clinically significant worsening of a 
pre-existing condition. Examples include: 
• Any sign, symptom, physical finding, or laboratory result that has worsened in 
nature, severity or frequency compared to baseline 
• Reactions from an investigational drug, including those occurring as a result of an 
overdose, abuse of the study drug, withdrawal phenomena, sensitivity or toxicity 
• Concurrent illness that was not present or worsens in nature, severity, or 
frequency compared to baseline 
• Injury or accident and/or 
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• Exacerbation of a pre-existing condition 
For the purpose of data collection, all untoward events that occur after informed consent 
through 28 days after last dose of study drug are to be recorded on eCRFs by the 
investigational site.   
9.3 
EVALUATING ADVERSE EVENTS  
The Investigator will determine the seriousness, intensity, and causality of an AE 
associated with the use of the study drug (i.e., events where there is a reasonable 
possibility that the event may have been caused by the study drug) based on the 
definitions that follow. 
9.3.1 Serious Adverse Events  
The SAE definition and reporting requirements are in accordance with Title 21 Part Code 
of Federal Regulations (CFR) 312.32 and the Guidance for Industry and Investigators 
Safety Reporting Requirements for Investigational New Drug (INDs) and 
Bioavailability/Bioequivalence Studies. 
SAE: An adverse event is considered "serious" if, in the view of either the Investigator or 
sponsor, it results in any of the following outcomes: 
Death:  This includes any death that occurs while the subject is “on study” as well as any 
death that occurs within 28 days after study drug discontinuation.  
Note: Death is an outcome of an AE, and not an AE in itself.  The event(s) that caused 
death (e.g., illness, accident) is the SAE. Death due to any other cause(s) must also be 
reported as an outcome of the reportable SAE. 
Life-threatening adverse event:  An AE or suspected adverse reaction is considered 
“life-threatening” if, in the view of either the Investigator or sponsor, its occurrence 
places the patient or subject at immediate risk of death. It does not include an AE or 
suspected adverse reaction that, had it occurred in a more severe form, might have caused 
death.  
Inpatient hospitalization or prolongation of existing hospitalization:  In the absence 
of an AE, the Investigator should not report hospitalization or prolongation of 
hospitalization. This is the case in the following situations: 
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• Hospitalization or prolongation of hospitalization is needed for a procedure required 
by the protocol 
• Hospitalization or prolongation of hospitalization is part of routine procedure 
followed by study center 
• Hospitalization for survey visits or annual physicals 
In addition, a hospitalization planned before the start of the study for a pre-existing 
condition which has not worsened does not count as an SAE.  
• Persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions  
• Congenital anomaly/birth defect 
• Important medical event:  An event that may not result in death, be life-threatening, 
or require hospitalization may be considered serious when, based upon appropriate 
medical judgment, it may jeopardize the subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition.   
All SAEs will be collected from the time of ICF. 
9.3.2 Protocol-related Adverse Events  
AEs that are not study drug related may nevertheless be considered by the Investigator or 
the Medical Monitor to be related to the conduct of the clinical study.  That is, the event 
may be related to the fact that a subject is participating in the study.  For example, a 
protocol-related AE may be an event that occurs during a washout period or that is 
related to a procedure required by the protocol. 
9.3.3 Relationship to Study Drug  
The Investigator will attempt to assess the relationship of the event to study drug using a 
5-point scale (not related, unlikely-related, possibly related, probably related, or 
definitely related). 
9.3.4 Recording Adverse Events  
All AEs (including SAEs) are to be accurately recorded on the Adverse Event page of the 
subject’s eCRF during the subject’s participation in the study. The severity of each AE 
will be graded using the CTCAE v5.0 scale. The date of onset as well as the end date of 
the event also should be recorded, or the event should be entered as “ongoing”.  In 
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addition, the method used to treat the AE and the outcome of the AE also will be noted. 
In the event that the grade of an AE worsens, an end date should be entered to the initial 
AE and a new AE entered with the updated grade and date of onset.  The Investigator will 
assess the relationship of the event to study drug. Note: All SAEs also are to be entered 
onto an SAE form and sent to sponsor or designee. 
9.3.5 Hospitalization  
In the absence of an AE, the Investigator should not report hospitalization or prolongation 
of hospitalization.  This is the case in the following situations: 
• Hospitalization or prolongation of hospitalization is needed for a procedure 
required by the protocol. 
• Hospitalization or prolongation of hospitalization is part of routine procedure 
followed by study center. 
• Hospitalization for survey visits or annual physicals. 
In addition, a hospitalization for elective procedures planned before or after the start of 
the study for a pre-existing condition that has not worsened does not count as an SAE. 
9.3.6 Serious Adverse Event Reporting  
9.3.6.1 Governing Regulatory Requirements  
Compliance with this request for prompt reporting is essential in that the sponsor is 
responsible for informing the US Food and Drug Administration (FDA) as well as all 
other participating Investigators of the event.  
Under FDA ruling (US Code of Federal Regulations, Title 21 CFR Part 312.32) and the 
Guidance for Industry and Investigators Safety Reporting Requirements for INDs and 
Bioavailability/Bioequivalence studies, the sponsor is required to submit written 
documentation, in the form of an IND safety report, detailing: 
• Any event associated with the use of the drug, that is both serious and unexpected, 
or  
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• Any findings from clinical, epidemiological, or pooled analysis of multiple 
studies or any findings from animal or in vitro testing that suggest a significant 
risk in humans exposed to the drug.  
Written submission must be made by the sponsor to the FDA and the IRB/IECs as soon 
as possible and in no event later than 15 calendar days after the sponsor’s initial 
notification of the event.  Any unexpected death or life-threatening suspected adverse 
drug reaction must be reported to FDA no later than 7 calendar days after the sponsor’s 
initial receipt of the information.  The sponsor shall also inform all Investigators. 
Time Frame for Reporting 
Any death, SAE, pregnancy (including pregnancy of a partner), experienced by a subject 
while receiving or within 28 days of receiving study drug, regardless of relationship to 
study drug, or any death that occurs more than 28 days after receiving study drug, and is 
believed to be study drug-related, must be promptly reported (within 24 hours of the 
Investigator becoming aware of the event) by e-mail to the sponsor (or designee).  The 
contact information for SAE reporting: 
For medical questions contact the Kadmon Medical Monitor: 
E-mail:  
 
Phone:  
 
 
For SAE reporting send the SAE form, pregnancy form, or follow-up within 
24 hours of becoming aware: 
Kadmon Pharmacovigilance  
Email: 
 
or 
Fax:  
 
 
 
In the event of a subject, or a subject’s partner, becomes pregnant while on study, they 
will be monitored until the outcome of the pregnancy is known. The baby will continue to 
be monitored to 30 days after delivery. The data are reported on a pregnancy form within 
24 hours of becoming aware. 
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9.3.6.2 Information to be Provided by the Investigator  
The SAEs for all enrolled subjects must be recorded on the SAE form (during study 
participation). This requirement includes all SAEs that occur after informed consent and 
through 28 days after last dose of study drug, and in addition, any SAEs that are 
assessed as possibly related to study drug by the Investigator, even if the SAE occurs 
more than 28 days after the last dose of study drug must be reported to the Kadmon 
Corporation Pharmacovigilance Department (or designee). 
The minimum information required for SAE reporting includes identity of Investigator, 
site number, subject number, an event description, SAE term(s), onset date, the reason 
why the event is considered to be serious (i.e., the seriousness criteria) and the 
Investigator’s assessment of the relationship of the event to study drug. Additional SAE 
information including medications or other therapeutic measures used to treat the event, 
action taken with the study drug due to the event, and the outcome/resolution of the event 
will be recorded on the SAE form. Forms for reporting SAE will be provided to the study 
sites. 
In all cases, the Investigator should continue to monitor the clinical situation and report 
all material facts relating to the progression or outcome of the SAE. Furthermore, the 
Investigator may be required to provide supplementary information as requested by the 
Kadmon Corporation Drug Safety personnel or designee. 
When reporting SAEs, the following additional points should be noted: 
• When the diagnosis of an SAE is known or suspected, the Investigator should report 
the diagnosis or syndrome as the primary SAE term, rather than as signs or 
symptoms. Signs and symptoms may then be described in the event description. For 
example, dyspnea should not be used as an SAE term if the diagnosis which caused 
the dyspnea is known to be malignant pleural effusion.   
• Death should not be reported as an SAE, but as an outcome of a specific SAE, unless 
the event preceding the death is unknown. In the exceptional case where the events 
leading to death are unknown, then death may be used as an event term. If an autopsy 
was performed, the autopsy report should be provided.  
• While most hospitalizations necessitate reporting of an SAE, some hospitalizations do 
not require SAE reporting, as follows:  
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o Elective or previously scheduled surgery (e.g., a previously scheduled ventral 
hernia repair) 
o Procedures for pre-existing conditions that have not worsened after initiation 
of treatment 
o Pre-specified study hospitalizations for observation 
o Events that result in hospital stays of less than 24 hours and that do not require 
admission (e.g., an emergency room visit for hematuria that results in a 
diagnosis of cystitis and discharge to home on oral antibiotics) 
o SAEs must, however, be reported for any surgical or procedural complication 
resulting in prolongation of the hospitalization. 
 
9.3.6.3 Regulatory Reporting  
Kadmon Corporation Pharmacovigilance Department (or designee) will process and 
evaluate all SAEs as soon as the reports are received. For each SAE received, Kadmon 
Corporation will determine whether the criteria for expedited reporting have been met. 
Kadmon Corporation (or designee) will submit SAEs that meet the criteria for expedited 
reporting to the Regulatory Authorities in accordance with local regulations governing 
safety reporting. Reporting of SAEs by the Investigator to his or her IRB/IEC will be 
done in accordance with the standard operating procedures and policies of the IRB/IEC. 
Adequate documentation must be maintained showing that the IRB/IEC was properly 
notified. 
9.4 
FOLLOW-UP FOR ADVERSE EVENTS  
Any SAE or AE assessed as at least possibly related that led to treatment discontinuation 
(including clinically significant abnormal laboratory values that meet these criteria) and 
is ongoing 28 days after last dose of study drug must be followed until either resolution 
of the event or determination by the Investigator that the event has become stable or 
irreversible. This follow-up guidance also applies to possibly related SAEs that occur 
more than 28 days after last dose of study drug. The status of all other continuing AEs 
will be documented as of 28 days after last dose of study drug.   
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9.5 
OTHER SAFETY CONSIDERATIONS  
9.5.1 Laboratory Data  
All laboratory data obtained during the course of the study should be reviewed. Any 
abnormal value that leads to a change in subject management (e.g., dose reduction or 
delay, requirement for additional medication or monitoring) or is considered to be of 
clinical significance by the Investigator should be reported as an AE and/or SAE as 
appropriate, unless this value is consistent with the subject’s present disease state or is 
consistent with values obtained before entry into the study. 
Laboratory results will be classified using the CTCAE v5.0. 
9.5.2 Medication Errors  
Any medication error that results in an AE, even if it does not meet the definition of 
serious, requires reporting within 24 hours to the safety monitor. 
9.6 
STUDY  STOPPING  RULES  
9.6.1 Stopping Rules for Study  
Kadmon reserves the right to discontinue the trial at any time for the following reasons: 
 
1. Failure to meet expected enrollment goals 
 
2. Emergence of any safety information that could significantly affect continuation 
of the trial  
 
3. Violation of GCP (R2), the Clinical Trial Program, or the contract by a trial site or 
Investigator, or any other administrative reasons, disturbing the appropriate 
conduct of the trial 
 
4. Results from other competing clinical trials make this trial not worthy to continue 
 
9.6.2 Stopping Criteria for Subjects  
Subjects will be discontinued from the study at any time for the following reasons:  
 
1. Grade ≥ 3 LFT increase (AST, ALT, or total bilirubin) 
 
2. Grade ≥ 3 clinically significant toxicity considered related to belumosudil 
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3. QTc > 500 ms or AE of Torsade de Pointe 
9.7 
STATISTICAL CONSIDERATIONS  
9.7.1 Hypothesis  
This study will explore the efficacy of belumosudil (200 mg QD, 200 mg BID) compared 
to placebo on proposed primary, secondary, and exploratory endpoints. The main focus is 
to provide guidance for the follow up studies. 
9.7.2 Sample Size  
This is an exploratory study; sample size and power are not driven by hypothesis testing. 
A total of 60 subjects will be randomized (1:1:1) to receive orally administered 
belumosudil 200 mg QD (n = 20), belumosudil 200 mg BID (n = 20), or matched placebo 
(n = 20).    
9.7.3 Analysis Populations  
Two populations will be employed in the analysis of study data: 
• The mITT Population will consist of all subjects who receive at least 1 dose of study 
drug. 
• The Evaluable for Efficacy/Activity Population will consist of subjects who have 
received at least 80% of expected study drug and have post-baseline efficacy data. 
The primary analysis will be performed on the mITT Population. 
9.7.4 Data Analysis  
All pre-specified analyses will be described in a Statistical Analysis Plan (SAP). 
Demographics, subject disposition, and screening and baseline characteristics will be 
summarized in each population and by group. 
9.7.5 Interim Analysis  
There is no interim analysis planned. 
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9.8 
EFFICACY ANALYSIS  
9.8.1 Primary Efficacy Endpoint  
The primary efficacy endpoint of this study is to evaluate the efficacy of belumosudil 
compared to placebo for the CRISS score at Week 24  
9.8.2 Secondary Efficacy Endpoints  
Secondary endpoints are as follows: 
• To assess the CRISS for each group at Week 52 
• To evaluate the efficacy of belumosudil compared to placebo at Week 24 for: 
o mRSS 
o FVC 
o Physician global assessment 
o Patient global assessment 
o SHAQ-DI 
• To evaluate the efficacy of belumosudil at Week 52 compared to baseline for 
subjects randomized to belumosudil for the parameters in the bullet above 
• To assess changes in lung fibrosis via HRCT performed at baseline, Weeks 24, 
and Week 52 only in subjects with ILD at screening 
• To assess the PK of belumosudil by sparse sampling of belumosudil on Weeks 4 
and 8 (i.e., Days 29 and 57) immediately prior to belumosudil dosing and 3 hours 
post-dose 
• To assess the safety of belumosudil compared to placebo in subjects with dcSSc 
by examining the percentage of subjects with TEAEs by CTCAE v5.0 in subjects 
with diffuse cutaneous systemic sclerosis 
9.8.3 Exploratory Efficacy Endpoints  
Exploratory endpoints are as follows: 
• To evaluate changes in biomarkers of endothelial cell dysfunction, fibrosis, 
immune system function, and cytokine alterations from subjects receiving 
belumosudil or placebo 
• To assess histology and gene expression from skin biopsies taken from subjects at 
baseline, Week 24, and optionally at Week 52 
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9.8.4 Analysis Method  
• Mixed models with treatment and week as fixed effects, and subject as random 
effect will be used to analyze all longitudinal efficacy endpoints.  
• Descriptive statistics will be provided for all endpoints by treatment groups and 
visits. 
9.9 
SAFETY ANALYSES  
Treatment exposure will be summarized. 
The TEAEs will be evaluated using the CTCAE v5.0.  The total sample size of 
20 subjects per belumosudil dose group will provide > 90% probability of one or more 
belumosudil subjects experiencing an AE that has an underlying rate of ≥ 14% and 
> 80% probability of one or more subjects in the study experiencing an AE that has an 
underlying rate of ≥ 10%. 
The TEAEs will be summarized overall and by group using Medical Dictionary of 
Regulatory Activities Version 21.0 (MedDRA v21.0) or higher, System Organ Class 
(SOC) and preferred term (PT), classified from verbatim terms. The incidence and 
percentage of subjects with at least one occurrence of a preferred term will be included, 
according to the most severe grade using a 5-point scale (mild, moderate, severe, life 
threatening, or death). The number of events per preferred term will also be summarized. 
Causality (relationship to study treatment) will be summarized separately. 
AEs, SAEs, related AEs, related SAEs, Grade ≥ 3 AEs, related Grade ≥ 3 AEs, and AEs 
leading to withdrawal or treatment discontinuation will be summarized overall and by 
group according to SOC and PT. Adverse events will also be presented in listings. 
Duration of AEs will be determined and included in listings, along with action taken and 
outcome. 
Laboratory results will be graded; Incidence of laboratory abnormalities will be 
summarized.  The worst on-study grade after the first dose of study drug will be 
summarized.  The incidence of Grade ≥ 3 laboratory abnormalities under treatment and 
shifts in toxicity grading from baseline to highest-grade post-baseline will be displayed.   
Vital sign measurements and ECGs will be summarized by group at each scheduled time 
point using descriptive statistics and included in data listings. 
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9.10 PHARMACOKINETIC ANALYSES  
Further details will be described in the SAP. 
9.11 DATA QUALITY ASSURANCE  
Accurate and reliable data collection will be ensured by verification and cross check of 
the eCRFs against the Investigator’s records by the study monitor (source document 
verification) and by the maintenance of a drug–dispensing log by the Investigator.  
Collected data will be entered into a computer database and subject to electronic and 
manual quality assurance procedures. 
 
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10. REGULATORY OBLIGATIONS  
This study will be conducted in compliance with GCP, including International 
Conference on Harmonization of Technical Requirements for Registration of 
Pharmaceuticals for Human Use, and in general, consistent with the most recent version 
of the Declaration of Helsinki.  In addition, the Investigator agrees to adhere to all 
applicable local laws and regulatory requirements relevant to the use of new therapeutic 
agents in the countries involved. 
The study is to be conducted in compliance with the protocol.  The appropriate 
IRBs/IECs must approve the protocol and any amendments, and the subject ICF before 
implementation.   
Freely given written informed consent must be obtained from every subject before 
participation in this clinical trial.  The rights, safety, and well-being of participating 
subjects are the most important considerations and should prevail over interests of 
science and society. 
Study personnel involved in conducting this trial will be qualified by education, training, 
and experience to perform their respective task(s).  This trial will not use the services of 
study personnel where sanctions have been invoked or where there has been scientific 
misconduct of fraud (e.g., loss of medical licensure, debarment). 
 
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11. ETHICAL ASPECTS  
11.1 LOCAL REGULATIONS  
The study must fully adhere to the principles outlined in Guideline for Good Clinical 
Practice ICH E6(R2) Integrated Addendum to ICH E6(R1) (March 2018), and in general, 
be conducted in a manner consistent with the most recent version of the Declaration of 
Helsinki.  The Investigator will ensure that the conduct of the study complies with the 
basic principles of GCP as outlined in the current version of 21 CFR, subpart D, Part 312, 
“Responsibilities of Sponsors and Investigators”, Part 50, “Protection of Human 
Subjects”, and Part 56, “Institutional Review Boards”. 
11.2 INFORMED CONSENT  
Sample ICFs will be supplied to each site.  Kadmon Corporation or its designee must 
review any ICF prior to submission for review by the IRB/IEC.  The final 
IRB/IEC-approved document must be provided to Kadmon Corporation for regulatory 
purposes. 
It is the responsibility of the Investigator, or a person designated by the Investigator, to 
obtain written informed consent from each subject (or the subject’s legally authorized 
representative) participating in this study after adequate explanation of the aims, 
methods, anticipated benefits, and potential hazards of the study in accordance with 
federal and state regulations.  In the case where the subject is unable to read, an impartial 
witness should be present during the entire informed consent discussion.  After the 
subject has orally consented to participation in the trial, the witness’ signature on the 
form will attest that the information in the consent form was accurately explained and 
understood.  A copy of the ICF must be provided to the subject.  If applicable, it will be 
provided in a certified translation of the local language. 
The eCRF for this study contains a section for documenting informed subject consent, 
and this must be completed appropriately.  Signed ICFs must remain in each subject’s 
study file and must be available for verification by study monitors at any time.  If new 
safety information results in changes in the risk/benefit assessment, the consent form 
should be reviewed and updated as necessary.  All subjects (including those already being 
treated) should be informed of the new information, should be given a copy of the revised 
form, and should give their consent to continue in the study. 
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11.3 INSTITUTIONAL REVIEW BOARD  
This study is being conducted under a United States IND application.  This protocol (and 
any modifications) and appropriate consent procedures must be reviewed and approved 
by an IRB/IEC.  This board must operate in accordance with the current federal or local 
regulations.  The Investigator will send a letter or certificate of IRB/IEC approval to 
Kadmon Corporation (or designee) before subject enrollment and whenever subsequent 
modifications to the protocol are made. 
11.4 FUTURE USE OF SUBJECT SAMPLES  
Not all of the tissue and blood components obtained during this study may be required for 
the tests that are part of the clinical trial.  Following the conclusion of the study, the 
samples may be used for additional research.  This research will help to understand 
disease subtypes, drug response and toxicity, and possibly identify new drug targets or 
biomarkers that predict subject response to treatment.  The use of the samples for internal 
research will be done according to the guidelines defined by the FDA guidance for 
In Vitro Diagnostic Device Studies Using Leftover Human Specimens that are Not 
Individual Identifiable (issued April 25, 2006) and/or the European Medicines Agency 
Reflection Paper on Pharmacogenetic Samples, Testing and Data Handling 
(EMEA/CHMP/PGxWP/201914/2006).  If a subject requests destruction of their tissue 
and blood samples and the samples have not yet been de-identified, Kadmon Corporation 
will destroy the samples as described in this FDA guidance.  Kadmon Corporation will 
notify the Investigator in writing that the samples have been destroyed.  Once all samples 
have been analyzed for additional research, the samples will be discarded and will not be 
stored for future research. 
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12. CONDITIONS FOR MODIFYING THE PROTOCOL  
Protocol modifications will be reviewed and approved by Kadmon Corporation 
representatives. 
All protocol modifications must be submitted to the IRB/IEC for information and 
approval in accordance with local requirements, and to regulatory agencies if required.  
Approval must be obtained before any changes can be implemented, except for changes 
necessary to eliminate an immediate hazard to study subjects, or when the change 
involves only logistical or administrative aspects of the trial (e.g., change in monitor, 
change of telephone number). 
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13. CONDITIONS FOR TERMINATING THE STUDY  
Kadmon Corporation has the right to terminate the study at any time.  In terminating the 
study, Kadmon Corporation and the Investigator will ensure that adequate consideration 
is given to the protection of the subjects’ interests. 
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14. STUDY DOCUMENTATION, CRFS AND RECORD KEEPING  
14.1 INVESTIGATOR’S FILES AND RETENTION OF DOCUMENTS  
The Investigator must maintain adequate and accurate records to enable the conduct of 
the study to be fully documented and the study data to be subsequently verified.  These 
documents should be classified into 2 separate categories as follows: (1) Investigator’s 
study files and (2) subject clinical source documents. 
The Investigator’s study file will contain the protocol and protocol amendments, eCRFs, 
query forms, IRB/IEC, and governmental approval with correspondence, sample ICF, 
drug records, staff curriculum vitae and authorization forms, and other appropriate 
documents and correspondence. 
Subject clinical source documents (usually predefined by the project to record key 
efficacy and safety parameters independent of the eCRFs) may include subject 
hospital/clinic records, physician’s and nurse’s notes, appointment book, original 
laboratory reports, ECG, electroencephalogram, X-ray, pathology and special assessment 
reports, signed ICFs, consultant letters, and subject screening and enrollment logs.  The 
Investigator must keep these 2 categories of documents on file for at least 2 years 
following the marketing application approval date for the study drug and for the 
indication being investigated or for 2 years after the investigation is discontinued and the 
FDA notified.  After that period of time, the documents may be destroyed subject to local 
regulations with prior written permission from Kadmon Corporation.  If the Investigator 
wants to assign the study records to another party or move them to another location, 
Kadmon Corporation must be notified in advance. 
If the Investigator cannot guarantee the archiving requirement at the study site for any or 
all of the documents, special arrangements must be made between the Investigator and 
Kadmon Corporation to store these in a sealed container outside of the study site so that 
they can be returned sealed to the Investigator in case of a regulatory audit.  When source 
documents are required for the continued care of the subject, appropriate copies should be 
made for storing outside of the study site. 
14.2 SOURCE DOCUMENTS AND BACKGROUND DATA  
Upon request, the Investigator will supply Kadmon Corporation with any required 
background data from the study documentation or clinic records.  In case of special 
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problems or governmental queries or requests for audit inspections, it is also necessary to 
have access to the complete study records, provided if subject confidentiality is protected. 
14.3 AUDITS AND INSPECTIONS  
The Investigator should understand that source documents for this study should be made 
available to appropriately qualified personnel from the Kadmon Corporation Quality 
Assurance Unit (or designee) or to health authority inspectors after appropriate 
notification.  The verification of the eCRF data must be by direct inspection of source 
documents. 
14.4 ELECTRONIC CASE REPORT FORMS  
Clinical trial data for this study will be captured on electronic eCRF.  The Investigator 
agrees to provide all information requested on the eCRF in an accurate manner according 
to instructions provided.  Electronic CRFs are designed for computer processing and 
analysis.  The Investigator should ensure the accuracy, completeness, and timeliness of 
the data reported to Kadmon Corporation (or designee) in the eCRF and in all required 
reports. 
An eCRF is required to be submitted for every subject who receives any amount of study 
drug.  This includes submission of retrievable data on subjects who withdraw before 
completion of the study.  The eCRFs must be reviewed for completeness and accuracy, 
and electronically signed where indicated, by the Principal Investigator or authorized 
delegate from the study staff.  If a subject stops treatment or terminates from the study, 
the dates and reasons must be noted on the eCRF. 
 
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15. MONITORING OF THE STUDY  
It is understood that the responsible monitor (or designee) will contact and visit the 
Investigator regularly and will be allowed on request to inspect the various records of the 
trial (eCRFs and other pertinent data) provided if subject confidentiality is maintained in 
accordance with local requirements. 
It will be the monitor’s responsibility to inspect the eCRFs at regular intervals throughout 
the study, to verify the adherence to the protocol and the completeness, consistency, and 
accuracy of the data being entered on them.  The monitor should have access to 
laboratory test reports and other subject records needed to verify the entries on the eCRF.   
The Investigator (or designee) must agree to cooperate with the monitor to ensure that 
any problems detected in the course of these monitoring visits are resolved. 
 
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16. CONFIDENTIALITY OF TRIAL DOCUMENTS AND SUBJECT 
RECORDS  
The Investigator must ensure that subjects’ anonymity will be maintained and that their 
identities are protected from unauthorized parties.  On eCRFs or other documents 
submitted to Kadmon Corporation, subjects should be identified by an identification code 
and not by their names.  The subjects’ personal information should be redacted on all 
source documents prior to submission to Kadmon Corporation (or designee).  The 
Investigator should keep a subject enrollment log showing codes, names, and addresses.   
The Investigator should maintain documents not for submission to Kadmon Corporation 
(e.g., subjects’ written consent forms) in strict confidence. 
 
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17. PUBLICATION OF DATA AND PROTECTION OF TRADE 
SECRETS  
The results of this study may be published or presented at scientific meetings.   The 
Investigator agrees to submit all manuscripts or abstracts to Kadmon Corporation for 
review at least 30 days before submission.   This allows Kadmon Corporation to protect 
proprietary information and to provide comments based on information from other 
studies that may not yet be available to the Investigator. 
In the event that Kadmon Corporation coordinates a publication or presentation of study 
results from all study sites, the participation of Investigator or other representatives of 
study site as a named author shall be determined in accordance with Kadmon Corporation 
policy and generally accepted standards for authorship. 
 
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15. Shi J, Surma M, Zhang L, Wei L. Dissecting the roles of ROCK isoforms in 
stress-induced cell detachment. Cell Cycle. 2013;12(10):1492-500. 
16. Zanin-Zhorov A, Weiss JM, Nyuydzefe MS, Chen W, Scher JU, Mo R, et al. 
Selective oral ROCK2 inhibitor down-regulates IL-21 and IL-17 secretion in human 
T cells via STAT3-dependent mechanism. Proc Natl Acad Sci U S A. 
2014;111(47):16814-9. 
17. Zhou Y, Huang X, Hecker L, Kurundkar D, Kurundkar A, Liu H, et al. Inhibition of 
mechanosensitive signaling in myofibroblasts ameliorates experimental pulmonary 
fibrosis. J Clin Invest. 2013;123(3):1096-108. 
18. Tybulewicz VL, Henderson RB. Rho family GTPases and their regulators in 
lymphocytes. Nat Rev Immunol. 2009;9(9):630-44. 
19. Biswas PS, Gupta S, Chang E, Song L, Stirzaker RA, Liao JK, et al. Phosphorylation 
of IRF4 by ROCK2 regulates IL-17 and IL-21 production and the development of 
autoimmunity in mice. J Clin Invest. 2010;120(9):3280-95. 
20. Isgro J, Gupta S, Jacek E, Pavri T, Duculan R, Kim M, et al. Enhanced rho-associated 
protein kinase activation in patients with systemic lupus erythematosus. Arthritis 
Rheum. 2013;65(6):1592-602. 
21. Sakaguchi S, Yamaguchi T, Nomura T, Ono M. Regulatory T cells and immune 
tolerance. Cell. 2008;133(5):775-87. 
 
 
 
  
 
 
25. Clements PJ et al.  Skin thickness score in systemic sclerosis: an assessment of 
interobserver variability in 3 independent studies.  J Rheumatol. 1993; 20(11)::1892-
96. 
26. Merkel PA et al.  Measuring disease activity and functional status in patients with 
scleroderma and Raynaud’s Phenomenon.  Arthr Rheum 2002; 46(9):2410-20. 
27. Adapted from Cobert B.  Cobert’s Manual of Drug Safety and Pharmacovigilance 
(2nd Ed).  Massachusetts:  Jones & Bartlett Learning, LLC.  2012. 
28. https://www.fda.gov/drugs/developmentapprovalprocess/developmentresources/drugi
nteractionslabeling/ucm093664.htm.  Accessed 05 Apr 2018 
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29. https://crediblemeds.org/pdftemp/pdf/CombinedList.pdf  Accessed 04 Jun 2018 
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b.       Re-randomization of the placebo group to one of two arms will take place after the un-blinding procedures take place.  
c.        CRISS will not be performed on site, but rather will be calculated outside of EDC. 
d.        mRSS, SHAQ-DI, FVC, physician global assessment and patient global assessment will be performed at baseline Day 1, Day 57, Day 113, Day 169, Day 197,  and then every 
8 weeks thereafter until Week 52.  In addition, after their last dose of study drug (4-Week Follow-Up Visit).  mRSS and FVC will also be performed at screening as one of the 
inclusion criteria. FVCs should be performed if PFT is not performed at the same visit.  FVCs need not be performed if PFT is performed at the same visit.  
e.        HRCT and PFTs, to include FEV1, FVC, DLCO (corrected for Hb), TLC, and RV, will be performed at baseline, Day 169, and Day 365 (each ± 7 days).   In addition, PFTs 
will be performed after their last dose of study drug (4-Week Follow-Up Visit).  If the HRCT or PFTs is performed within one month of the EOT visit, it does not need to be done 
again at the EOT visit.     
f.         HRCT will be done only in subjects at Day 1, Day 169, and Day 365 (each ± 7 days) if they have confirmed ILD at baseline. This is not required at the End of Treatment 
visit.  
g.        Double punch Skin biopsies are MANDATORY for all subjects on Day 1 and Day 169 and Optional on Day 365 and will be obtained from the dorsal mid-forearm for Gene 
Profiling. This assessment is not required for End of Treatment.   
h.        A complete PE is to include documentation of height (screening only), weight, body temperature, and vital signs (blood pressure [sitting], pulse rate [sitting], and respiratory 
rate) and will be performed by a physician or staff member who is qualified to perform such examinations (e.g., physician assistant, nurse practitioner).   All PEs, whether complete 
or symptom-directed, will include assessment of cardiac (including heart rate and vital signs), musculoskeletal (i.e., muscle aches), and neurological (i.e., gait) systems.  A complete 
PE include will include evaluation of primary endpoints.  A symptom-directed PE will be focused on symptoms and not include evaluations of primary endpoints. 
i.         Sitting blood pressure, heart rate to be obtained (after 5 minutes of rest) 
j.         See Section 6.2.4 for a complete list of laboratory safety assessments.  If increases in liver enzymes are observed at any time in a subject, refer to Section 4.13. 
k.        Women of childbearing potential must have a negative urine pregnancy test.  Positive results are to be confirmed with serum testing. 
l.         Subjects will take their morning dose at the clinic and then will be dispensed study drug for home administration. 
m.     Pharmacodynamics will be collected as follows: within 60 minutes pre-dose at baseline, Week 8, week 24, and Week 52. ELFT collected at Baseline, Week 8, Week 24 and 
Week 52. 
n.      Pharmacokinetics will be collected within 60 minutes pre-dose of dosing and 3 hours post-dose with a window of 10 minutes at Week 4 and Week 8.   
o.     All subjects will be un-blinded at this visit.  
Note:  At Week 1, Day 1 visit, if screening was completed within 7 days of baseline, only the complete PE and vital sign measurements need to be repeated. 
Note:  The term EOT refers to early withdrawal or Week 52, as appropriate. 
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Source: https://eprovide.mapi-trust.org/instruments/scleroderma-health-assessment-questionnaire 
22. APPENDIX D:  PHYSICIAN GLOBAL ASSESSMENT  
 
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23. APPENDIX E:  PATIENT GLOBAL ASSESSMENT  
 
 
 
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24. APPENDIX F: DETERMINING RELATIONSHIP OF ADVERSE 
EVENTS TO STUDY DRUG  
Determination the relationship of AEs to study drug is displayed below.(27) 
1 
NOT RELATED 
This category applies to those AEs, which, after careful medical consideration, are clearly felt to 
be due to extraneous causes (e.g., disease, environment, etc.) that are unrelated to the 
administration of study drug. 
 
2 
UNLIKELY RELATED (must have first 2) 
This category applies to those AEs, which, after careful medical consideration, are felt unlikely to 
be related to the administration of the study drug.  The relationship of an AE to the study drug can 
be considered unlikely if: 
• 
It does not follow a reasonable temporal sequence from administration of the drug. 
• 
It could readily have been a result of the subject’s clinical state, environmental or toxic 
factors, or other modes of therapy administered to the subject. 
• 
It does not follow a known response pattern to the suspected drug. 
• 
It does not reappear or worsen when the drug is re-administered. 
3 
POSSIBLY RELATED (must have first 2) 
This category applies to those AEs, which, after careful medical consideration, are felt unlikely to 
be related to the administration of the study drug, but the possibility cannot be ruled out with 
certainty.  The relationship of an AE to the study drug can be considered possible if: 
• 
It follows a reasonable temporal sequence from administration of the drug. 
• 
It could readily have been a result of the subject’s clinical state, environmental or toxic 
factors, or other modes of therapy administered to the subject. 
• 
It follows a known response pattern to the suspected drug. 
4 
PROBABLY RELATED (must have first 3) 
This category applies to those AEs, which, after careful medical consideration, are felt with a 
high degree of certainty to be related to the administration of the study drug.    The relationship of 
an AE to the study drug can be considered probable if: 
• 
It follows a reasonable temporal sequence from administration of the drug.    
• 
It could not be reasonably explained by the known characteristics of the subject’s clinical 
state, environmental or toxic factors or other modes of therapy administered to the 
subject. 
• 
It disappears or decreases upon cessation of drug or reduction in dose.* 
• 
It follows a known response pattern to the suspected drug. 
 
 
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5 
DEFINITELY RELATED (must have first 3) 
This category applies to those AEs, which, after careful medical consideration, are felt to be 
related to the administration of the study drug.  The relationship of an AE to the study drug can be 
considered related if: 
• 
It follows a reasonable temporal sequence from administration of the drug or drug levels 
have been established in body fluids or tissues. 
• 
It could not be reasonably explained by the known characteristics of the subject’s clinical 
state, environmental or toxic factors or other modes of therapy administered to the 
subject. 
• 
It disappears or decreases upon cessation of drug or reduction on dose and appears upon 
rechallenge.* 
• 
It follows a known response pattern to the suspected drug. 
 
*There are exceptions when an AE does not disappear upon discontinuation of the drug, yet drug 
relatedness clearly exists. 
 
Adapted from Cobert, B (2012).  Cobert’s Manual of Drug Safety and Pharmacovigilance 
(2nd Ed).  Massachusetts:  Jones & Bartlett Learning, LLC. 
 
 
 
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25. APPENDIX G: DRUGS THAT INDUCE AND INHIBIT CYP3A4  
This is not a comprehensive list, and all concomitant medications should be evaluated for 
possible interactions with belumosudil.(28) 
Examples of Clinical Inducers / Inhibitors of CYP3A4 
 
Strong 
Moderate 
Weak 
Inducers 
Carbamazepine 
Enzalutamide 
Mitotane 
Phenytoin 
Rifampin 
St. John’s wort 
Bosentan 
Efavirenz 
Etravirine 
Modafinil 
Armodafinil 
Rufinamide 
Inhibitors 
Boceprevir 
Cobicistat 
Conivaptan 
Danoprevir 
Dasabuvir 
Elvitegravir 
Grapefruit juice 
Indinavir 
Itraconazole 
Ketoconazole 
Lopinavir 
Paritaprevir 
Ombitasvir 
Posaconazole 
Ritonavir 
Saquinavir 
Telaprevir 
Tipranavir 
Troleandomycin 
Voriconazole 
Aprepitant 
Cimetidine 
Ciprofloxacin 
Clotrimazole 
Crizotinib 
Cyclosporine 
Dronedarone 
Erythromycin 
Fluconazole 
Fluvoxamine 
Imatinib 
Tofisopam 
Verapamil 
Chlorzoxazone 
Cilostazol 
Fosaprepitant 
Istradefylline 
Ivacaftor 
Lomitapide 
Ranitidine 
Ranolazine 
Tacrolimus 
Ticagrelor 
 
 
 
 
 
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Source: 
https://www.fda.gov/drugs/developmentapprovalprocess/developmentresources/druginteractionsl
abeling/ucm093664.htm  Accessed 05 Apr 2018 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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26. APPENDIX H: DRUGS KNOWN TO HAVE THE POTENTIAL 
FOR QTC PROLONGATION  
Drugs known to have the potential for prolonging of QTc are prohibited. The list below is not 
comprehensive. All concomitant medications should be evaluated for possible interactions with 
belumosudil.(29) 
Drugs Known to Prolong QTc 
Generic Name 
• 
Aclarubicin 
• 
Iloperidone 
• 
Amiodarone 
• 
Levofloxacin 
• 
Anagrelide 
• 
Levomepromazine 
• 
Arsenic trioxide 
• 
Levomethadyl acetate 
• 
Astemizole 
• 
Levosulpiride 
• 
Azithromycin 
• 
Mesoridazine 
• 
Bepridil 
• 
Methadone 
• 
Chloroquine 
• 
Moxifloxacin 
• 
Chlorpromazine 
• 
Ondansetron 
• 
Cilostazol 
• 
Oxaliplatin 
• 
Ciprofloxacin 
• 
Papaverine HCl 
• 
Cisapride 
• 
Pentamidine 
• 
Citalopram 
• 
Pimozide 
• 
Clarithromycin 
• 
Probucol 
• 
Disopyramide 
• 
Procainamide 
• 
Dofetilide 
• 
Propofol 
• 
Domperidone 
• 
Quinidine 
• 
Donepezil 
• 
Roxithromycin 
• 
Dronedarone 
• 
Sevoflurane 
• 
Droperidol 
• 
Sotalol 
• 
Erythromycin 
• 
Sparfloxacin 
• 
Escitalopram 
• 
Sulpiride 
• 
Flecainide 
• 
Sultopride 
• 
Fluconazole 
• 
Terfenadine 
• 
Gatifloxacin 
• 
Terlipressin 
• 
Grepafloxacin 
• 
Terodiline 
• 
Halofantrine 
• 
Thioridazine 
• 
Haloperidol 
• 
Vandetanib 
• 
Ibogaine 
 
• 
Ibutilide 
 
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Source: https://crediblemeds.org/pdftemp/pdf/CombinedList.pdf  Accessed 04 Jun 2018 
 
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