A Phase 2, Multi-Center, Randomized, Placebo-Controlled Study of IV Gallium Nitrate in Patients With Cystic Fibrosis (IGNITE Study)
Phase: PHASE2
Conditions: Cystic Fibrosis
Sponsor: University of Washington



Protocol Number: GALLIUM-IP-13 
 
Confidential 
PROTOCOL AGREEMENT 
 
I have read the protocol specified below. In my formal capacity as Investigator, my duties 
include ensuring the safety of the study subjects enrolled under my supervision and providing the 
Sponsor with complete and timely information, as outlined in the protocol.  It is understood that 
all information pertaining to the study will be held strictly confidential and that this 
confidentiality requirement applies to all study staff at this site. Furthermore, on behalf of the 
study staff and myself, I agree to maintain the procedures required to carry out the study in 
accordance with accepted GCP principles and to abide by the terms of this protocol. 
 
Protocol Number:  GALLIUM-IP-13 
 
Protocol Title:  A Phase 2, Multi-Center, Randomized, Placebo-Controlled Study of IV Gallium 
Nitrate in Patients with Cystic Fibrosis (The IGNITE Study) 
 
Protocol Date:  28 August 2014 
 
 
 
 
Investigator Signature  
 
Date   
 
Print Name and Title   
Site # 
 
 
Site Name 
 
Address 
 
 
 
 
 
 
 
Phone Number 
 
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Contents 
1 
BACKGROUND 
14 
1.1 
Overview of Non-Clinical Studies ..................................................................................... 14 
1.2 
Overview of Clinical Studies ............................................................................................. 15 
2 
STUDY RATIONALE 
18 
2.1 
Rationale for Gallium Treatment in CF Patients ................................................................ 18 
2.2 
Risk / Benefit Assessment .................................................................................................. 19 
2.3 
Measures to Minimize Risk ............................................................................................... 20 
3 
STUDY OBJECTIVES 
21 
3.1 
Primary Objective .............................................................................................................. 21 
3.2 
Secondary Objectives ......................................................................................................... 21 
4 
STUDY DESIGN 
21 
4.1 
Study Overview .................................................................................................................. 21 
5 
CRITERIA FOR EVALUATION 
22 
5.1 
Primary Efficacy Endpoint ................................................................................................. 22 
5.2 
Secondary Endpoints .......................................................................................................... 22 
6 
SUBJECT SELECTION 
23 
6.1 
Study Population ................................................................................................................ 23 
6.2 
Inclusion Criteria ................................................................................................................ 23 
6.3 
Exclusion Criteria .............................................................................................................. 23 
7 
CONCURRENT MEDICATIONS 
24 
7.1 
Allowed .............................................................................................................................. 24 
7.2 
Prohibited ........................................................................................................................... 24 
8 
STUDY TREATMENTS 
24 
8.1 
Method of Assigning Subjects to Treatment Groups ......................................................... 24 
8.2 
Blinding .............................................................................................................................. 25 
8.3 
Test and Control Formulation ............................................................................................ 25 
8.3.1 
Test product ....................................................................................................... 25 
8.3.2 
Placebo Control.................................................................................................. 26 
8.3.3 
Packaging and Labeling ..................................................................................... 26 
8.3.4 
Preparation/Dispensing ...................................................................................... 26 
8.3.5 
Dosage/Dosage Regimen ................................................................................... 26 
8.3.6 
Administration Instructions ............................................................................... 26 
8.4 
Supply of Study Drug at the Site ........................................................................................ 27 
8.4.1 
Storage ............................................................................................................... 27 
8.5 
Study Drug Accountability ................................................................................................ 27 
8.6 
Measures of Treatment Compliance .................................................................................. 27 
8.7 
Discontinuation of Study Drug .......................................................................................... 27 
9 
STUDY PROCEDURES AND GUIDELINES 
28 
9.1 
Clinical Assessments .......................................................................................................... 28 
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9.1.1 
Concomitant Medications .................................................................................. 28 
9.1.2 
Demographics .................................................................................................... 28 
9.1.3 
Medical History ................................................................................................. 28 
9.1.4 
Physical Examination ........................................................................................ 28 
9.1.5 
Weight and Height ............................................................................................. 28 
9.1.6 
Vital Signs ......................................................................................................... 29 
9.1.7 
Oximetry ............................................................................................................ 29 
9.1.8 
Spirometry ......................................................................................................... 29 
9.1.9 
CFRSD-CRISS and Subject Diary..................................................................... 29 
9.1.10 
Adverse Events .................................................................................................. 29 
9.2 
Clinical Laboratory Measurements .................................................................................... 30 
9.2.1 
Hematology ........................................................................................................ 30 
9.2.2 
Serum Chemistry Profile ................................................................................... 30 
9.2.3 
Pregnancy Test ................................................................................................... 30 
9.2.4 
Urinalysis ........................................................................................................... 30 
9.3 
Pharmacokinetic Measurements ......................................................................................... 30 
9.4 
Research Laboratory Measurements .................................................................................. 31 
9.4.1 
Sputum Culture .................................................................................................. 31 
9.4.2 
Plasma Collection for Assessment of Blood Cytokines and Chemokines ......... 31 
10 EVALUATIONS BY VISIT 
32 
10.1 Screening/Baseline/Visit 1 (Day 1) .................................................................................... 32 
10.1.1 
Visit 1 (Day 1) – Combined Screening / Baseline ............................................. 32 
10.1.2 
Visit 1 (Day 1) – Separate Screening / Baseline ................................................ 33 
10.2 Phone Call (Day 3) ............................................................................................................. 34 
10.3 End of Treatment/Visit 2 (Day 6) ...................................................................................... 34 
10.4 Visit 3 (Day 14 +/-2 days) .................................................................................................. 35 
10.5 Visit 4 (Day 28 +/- 3 days) ................................................................................................. 35 
10.6 Visit 5 (Day 56 +/- 4 days) – Final Visit ............................................................................ 36 
10.7 Early Discontinuation of Study Drug ................................................................................. 36 
11 ADVERSE EXPERIENCE REPORTING AND DOCUMENTATION 
37 
11.1 Adverse Events .................................................................................................................. 37 
11.2 Serious Adverse Experiences (SAE) .................................................................................. 38 
11.2.1 
Serious Adverse Experience Reporting ............................................................. 38 
11.3 Medical Monitoring ........................................................................................................... 39 
12 EARLY DISCONTINUATION OF STUDY DRUG, WITHDRAWAL AND REPLACEMENT 
OF SUBJECTS 
39 
12.1 Discontinuation of Study Drug .......................................................................................... 39 
12.2 Withdrawal of Subjects from the Study ............................................................................. 39 
12.3 Replacement of Subjects .................................................................................................... 40 
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13 PROTOCOL VIOLATIONS 
40 
14 DATA SAFETY MONITORING 
40 
15 STATISTICAL METHODS AND CONSIDERATIONS 
40 
15.1 Data Sets Analyzed ............................................................................................................ 40 
15.2 Demographic and Baseline Characteristics ........................................................................ 41 
15.3 Analysis of Primary Endpoint ............................................................................................ 41 
15.4 Analysis of Secondary Endpoints ...................................................................................... 41 
15.5 Analysis of Safety Endpoints ............................................................................................. 42 
15.6 Interim Analysis ................................................................................................................. 42 
15.7 Sample Size and Randomization ........................................................................................ 43 
16 DATA COLLECTION, RETENTION AND MONITORING 
44 
16.1 Data Collection Instruments ............................................................................................... 44 
16.2 Data Management Procedures ............................................................................................ 44 
16.3 Data Quality Control and Reporting .................................................................................. 44 
16.4 Security and Archival of Data ............................................................................................ 44 
16.5 Availability and Retention of Investigational Records ...................................................... 45 
16.6 Monitoring ......................................................................................................................... 45 
16.7 Subject Confidentiality....................................................................................................... 45 
17 ADMINISTRATIVE, ETHICAL, REGULATORY CONSIDERATIONS 
45 
17.1 Protocol Amendments ........................................................................................................ 46 
17.2 Institutional Review Boards ............................................................................................... 46 
17.3 Informed Consent Form ..................................................................................................... 46 
17.4 Publications ........................................................................................................................ 47 
17.5 Investigator Responsibilities .............................................................................................. 47 
18 APPENDIX 1.  SCHEDULE OF EVENTS 
53 
Combined Screening/Baseline Schedule of Events ..................................................................... 53 
 
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LIST OF ABBREVIATIONS 
AE 
adverse event 
ALT 
alanine aminotransferase 
AST 
aspartate aminotransferase 
AUC 
Area under the curve 
BUN 
blood urea nitrogen 
CDC 
Centers for Disease Control and Prevention 
CFR 
Code of Federal Regulations 
CFTR 
cystic fibrosis transmembrane conductance regulator 
CFRSD-CRISS 
Cystic Fibrosis Respiratory Symptom Diary- Chronic 
Respiratory Infection Symptom Score 
CF 
cystic fibrosis 
CFFT 
Cystic Fibrosis Foundation Therapeutics 
CFU 
colony forming units 
CI 
Confidence interval 
CLSI 
Clinical and Laboratory Standard Institute 
CRF 
case report form 
CSS 
Steady state concentration 
CTCAE 
 Common Terminology Criteria for Adverse Events 
DSMB 
Data Safety Monitoring Board 
EDC 
Electronic Data Capture 
EC 
Ethics Committee 
FDA 
Food and Drug Administration 
FEV1 
forced expiratory volume over one second 
FVC 
forced vital capacity 
Ga 
gallium  
GCP 
Good Clinical Practice 
GGT 
gamma-glutamyl transferase 
HIPAA 
Health Insurance Portability and Accountability Act of 1996 
hsCRP 
highly sensitive C-Reactive Protein 
IL-1ra 
Interleukin-1ra 
IL-6 
Interleukin-6 
IL-8 
Interleukin-8 
ICF 
informed consent form 
ICH 
International Conference on Harmonisation 
IRB 
Institutional Review Board 
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IV 
Intravenous 
ITT 
intent-to-treat 
LD50 
Lethal Dose, 50% 
LDH 
lactate dehydrogenase 
L 
liter 
LSMeans 
least squares means 
mEq 
Milliequivalent 
mL 
Milliliter 
MHB 
Mueller Hinton broth 
MCH 
Major histocompatibility complex 
mM 
Millimole 
MMRM 
mixed model repeated measures 
NIH 
National Institutes of Health 
NPD 
nasal potential difference 
P. aeruginosa 
Pseudomonas aeruginosa 
PI 
Principal Investigator 
PICC 
peripherally inserted central catheter 
PK 
Pharmacokinetic 
PMNeL 
Neutrophil elastase antiprotease complex 
QPIT 
quantitative pilocarpine iontophoresis test 
SAA 
serum amyloid A 
SAE 
serious adverse experience 
SGOT 
serum glutamic oxaloacetic transaminase 
SGPT 
serum glutamate pyruvate transaminase 
SOC 
System Organ Class 
TNF-α 
Tumor Necrosis Factor- α 
TGF-β1 
Transforming Growth Factor-β1 
t1/2β  
elimination half-life  
t1/2  
Half life 
WBC 
White blood cells 
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PROTOCOL SYNOPSIS  
TITLE 
A Phase 2, Multi-Center, Randomized, Placebo-Controlled Study 
of IV Gallium Nitrate in Patients with Cystic Fibrosis 
FUNDING  
ORGANIZATION 
 National Heart, Lung, and Blood Institute (NHLBI)  
NUMBER OF SITES Approximately twenty 
RATIONALE 
Much attention has been focused on the need for new antibiotics.  
One reason for this is that heavy antibiotic use has greatly 
increased resistance due to genetic mutations.  But new agents are 
also needed because conventional antibiotics work poorly in 
chronic infections, even when the organisms are sensitive when 
tested ex vivo.  These chronic infections resist treatment in large 
part because the organisms live in biofilms.  Biofilms are 
communities of bacteria associated with surfaces and encased in a 
polymeric matrix making the bacteria far more resistant to killing 
than they are in the free-living (planktonic) state.  Examples of 
biofilm infections include cystic fibrosis (CF) lung infections, 
endocarditis, osteomyelitis, wound, sinus, and device infections.   
 
We are pursuing a novel approach that uses the metal gallium 
(Ga) to disrupt intracellular bacterial iron metabolism.  Gallium 
has a nearly identical ionic radius as iron, and many biologic 
systems are unable to distinguish gallium from iron (1;2).  
Gallium disrupts iron dependent processes because Ga3+ cannot 
be reduced and redox cycling is critical for iron's biological 
functions (1;2).  Importantly, gallium is already approved by the 
Food and Drug Administration (FDA) for intravenous (IV) use.  
Our data shows that gallium kills Pseudomonas aeruginosa (P. 
aeruginosa; including antibiotic resistant strains), is active 
against biofilms, and treats three different animal models P. 
aeruginosa infections.  In our phase 1b study, we demonstrated 
that IV gallium was both safe and had favorable 
pharmacokinetics (PK) in CF patients.  We also found 
suggestions of preliminary efficacy.  We will study the 
preliminary efficacy as assessed by both lung function and 
sputum microbiology of IV gallium in CF adults.  We will also 
continue to assess PK and safety of IV gallium in CF patients. 
STUDY DESIGN 
This is a phase 2, multi-center, randomized, placebo-controlled 
trial in adults with CF chronically infected with P. aeruginosa.  
The study will evaluate the safety and clinical efficacy of a five-
day infusion of IV gallium nitrate (IV gallium).   
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PRIMARY 
OBJECTIVE 
To assess the efficacy of IV gallium to improve pulmonary 
function as measured by a 5% or greater relative improvement in 
forced expiratory volume in one second (FEV1) from baseline to 
Day 28.  
SECONDARY 
OBJECTIVES 
• To assess the safety and tolerability of IV gallium  
• To assess the efficacy of IV gallium in improving measures of 
lung function including relative change in FEV1, absolute 
change in FEV1, and forced vital capacity (FVC) 
• To assess the efficacy of IV gallium in reducing P. 
aeruginosa in the lungs of CF patients based on quantitative 
cultures of sputum  
• To assess the efficacy of IV gallium in improving respiratory 
symptoms as measured by the CF Respiratory Symptoms 
Diary-Chronic Respiratory Infection Symptom Severity Score 
(CFRSD-CRISS) 
• To assess the sputum and blood PK profile of IV gallium  
• To assess the rate of acquired resistance of P. aeruginosa to 
gallium 
• To explore the anti-inflammatory properties of IV gallium 
• To explore the efficacy of IV gallium in reducing the use of 
antibiotics for an acute indication 
NUMBER OF 
SUBJECTS 
Approximately120, approximately 60 per treatment arm 
SUBJECT 
SELECTION 
CRITERIA 
Inclusion Criteria: 
1. Greater than or equal to 18 years of age at Screening 
2. Documented chronic colonization with P. aeruginosa defined 
as identification in two sputum or oropharyngeal cultures 
within the year prior to Day 1 
3. Documentation of a CF diagnosis as evidenced by one or 
more clinical features consistent with the CF phenotype and 
one or more of the following criteria: 
a. sweat chloride ≥ 60 mEq/liter by quantitative 
pilocarpine iontophoresis test (QPIT)  
b. two well-characterized mutations in the cystic 
fibrosis transmembrane conductance regulator 
(CFTR) gene  
c. Abnormal nasal potential difference (NPD; change 
in NPD in response to a low chloride solution and 
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isoproteronol of less than -5 mV)  
4. FEV1 ≥ 25 % of predicted value at Screening 
5. Able to expectorate sputum  
6. Serum liver function tests ≤ 2.5 x upper limit of normal at 
Screening 
7. Serum urea nitrogen (BUN) ≤ 1.5 x upper limit of normal at 
Screening 
8. Serum creatinine ≤ 2.0 mg/dl and  ≤ 1.5 x upper limit of 
normal at Screening 
9. Hemoglobin ≥ 9 g/dl, platelets ≥ 100,000/mm3, and white 
blood cells (WBC) ≥ 4,500/mm3 at Screening 
 
10. Ionized calcium ≥  lower limit of normal at Screening 
11. Written informed consent obtained from subject or subject’s 
legal representative, able to communicate with the 
Investigator and comply with the requirements of the protocol 
12. If female and of childbearing potential, must have a negative 
pregnancy test on Day 1 prior to receiving study drug 
13. If female and of childbearing potential, is willing to use 
adequate contraception for the duration of the study through 
Visit 5, as determined by the investigator 
14. If male and able to father a child, is willing to use adequate 
contraception for the duration of the study through Visit 5, as 
determined by the investigator 
15. Clinically stable with no significant changes in health status 
within 14 days  prior to Day 1 
 
Exclusion Criteria: 
1. Use of inhaled antibiotics within seven days prior to Day 1    
2. Unable or unwilling to withhold use of chronic inhaled 
antibiotics through Day 28 
3. Use of intravenous, inhaled, or oral antibiotics for an acute 
indication within 14 days prior to Day 1 
4.  Use of bisphosphonates within seven days prior to Day 1 
5. History of osteoporosis  (defined as the most recent dexa scan 
with a T-score ≤ -2.5 with the dexa scan performed within the 
five years prior to Screening) 
6. Lactating female  
7. Known sensitivity to gallium 
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8. Use of any investigational drug and/or participated in any 
interventional clinical trial within 28 days prior to Screening 
9. Presence of a condition or abnormality (e.g., pre-existing 
heart disease) that in the opinion of the site investigator would 
compromise the safety of the subject or the quality of the data 
TEST PRODUCT, 
DOSE AND MODE 
OF 
ADMINISTRATION 
Subjects will receive a five-day continuous infusion of 200 
mg/m2/day of IV gallium nitrate or volume-matched placebo 
(0.9% sodium chloride). 
Subjects will be permitted to remain in the clinical research 
center for the full five days of continuous infusion at the 
discretion of the investigator or can receive the infusion as an 
outpatient. 
DURATION OF 
SUBJECT 
PARTICIPATION  
Subjects will be on study for up to 63 days: 
     Screening:  0-7 days (can be combined with Baseline/Day 1) 
Treatment:  5 days  
Primary Efficacy Evaluation:  Day 28 
Final safety evaluation:  Day 56 
Total Follow-up time after first dose of study drug:  56 days 
CONCOMITANT 
MEDICATIONS 
Allowed: Standard therapy for CF is allowed except for 
treatments noted in the exclusion criteria described above and as 
noted in the prohibited medications section below.  Ongoing 
chronic treatment (>30 days prior to Day 1) with oral antibiotics, 
including azithromycin, is allowed.  Treatment for pulmonary 
exacerbations and as required for acute care is allowed, including 
acute oral, inhaled and IV antibiotics.  Physicians are encouraged 
to prescribe acute antibiotic therapy only in the presence of 
symptoms.   
Prohibited: The following medications are prohibited within 
seven days prior to Day 1 through Day 28: 
• inhaled chronic antibiotics  
• bisphosphonates 
The use of nonsteroidal anti-inflammatory drugs (NSAIDs) and 
aspirin is prohibited from Day 1 through 24 hours after the study 
drug infusion is stopped (e.g., Day 7 for subjects that complete 
the entire course of study drug). 
STUDY 
EVALUATIONS 
 
PRIMARY 
ENDPOINT 
Difference between treatment groups in the proportion of subjects 
with a 5% or greater relative change in FEV1 (liters) from 
baseline to Day 28  
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SECONDARY 
ENDPOINTS 
• 
Difference between treatment groups in safety parameters 
including the incidence of adverse events (AEs), changes in 
clinical safety labs, and hospitalizations through the end of 
follow-up 
• 
Difference between treatment groups in the change in 
pulmonary function parameters from baseline through end of 
follow-up  including relative change in FEV1 (liters), absolute 
change in FEV1 (liters) and in FEV1 % predicted, and change 
in FVC (liters and % predicted)  
• 
Difference between treatment groups in the change in sputum 
P. aeruginosa density based on quantitative cultures from 
baseline through end of follow-up 
• 
Difference between treatment groups in the emergence of 
other CF pathogens, including gallium-resistant P. 
aeruginosa,  from baseline through end of follow-up 
• 
Difference between treatment groups in the change in the 
CFRSD-CRISS from baseline through end of follow-up 
• 
Determination of the steady state concentration (Css)  and 
elimination half life (t1/2β ) in those subjects receiving IV 
gallium  
• 
Difference between treatment groups in the change in blood 
inflammatory markers from baseline through end of follow-up 
• 
Difference between treatment groups in the rate of antibiotic 
usage including IV, oral, and inhaled for an acute indication 
from baseline through end of follow-up 
• 
Longitudinal trends in clinical features and CF pathogens 
following treatment through the CF Foundation National 
Patient Registry 
 
SAFETY 
MONITORING  & 
INTERIM 
ANLYSES 
An independent data safety monitoring board, the CF Foundation 
Data Safety Monitoring Board (DSMB), will review safety data 
for this study.    Summary reports tabulating SAEs by treatment 
group will be provided on a quarterly basis to the DSMB.  
Comprehensive safety interim reports will be provided twice 
yearly to the DSMB and will include detailed summaries of all 
SAEs, AEs, drug discontinuations, laboratory parameters and 
withdrawals. The DSMB will recommend continuation or 
discontinuation of the study based on these interim reviews.    
STATISTICS 
Primary Analysis 
Plan 
The primary analysis will be conducted on the intent-to-treat 
(ITT) population including all randomized subjects who had the 
study drug infusion started. The primary endpoint is the 
difference between treatment groups in the proportion of subjects 
with a 5% or greater improvement in the relative change in FEV1 
(liters) from baseline to Day 28.  To test the null hypothesis that 
no difference exists between treatment groups, a two-sided 0.05 
level of significance test of proportions will be performed 
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adjusted for baseline lung function. The primary analysis will 
also be run on a per protocol population consisting of a subset of 
ITT population who had no protocol violations, did not use 
inhaled chronic antibiotics  and bisphosphonates from seven days 
prior to Day 1 through Day 28 and received gallium infusion for 
five sequential days. Additional analyses of the relative change in 
FEV1 through end of follow-up will include the development of a 
mixed-effect model for repeated measures (MMRM).  
Rationale for 
Number of Subjects 
With a sample size of 60 per group and assuming a responder rate 
of 30% in the placebo group, the study has 90% power to detect a 
28.3% or greater improvement in the responder rate.  Accounting 
for an attrition rate of 10% and interim analyses, the study will 
still have 90% power to detect a treatment difference of 30.0% or 
greater between groups.   
 
 
 
 
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1 
BACKGROUND 
Most adult patients with cystic fibrosis (CF) develop chronic bronchiectasis caused by life-long 
airway infections that is punctuated by recurrent acute exacerbations.  This process progressively 
destroys the lungs, leading to premature death.  The current median survival for CF patients is 
approximately 36 years (3).  Pseudomonas aeruginosa (P. aeruginosa) accounts for 
approximately 60% of the chronic lung infections in CF (4) and ~ 90% of deaths are attributed to 
chronic airway damage caused by this organism (4).  Despite intensive research, the airway 
colonization in CF patients cannot be eradicated by any known therapy and intensive antibiotic 
treatment is only effective at suppressing these persistent infections.  Moreover, the frequent use 
of suppressive antibiotics has made antibiotic resistance a vexing problem in CF patients.   
At present, new antimicrobial development by the pharmaceutical industry is at a historic low 
and the prospects for new classes of antimicrobial agents effective against P. aeruginosa (and 
other Gram-negative bacteria) are poor.  Responding to this problem, ten federal agencies 
[chaired by the National Institutes of Health (NIH), Centers for Disease Control and Prevention 
(CDC), and Food and Drug Administration (FDA)] generated an intra-agency action plan that 
emphasized the importance of developing novel antimicrobial agents (5). 
This negative outlook is compounded when one considers two additional points.  First, P. 
aeruginosa is well known for its intrinsic and acquired antibiotic resistance, and this makes 
management of P. aeruginosa infections in all types of patients challenging (6).  Second, in CF 
and other chronic infections, P. aeruginosa live in biofilms (7;8).  Growth in biofilms makes 
organisms much more resistant to killing by antibiotics and biocides.  Thus, new therapies 
directed against P. aeruginosa would optimally show activity against bacteria in the free-living 
(planktonic) state and in biofilms.  Furthermore, these treatments would optimally work by novel 
mechanisms so that resistance to conventional antibiotic does not limit their use.  Our studies 
suggest that gallium nitrate may fulfill these requirements.  
1.1 
Overview of Non-Clinical Studies 
Biofilm growth gives bacteria many advantages.  Biofilms are groups of bacteria, encased in a 
polymeric matrix (9).  Compared to free-living (planktonic) cells, biofilm bacteria exhibit 
important differences in physiology (10).  Most notorious is their resistance to killing by 
antibiotics and the immune system.  Biofilms can be 1,000-10,000 times more resistant than 
planktonic bacteria (9).  Resistance results from a combination of decreased antimicrobial 
penetration, metabolic inactivity of some biofilm cells, and other poorly defined changes (9).  
Biofilms accounts for the persistence of many chronic infections including endocarditis, medical 
device infections, and osteomyelitis (11).  A prototypical biofilm disease is the chronic P. 
aeruginosa airway infections that afflict CF patients (11).  
Iron limitation could be exploited in new antimicrobial and anti-biofilm treatments.  Iron 
sequestration is an evolutionary ancient host defense strategy (12).  The extremely low iron 
levels in vivo (~10-20 M) (13) prevent infection because all pathogens require iron for growth.  
Iron is also a key signal that promotes biofilm development, separate from its requirement for 
growth (14;15).  Thus, disrupting bacterial iron metabolism could be effective against biofilm 
and planktonic bacteria.  Unfortunately, exploiting this has been difficult.  Treatment with iron 
chelators has been tried, but bacteria used the chelator-bound iron and secondary infection 
occurred (16).  Another approach would develop drugs that interfere with iron uptake.  However, 
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pathogens have many redundant acquisition systems; P. aeruginosa has over 30 genes encoding 
iron receptors.  New approaches to interfere with iron-dependent processes are needed if the 
therapeutic potential of this approach is to be fully realized. 
Gallium can substitute for iron and can disrupt iron-dependent processes.  Gallium has 
many features similar to iron(III), including a nearly identical ionic radius, and biologic systems 
are often unable to distinguish gallium from iron(III).  Unlike iron(III), gallium cannot be 
reduced to the divalent state.  Thus placing gallium rather than iron in enzymes renders them 
non-functional (1;2).  Our work suggests that P. aeruginosa may have a higher affinity for 
gallium than for iron.  We have also found that gallium has bacteriostatic, bactericidal, and anti-
biofilm actions in vitro and in three  animal models (17).  
1.2 
Overview of Clinical Studies 
All of the clinical studies noted in this section have been conducted using the FDA approved 
Gallium nitrate [Ga(NO3)3, trade name Ganite®].  This product is no longer available. The 
current study will use an identical formulation manufactured by the National Institutes of 
Health/National Heart, Lung, and Blood Institute (NHLBI) Science Moving towArds Research 
Translation and Therapy (SMARTT) Program. 
Clinical uses of Gallium in humans. Gallium nitrate [Ga(NO3)3, trade name Ganite®] is an 
FDA-approved treatment for hypercalcemia of malignancy (18-20).  The drug has also 
demonstrated activity against a variety of other skeletal conditions, including Paget’s disease, 
metastatic bone disease, malignant hyperparathyroidism, and osteoporosis (presumably by 
inhibiting osteoclast activity (18)), as well as certain neoplastic diseases, including bladder 
cancer and lymphoma.  Relative to doses used in skeletal diseases, substantially larger doses (~ 
300-400 mg/m2/day for seven consecutive days repeated every 21-28 days) have been broadly 
used for treatment of neoplastic diseases and have generally been well tolerated by debilitated 
patients.  In addition, trace doses of Gallium-67 citrate have been used for nuclear scintiscanning 
to identify areas of neoplasia, inflammation and infection.  
Pharmacokinetics of intravenous gallium nitrate in non-CF patients.  As noted above, 
gallium nitrate is an FDA-approved agent to treat patients with cancer-related hypercalcemia that 
is resistant to hydration.  In non-CF patients with disseminated cancer with normal renal 
function, gallium showed a biphasic plasma disappearance with an initial half-life (t1/2) of 0.5 to 
1.8 hours (mean 1.0) and a terminal t1/2 of 10.5 to 50.4 hours (mean 25.1) (21).  Gallium was 
distributed in total body water and localized in some body compartments as evidenced by a 
volume of distribution ranging from 0.25 to 2.53 L/kg (mean 1.19). The estimated steady state 
concentration (Css) of gallium at an infusion rate of 100 mg/m2/day infusion is 1.0 to 4.3 µg/mL 
(21;22).  
For more detail, refer to the Prescribing information. 
Clinical experience in CF.  We completed a Phase 1b non-randomized safety and 
pharmacokinetic (PK) trial in CF adults. The study involved two different dosing cohorts, 100 
mg/m2/day and 200 mg/m2/day infused for a total of 5 days. The first dosing cohort included 9 
CF subjects (4 males and 5 females) and the second included 11 CF subjects (6 males and 5 
females).  The mean baseline forced expiratory volume in one second (FEV1) and forced vital 
capacity (FVC) were 2.25 liters (L) (range 1.06 to 4.59 L) and 3.60 L (range 1.84 to 6.11 L).  
The mean body mass index was 22.7 kg/m2 (range 17.3 to 31.2 kg/m2) thus representing a broad 
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spectrum of disease in CF adults. No serious adverse experiences (SAEs) were noted in the 
study.  There were a total of 41 adverse events (AEs); 8 were deemed possibly related, one 
definitely related and 32 unrelated to study agent.  Of the 9 AEs that were deemed related, 8 
were categorized as mild and one was categorized as moderate severity.  The AE categorized as 
definitely related to the study was bruising at the site of an intravenous line site (related to study 
procedure, not study drug).  The other AEs included headache, dizziness, chest pain, 
gastroesophogeal reflux disease, increased sputum production, migraine headache, increased 
lethargy, gastrointestinal bloating and elevated blood glucose. Of the 41 AEs, 39 were deemed 
mild in severity with one moderate and one severe in severity.  The severe AE was a headache. 
No AE led to a treatment discontinuation. The primary safety concern of IV gallium is renal 
toxicity.  No evidence was found of renal injury during and after infusion using serum creatinine, 
blood urea nitrogen (BUN) and urine albumin/creatinine ratio.  We found no evidence of 
perturbation of calcium homeostasis as noted by blood ionized calcium levels. Overall, the drug 
appeared safe and well tolerated in CF. 
PK data has been determined in 9 patients receiving 100 mg/m2/day and 10 patients receiving 
200 mg/m2/day in the Phase 1b study (the PK samples for one subject were lost).  Steady state 
concentrations were achieved by 48 hours after initiation of the infusion.  As shown in Table 1, 
there was no apparent increased in the gallium serum or sputum concentration area under the 
concentration time curve (AUC) with the increased dose.  The clearance (Cl) was significantly 
increased with the higher dose due to increases in both renal and non-renal clearance.  The lack 
of effect of dose on serum and sputum concentrations may reflect the uptake of gallium by white 
blood cells (WBC).  The elimination half-life (t1/2β) determined as the ratio of Cl and the 
elimination rate constant (K) reflects a prolonged elimination from a depot compartment. 
 
Table 1: 
Pharmacokinetics of Galium 
 (mean ± standard deviation)
. C 48hr: steady 
state concentration
at 48 hrs; C 61hr: steady state concentration
 at 61  hrs; T1/2β: 
elimination half
-life; Fe: Fractional excretion; Cl: clearance
. 
100 mg/m
N =  9 
2 /day
200 mg/m
N = 10 
2 /day
P
SERUM
 
 
 
C 48hr  ( µ g/mL)  
 
C 61hr  (µg/mL)  
2.6 ±  0.6 
2.1 ± 0. 6 
2.3 ± 1.0 
2.2 ± 0. 6 
0.35  
0. 79  
 
T 1/2β  (hr) 
105 ± 14
129 ± 44
0.16  
 
AUC (ug/mL
⋅hr) 
503 ± 98
537  ± 153  
0.59  
 
Cl  (L/hr) 
 
(L/hr/m 2)  
3.8 ± 1.0
2.1 ± 0.4
7.2 ± 2.1
4.0  ± 1. 1 
0.0011* 
0.007 *  
 
Fe (%) 
0.19 ± 0.07
0.20  ± 0.0 9  
0. 67  
 
Cl renal (L/hr)  
0.71 ± 0.29
1.35  ± 0. 52  
0.0077*
 
Cl nonrenal  (L/hr)  
3.0 ±  0.9 
5.8  ± 2.2 
0.0 052* 
SPUTUM 
 
 
 
C max ( µ g/mL) 
 AUC (ug/mL ⋅hr) 
0.92 ± 0.73
480 ± 397 
1.11 ± 0.80  
567 ± 518  
0.61  
0. 69  
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Lung function increased in the pooled subjects (dosing cohorts 1 and 2). The mean change in 
FEV1 and FVC by day 14 was 0.118 liters (95% confidence interval (CI): 0.041 to 0.196) and 
0.124 liters (95% CI: 0.059 to 0.188) for 20 subjects.  Both changes were statistically significant.  
The mean change in FEV1 and FVC by day 28 was 0.095 liters (95% CI: 0.031 to 0.160) and 
0.147 liters (95% CI: 0.063 to 0.231) for 20 subjects.  Both changes were statistically significant. 
The effect on lung function appeared to be driven by cohort 2 (200 mg/m2/day).  In cohort 2, the 
mean change in FEV1 and FVC by day 14 was 0.169 liters (95% CI: 0.08 to 0.260) and 0.204 
liters (95% CI: 0.13 to 0.277) for 11 subjects. Both changes were statistically significant. The 
mean change in FEV1 and FVC by day 28 was 0.085 liters (95% CI: -0.006 to 0.176) and 0.169 
liters (95% CI: 0.04 to 0.293) for 11 subjects.   Only the FVC change was significant.  Figure 1 
notes the change in FEV1 in liters from baseline by study visit and cohort. These lung function 
changes are quite similar and comparable to other major treatments used in CF.   
Figure 1. Box plots of change in lung function from baseline to day 14 and day 28 in mLs 
(Cohort 1: 9 subjects; Cohort 2: 11 subjects). 
 
Interestingly, no significant change was noted in quantitative culture from the sputum of P. 
aeruginosa isolates. Sputum quantitative cultures noted wide variability with some subjects 
having a response akin to prior antimicrobial therapies in CF while others noted no clear 
treatment effect. The mean P. aeruginosa quantitative culture at baseline was 116.7 million 
colony forming units (CFUs)/gram of sputum (95% CI: 20.4 to 213.0 million CFU/gm). The 
mean change from baseline to day 14 was -5.5 million CFU/gm (95% CI: -110.5 to 99.5 million 
CFU/gm) and from baseline to day 28 was -28.7 million CFU/gm (95% CI: -111.0 to 53.7 
million CFU/gm). Overall, the mean change was in the appropriate direction of a treatment 
response. 
-200
0.0
200
400
600
Cohort 1 (100 mg/m2/day)
FEV1 change day 14
FEV1 change day 28
Cohort 2 (200 mg/m2/day)
Change in Lung Function from Baseline mls)
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2 
STUDY RATIONALE 
2.1 
Rationale for Gallium Treatment in CF Patients 
Gallium nitrate is a promising therapeutic for CF airway infections for a number of reasons. 
A large proportion of infecting organisms in CF airway infections are living in biofilms.  
Gallium nitrate could deliver "multiple hits" against infecting bacteria.  At low concentrations, it 
blocks biofilm formation and inhibits bacterial growth; at higher concentrations, it kills 
planktonic and biofilm bacteria (17).   
Gallium exhibits antimicrobial properties against laboratory P. aeruginosa strains and against 
mucoid and non-mucoid clinical isolates from CF patients.  The vast majority of antibiotic 
resistant P. aeruginosa strains that we have tested so far are also susceptible to gallium (17).  
Microbial resistance to gallium may be difficult for P. aeruginosa to acquire because gallium 
substitutes for iron in some metabolic processes and iron is an essential nutrient that is avidly 
taken up by bacteria.  We have shown that mutations in three different iron uptake systems of P. 
aeruginosa did not change susceptibility to anti-biofilm or growth inhibitory actions of gallium 
(17).  This suggests that multiple different iron uptake pathways can mediate the effects of 
gallium. 
If resistance to gallium develops via mutation of gallium targets, it may not compromise the 
effectiveness of conventional anti-pseudomonal antibiotics currently in use.  This is because 
gallium's antimicrobial mechanism differs from that of conventional antibiotics. 
Laboratory data demonstrates that gallium's antimicrobial effect is enhanced in iron-limited 
conditions (17).  Because bio-available iron is scarce in the lung (23), the antimicrobial action of 
gallium may be augmented in vivo.  Thus, the concentrations of gallium required for efficacy in 
humans may be even lower than we have found in vitro.  
Although P. aeruginosa is generally regarded as the most important pathogen in CF, patients 
also develop serious airway infections with other organisms including Staphylococcus aureus 
(methicillin sensitive and resistant strains), Haemophilus influenzae, and Burkholderia cepacia 
(24).  Like P. aeruginosa infections, these organisms can be found in high concentrations in the 
sputum (3), develop antibiotic resistance (25;26), and can be difficult to treat with conventional 
antibiotics.  Though evidence is incomplete, some of these organisms may live in biofilms in the 
CF sputum (27).  Importantly, all of these organisms require iron for growth and thus they may 
also be sensitive to the antimicrobial action of gallium.  Work by our group and others indicates 
that gallium nitrate has activity against Stenotrophomonas maltophilia, the Burkholderia cepacia 
complex, Klebsiella pneumonia (including ESB strains), Escherichia coli, Acinetobacter 
baumannii, Bacillus anthracis, Francisella sp. and Salmonella typhi (28). 
Gallium may exhibit anti-inflammatory effects independent from the anti-microbial effect, which 
may be beneficial for CF lung infections.  Extensive literature indicates that gallium has anti-
inflammatory effects on various cells of the immune system and in intact animals. Gallium is a 
strong inhibitor of polyclonal and allo-antigen induced T-cell proliferation (29), and B-cell 
proliferation and antibody secretion (30).  Gallium reduces Interleukin-6 (IL-6), Tumor Necrosis  
Factor- α (TNF-α), and nitric oxide release from lipopolysaccharide stimulated macrophage-like 
cells (31),  and inhibits the expression of major histocompatibility complex and  interferon-γ 
stimulated peritoneal macrophages (19).   
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In addition, we now have data from two non-blinded dosing cohorts in adults with CF noted in 
section 1.2  showing no evidence of toxicity but preliminary indications of clinical efficacy with 
improvement in both FEV1 and FVC.  We also found that although the PK did not correspond 
well to treatment response, the levels achieved in the sputum were similar to those used in in 
vitro experiments assessing the antimicrobial and anti-biofilm activity of gallium on P. 
aeruginosa. Here, we propose an initial proof of concept Phase 2 blinded efficacy study of 
gallium in CF patients using the maximum FDA-approved dose for patients with hypercalcemia 
(200 mg/m2/day for a 5 day infusion). 
2.2 
Risk / Benefit Assessment 
No published studies exist that evaluate the safety of IV gallium nitrate in CF patients.  However, 
there is extensive published information on the use of this compound over a wide range of doses 
both above and below the doses proposed in this trial in patients with both neoplastic as well as 
benign metabolic diseases.  Moreover, this human experience extends over a period of more than 
30 years, including a post-marketing experience of 17 years duration.  Thus, the risks of the drug 
have been broadly described in thousands of patients and unique risks associated with the 
proposed dosing in CF patients would appear to be low.  In this trial, we propose to limit our trial 
to stable CF subjects with normal renal function at a dose previously tested and shown to be safe 
in our Phase 1b CF study.  Because of this, we anticipate potentially severe systemic adverse 
reactions to be unlikely.   
A specific minimum human toxic dose has not been established.  However, a “no effect” 
(placebo) dose of 0.05 mg/kg administered once per day subcutaneously was used in the 
randomized Phase 2 study in Paget’s disease.  A higher dose (0.5 mg/kg/d) demonstrated 
biological activity against markers of Paget’s disease activity, but demonstrated no significant 
AEs.  The lethal dose 50 (LD50) of gallium nitrate in mice is 4,360 mg/kg for oral doses and 600 
mg/kg for subcutaneous doses (32).  Renal toxicity is dose dependent and is usually the dose 
limiting adverse effect of parenteral gallium nitrate when administered by bolus injection or 
short (2 hours) IV infusion (2).  Elevation of serum BUN and creatinine levels has been observed 
in approximately 12.5% of patients receiving recommended therapeutic doses of IV gallium 
nitrate (~ 400 mg/day for a typical adult).  Toxicity depends on several factors: the total dose, the 
rate of administration, the underlying pathology, and use with other nephrotoxic drugs.  Doses up 
to 1400 mg/m2 by short IV infusion have been used in clinical trials.  No significant toxicity has 
been observed at doses of 50 mg/m2 (~ 100 mg for a typical adult) or less (33). 
Nephrotoxicity occurs most commonly after large IV boluses are rapidly administered.  While 
the exact mechanism of renal toxicity in humans is not known, studies in rats suggest that 
toxicity occurs when the influx of gallium into the circulation exceeds the ability of transferrin 
(or other binding proteins) to bind gallium (19;34).  Unbound gallium forms gallate (Ga(OH)4
-) 
which is rapidly excreted by the kidneys (35).  Under conditions where gallate transiently 
reaches high levels, it is thought to precipitate within renal tubules and cause obstruction.  Rats 
administered high levels of gallium nitrate developed flocculent complexes that were observed to 
be occluding the lumen of some renal tubules (34).  X-ray energy spectrometry showed that 
gallium was found in the presence of calcium and phosphorus in the occluding precipitates (34).   
This mechanism of renal toxicity is consistent with two additional observations.  First, in rats and 
humans, osmotic diuresis significantly reduced the levels of gallium found in the urine and the 
incidence of renal toxicity when high doses were administered (34;35).  Second, gallium 
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nephrotoxicity is markedly reduced by slow IV infusion or subcutaneous injection (19).  These 
methods of delivery lower the rate at which gallium appears in the plasma, preventing transferrin 
saturation and reducing gallate delivery to the kidneys.  Therapeutic doses of gallium have been 
administered to thousands of debilitated patients using slow infusions, without significant renal 
toxicity (36).  If it occurs, renal toxicity is generally mild (transient proteinuria) at doses < 300 
mg/m2 (21;22).  
Hematological toxicity has also been observed with IV gallium nitrate, although this is generally 
mild and interpretation of this adverse effect is complicated by the fact that patients receiving 
gallium nitrate had malignancies, were hospitalized, and were undergoing frequent phlebotomy 
(19).  In one study, 38% of gallium-treated cancer patients developed a greater than 3 gm/100mL 
drop in the hemoglobin level; however, only 18% of patients required a blood transfusion (22).  
Thrombocytopenia (platelet count< 150,000/mm3) occurred in 15% of patients and was most 
frequent at doses > 450 mg/m2/day (22).  No bleeding was observed.  Mild leukocytosis (mean 
increase of 0.9 x103/mm3) has also been observed in a dose dependent manner (22).  These 
toxicities were not observed in our Phase 1b CF clinical trial. 
Gallium can also produce hypocalcemia; treatment of hypercalcemia of malignancy is the 
approved indication for gallium.  In rats, a single injection produces a rapid increase in urinary 
excretion of calcium; however, this is transitory and was subsequently shown to be an effect of 
concomitant diuresis rather than the drug itself (19).  Several studies suggest that gallium lowers 
serum calcium levels in large part by inhibiting bone resorption (19;35;37;38).  In patients 
without elevated blood levels of calcium, the reduction in calcium levels is usually mild and 
asymptomatic and can usually be treated with oral calcium supplements (39).  These toxicities 
were not observed in our Phase 1b CF clinical trial. 
Other AEs associated with gallium include optic neuritis (observed at high doses), tinnitus and 
mild high frequency hearing loss (apparent on audiograms), anorexia, nausea, diarrhea, 
stomatitis, conjunctivitis, lethargy, mild respiratory alkalosis with hyperchloremia, and rash (19).  
A reversible pulmonary syndrome consisting of dyspnea, rales, rhonchi, pleural effusion, and 
pulmonary infiltrates has been reported in association with gallium nitrate infusion, but this is 
rare and has occurred in patients with serious underlying malignant conditions.  Thus the 
relationship of these other AEs and the pulmonary syndrome  to the  gallium infusion is 
uncertain (Ganite® (gallium nitrate injection) package insert,(21;40)).  A case of pulmonary 
toxicity occurred in a patient receiving 300 mg/m2/day for seven (7) days every four (4) weeks 
(41).  No pulmonary complaints were noted in our Phase 1b CF clinical trial; in fact, lung 
function improved with treatment. 
2.3 
Measures to Minimize Risk 
All subjects will be instructed to ingest a minimum of two (2) liters of fluid per day during the 
five (5) day infusion of study drug (gallium nitrate or placebo) and for two (2) days thereafter to 
minimize the risks of nephrotoxicity.  Fluid intake will be documented on a daily diary from Day 
1 through Day 8.  We will evaluate the respiratory status and general health of subjects before 
and after exposure to gallium.  In the event of an allergic reaction during the six hour observation 
period on Day 1, adrenaline and anti-histamine will be immediately available.  If needed, 
emergency services including an emergency room and medical ICU are immediately available in 
close proximity to the study site.  Bronchospasm, if it occurs, will be treated immediately with 
nebulized albuterol.  In addition, we will monitor the subject's physical exam, symptoms, 
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respiratory questionnaire results, spirometry, blood and urine clinical laboratory test results, and 
treat as indicated.   
The effects of gallium on an unborn child (fetus) are unknown and may be harmful.  Women 
cannot participate if they are pregnant, are breast feeding, or plan to become pregnant during the 
study.  Men cannot participate if they plan to father a child during the study.  
There is no proven benefit of IV gallium in CF. However, the risks of the infusion dose proposed 
in this trial appear to be both low and well-defined in non-CF populations.  In the future, IV 
gallium might be proved to be useful in the acute and chronic management of CF patients 
infected with P. aeruginosa. 
3 
STUDY OBJECTIVES 
3.1 
Primary Objective 
To assess the efficacy of IV gallium to improve pulmonary function as measured by a 5% or 
greater relative improvement in FEV1 from baseline to Day 28   
3.2 
Secondary Objectives 
• To assess the safety and tolerability of IV gallium  
• To assess the efficacy of IV gallium in improving measures of lung function including relative 
change in FEV1 absolute change in FEV1, and FVC 
• To assess the efficacy of IV gallium in reducing P. aeruginosa in the lungs of CF patients 
based on quantitative cultures of sputum 
• To assess the efficacy of IV gallium in improving respiratory symptoms as measured by the 
CF Respiratory Symptoms Diary -Chronic Respiratory Infection Symptom Severity Score 
(CFRSD-CRISS) 
• To assess the sputum and blood PK profile of IV gallium  
• 
To assess the rate of acquired resistance of P. aeruginosa to gallium 
• 
To explore the anti-inflammatory properties of IV gallium 
• To explore the efficacy of IV gallium in reducing the use of antibiotics for an acute 
indication 
4 
STUDY DESIGN 
4.1 
Study Overview 
This is a phase 2, multi-center, randomized, double-blind, placebo-controlled trial in adults with 
CF chronically infected with P. aeruginosa.  The study will evaluate the safety and clinical 
efficacy of a five-day infusion of IV gallium nitrate.  Approximately one hundred twenty eligible 
subjects will be randomized in equal allocation to receive either a single 5-day infusion of IV 
gallium or volume-matched placebo. Subjects will be randomized using an adaptive 
randomization scheme to prevent imbalances in treatment allocation within baseline FEV1 strata.   
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Five study visits will occur at Screening/Baseline (Day 1; Visit 1), Day 6 (Visit 2), Day 14 (Visit 
3), Day 28 (Visit 4), and Day 56 (Visit 5).  On Day 3, subject will be contacted by phone. 
Screening data will be reviewed to determine subject eligibility.  Screening can occur on Day 1 
prior to the start of study drug or within seven (7) days prior to Day 1.  If Screening takes place 
prior to Day 1, then on Day 1, in order to reconfirm eligibility, an abbreviated physical exam, 
spirometry and a urine pregnancy test for females must be completed prior to dosing on Day 1.  
Subjects who meet all inclusion criteria and none of the exclusion criteria will be eligible for the 
study.  
Subjects will be permitted to remain in the clinical research center for the full five (5) days of 
continuous infusion at the discretion of the investigator.  During each day of the infusion and for 
two subsequent days (Day 1 to Day 8), the subject will be instructed to consume at least two (2) 
liters of fluid.  Calcium, BUN and creatinine may be checked more frequently at the discretion of 
the investigator. 
All subjects who had the study drug infusions started will be considered evaluable for safety and 
efficacy analyses.  Incidence of AEs will be monitored during the trial.  
Total duration of subject participation will be up to 63 days.  Additional data regarding long-term 
health impact may be ascertained through the CF Foundation National Patient Registry with 
optional patient consent. 
5 
CRITERIA FOR EVALUATION 
5.1 
Primary Efficacy Endpoint 
Difference between treatment groups in the proportion of subjects with a 5% or greater relative 
change in FEV1 (liters) from baseline to Day 28   
5.2 
Secondary Endpoints 
• 
Difference between treatment groups in safety parameters including the incidence of AEs, 
changes in clinical safety labs, and hospitalizations through the end of follow-up 
• 
Difference between treatment groups in the change in pulmonary function parameters from 
baseline through end of follow-up  including relative change in FEV1  (liters), absolute 
change in FEV1 (liters) and in FEV1 % predicted, and change in FVC (liters and % predicted)  
• 
Difference between treatment groups in the change in sputum P. aeruginosa density based on 
quantitative cultures from baseline through end of follow-up 
• 
Difference between treatment groups in the emergence of other CF pathogens, including 
gallium-resistant P. aeruginosa,  from baseline through end of follow-up 
• 
Difference between treatment groups in the change in the CFRSD-CRISS from baseline 
through end of follow-up 
• 
Determination of the steady state concentration (Css) and elimination half life (t1/2β ) in those 
subjects receiving IV gallium 
• 
Difference between treatment groups in the change in blood inflammatory markers  from 
baseline through end of follow-up 
• 
Difference between treatment groups in the rate of antibiotic usage including IV, oral, and 
inhaled for an acute indication from baseline through end of follow-up 
• 
Longitudinal trends in clinical features and CF pathogens following treatment through the CF 
Foundation National Patient Registry 
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6 
SUBJECT SELECTION 
6.1 
Study Population 
Subjects with a diagnosis of CF who meet the inclusion and do not meet the exclusion criteria 
will be eligible for participation in this study.   
6.2 
Inclusion Criteria 
1.  Greater than or equal to 18 years of age at Screening 
2. Documented chronic colonization with P. aeruginosa  defined as identification in two 
sputum or oropharyngeal cultures within the year prior to Day 1 
3. Documentation of a CF diagnosis as evidenced by one or more clinical features consistent 
with the CF phenotype and one or more of the following criteria: 
a. sweat chloride ≥ 60 mEq/liter by quantitative pilocarpine iontophoresis test (QPIT)  
b. two well-characterized mutations in the cystic fibrosis transmembrane conductance 
regulator (CFTR) gene  
c. Abnormal nasal potential difference (NPD; change in NPD in response to a low 
chloride solution and isoproteronol of less than -5 mV)  
4. FEV1 ≥ 25 % of predicted value at Screening 
5. Able to expectorate sputum  
6. Serum liver function tests ≤ 2.5 x upper limit of normal at Screening 
7. Serum urea nitrogen (BUN) ≤ 1.5 x upper limit of normal at Screening 
8. Serum creatinine ≤ 2.0 mg/dl and ≤ 1.5 x upper limit of normal at Screening 
9. Hemoglobin ≥ 9 g/dl, platelets ≥ 100,000/mm3, and white blood cells (WBC) ≥ 4,500/mm3 at 
Screening  
10. Ionized calcium ≥  lower limit of normal at Screening 
11. Written informed consent obtained from subject or subject’s legal representative, able to 
communicate with the Investigator and comply with the requirements of the protocol 
12. If female and of childbearing potential, must have a negative pregnancy test on Day 1 prior 
to receiving study drug 
13. If female and of childbearing potential, is willing to use adequate contraception for the 
duration of the study through Visit 5, as determined by the investigator 
14. If male and able to father a child, is willing to use adequate contraception for the duration of 
the study through Visit 5, as determined by the investigator 
15. Clinically stable with no significant changes in health status within 14 days  prior to Day 1 
6.3 
Exclusion Criteria 
1. Use of inhaled antibiotics within seven days prior to Day 1  
2. Unable or unwilling to withhold use of chronic inhaled antibiotics through Day 28 
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3. Use of intravenous, inhaled, or oral antibiotics for an acute indication within 14 days prior to 
Day 1 
4. Use of bisphosphonates within seven days prior to Day 1 
5. History of osteoporosis (defined as the most recent dexa scan with a T-score ≤ -2.5 with the 
dexa scan performed within the five years prior to screening) 
6. Lactating female 
7. Known sensitivity to gallium 
8. Use of any investigational drug and/or participated in any interventional clinical trial within  
28 days prior to Screening 
9. Presence of a condition or abnormality (e.g., pre-existing heart disease) that in the opinion of 
the site investigator would compromise the safety of the subject  or the quality of the data 
7 
CONCURRENT MEDICATIONS 
All subjects should be maintained on the same medications throughout the entire study period, as 
medically feasible, with no introduction of new chronic therapies. 
7.1 
Allowed 
Standard therapy for CF is allowed except for treatments noted in the exclusion criteria described 
above and as noted in the prohibited medications section below.  Ongoing chronic treatment 
(>30 days prior to Day 1) with oral antibiotics, including azithromycin, is allowed.  Treatment 
for pulmonary exacerbations and as required for acute care is allowed, including acute oral, 
inhaled and IV antibiotics.  Physicians are encouraged to prescribe acute antibiotic therapy only 
in the presence of symptoms.  
7.2 
 Prohibited 
The following medications are prohibited within seven days prior to Day 1 through Day 28: 
• inhaled chronic antibiotics  
• bisphosphonates 
The use of nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin is prohibited from Day 1 
through 24 hours after the study drug infusion is stopped (e.g., Day 7 for subjects that complete 
the entire course of study drug).  
8 
STUDY TREATMENTS 
8.1 
Method of Assigning Subjects to Treatment Groups 
Approximately 120 eligible subjects will be randomly assigned to receive study drug (IV gallium 
or placebo) in equal allocation.  An adaptive randomization will be employed with the goal of 
ensuring equal representation in each study arm as noted in the Statistical Analysis Plan (SAP). 
Subject randomization will be stratified by baseline FEV1 group (FEV1 < 50% of predicted, 50-
70% of predicted and >70% of predicted).   Randomization will occur centrally using a web 
based randomization system linked to the electronic data capture (EDC) system.  Only 
authorized site personnel are given access to the randomization module. Authorized site 
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personnel will enter subject eligibility information and whether or not the subject signed 
informed consent. The system will verify that the subject is eligible and has provided signed 
informed consent, and then provide the appropriate authorized site personnel with a 
randomization assignment for that subject that matches a specific treatment. 
8.2 
Blinding 
Study treatments will be administered in a double-blind fashion (i.e., subjects and site research 
staff will not know the treatment assigned, with the exception of the dispensing site pharmacist, 
central pharmacy, and designated TDNCC personnel.  The following study procedures will be in 
place to ensure double-blind administration of test and control (IV gallium/placebo) study 
treatments: 
• Randomization assignments will be stored in a secure database and appropriately 
protected and backed up. 
• Access to the randomization code will be strictly controlled and limited  to designated 
TDNCC study personnel. All other study personnel, investigators, and subjects will 
remain blinded to their study drug assignment throughout the study.   
• A volume and appearance-matched placebo will be utilized. 
• The site pharmacist will apply a blinded label to each one-liter bag of study drug.   
The study blind will be broken on completion of the clinical study and after the study database 
has been locked and study results released.  The site investigators will be provided with each 
subject’s treatment assignment following completion of data analysis.   
During the study, the blind may be broken only in emergencies when knowledge of the subject’s 
treatment group is necessary for further patient management.   
8.3 
Test and Control Formulation 
8.3.1 Test product  
Gallium, a group IIIA transition metal, is the active component in gallium nitrate, Ga(NO3)3.  
Gallium nitrate crystallizes from the reaction of elemental gallium with nitric acid.  Anhydrous 
Ga(NO3)3 has a molecular weight of 258.76.  The hydrated form of gallium nitrate, 
Ga(N03)3•9H2O with molecular weight 417.87, is a white, crystalline powder.  Gallium nitrate is 
fully soluble in water and in normal saline up to 1 mM.  To achieve higher concentrations, 
gallium nitrate can be dissolved in chelators like sodium citrate.   
Gallium nitrate is a member of the calcium regulator drug class and is used primarily in the 
treatment of hypercalcemia of malignancy (19;21;35).  Gallium nitrate for injection  is a clear, 
colorless, tasteless, odorless, sterile solution of gallium nitrate.   
Each vial contains 100 mM gallium nitrate (on an anhydrous basis) and sodium citrate dihydrate.  
Each milliliter in the prepackaged 25 mL vials , contains 25 mg gallium nitrate (on an anhydrous 
basis) and 28.75 mg sodium citrate dihydrate.  The osmolarity of this solution is 570 mOsm.  The 
pH is adjusted to 6.0 to 7.0 using NaOH or HCl. 
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8.3.2 Placebo Control 
Placebo vials will be provided for this study.  Each placebo contains 25 mL of 0.9% sodium 
chloride  
8.3.3 Packaging and Labeling 
The study drug (gallium nitrate/placebo) is supplied in prepackaged 25 mL single-use vials. Each 
vial of study drug will be packaged and labeled according to current ICH GMP and GCP 
guidelines and FDA requirements.   
The site investigational pharmacy will affix a blinded label to each one-liter bag of study drug.  
The label will comply with FDA requirements (e.g., the required FDA warning statement, the 
protocol number, the name of the sponsors, and directions for patient use and storage).   Further 
details are provided in the Pharmacy Manual. 
8.3.4 Preparation/Dispensing 
To prepare a one-liter solution of study drug, the site investigational pharmacy will dilute the 
study drug vials with 1,000 mLs of 0.9% sodium chloride for a dose of 200 mg/m2/day. The site 
investigational pharmacy will label the solutions as described in section 8.3.3. 
The study drug will be dispensed by the site’s investigational pharmacist.  The pharmacist or 
appropriate designee will instruct the subject on the infusion of the study drug.  On Day 1, the 
investigator and clinical research nurse will review the use of the continuous infusion with the 
subject and inspect the catheter used for infusion. 
8.3.5 Dosage/Dosage Regimen 
Study drug will be infused continuously over five (5) days at 200 mg/m2/day.  
8.3.6 Administration Instructions  
The administration of study drug can occur via one of the following types of venous access. The 
type of access is determined by the site PI.   
• An existing long term vascular access (e.g. subcutaneous venous Port) 
• A midline catheter 
• A peripherally inserted central catheter (PICC) line 
• A peripheral IV 
Depending on the type of venous access and according to institutional standard practice, 
additional procedures may need to be performed to confirm the proper placement of the venous 
access (e.g., chest x-ray or ultrasound for PICC line placement). 
Study drug will be administered using an ambulatory infusion pump infused over 24 hours for 
five (5) sequential days.  The specifics of administration (e.g., pump type, bag vs. syringe, 
inpatient vs. outpatient) can be determined by each site according to institutional policy.  
Study drug will be started on Day1, in the presence of the clinical research nurse.  The first six 
(6) hours of the infusion will be directly observed in the clinical research center (or equivalent) 
of the institution.  Subsequent to leaving the clinical research center, the subject will receive 
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doses for Day 2 through Day 5 to be refrigerated upon their return home.  The subject will be 
instructed on changing the infusion once the first 24-hour infusion is complete.  A one-liter 
solution bag will be infused each day for five days.  Subjects will be permitted to remain in the 
clinical research center for the full five (5) days of continuous infusion at the discretion of the 
investigator.   
During each day of the infusion and for two (2) days following the infusion (Day 1 to Day 8), the 
subject will be instructed to consume at least two (2) liters of fluid.  Examples will be provided 
to assist the subject in determining the adequate volume to consume.   
8.4 
Supply of Study Drug at the Site 
Gallium nitrate will be donated by the CFFT. 
Each site’s investigational pharmacy will receive study drug in the form of vials containing 
either 100 mM gallium nitrate (on an anhydrous basis)/sodium citrate dihydrate or 0.9% sodium 
chloride (placebo).    
 For the dilution of the study drug, 0.9% sodium chloride will be provided by each 
investigational pharmacy.  
8.4.1 Storage 
Vials of study drug for injection and one-liter solutions of 0.9% sodium chloride will be stored at 
controlled room temperature (20 to 25 degrees Celsius; 68 to 77 degrees Fahrenheit) until the 
day prior to randomization.   The one-liter solution of study drug will remain stable for 48 hours 
at room temperature and for 7 days if refrigerated (2 to 8 degrees Celsius) [per the Ganite® 
(gallium nitrate injection) package insert].  All study drug must be stored separately from normal 
hospital inventories, in a locked facility with access limited to the investigator and authorized 
personnel. 
Once dispensed to the subject, the five one-liter solutions of study drug will be stored at 2 to 8 
degrees Celsius until 60 minutes prior to the start of the infusion.  
8.5 
Study Drug Accountability 
An accurate and current accounting of the dispensing and return of study drug for each subject 
will be maintained on an ongoing basis by a member of the study site staff.  The number of bags 
dispensed and returned by the subject and the volume remaining will be recorded on the 
Investigational Drug Accountability Record.   
8.6 
Measures of Treatment Compliance 
Subjects will be asked to keep a subject diary noting the date, start and stop times of the infusion, 
and any AEs. They will be asked to bring their diary to each study visit along with all used and 
unused study drug bags. 
8.7 
Discontinuation of Study Drug  
Indications for study drug discontinuation include symptoms of hypocalcemia confirmed on 
blood assay and development of an acute fall in urine output confirmed by a rise in creatinine.  
Additional indications for discontinuation include the development of a study drug related SAE 
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during infusion or any other study drug related adverse event that the investigator believes 
warrants discontinuation. 
9 
STUDY PROCEDURES AND GUIDELINES 
A Schedule of Study Visits representing the required testing procedures to be performed for the 
duration of the study is diagrammed in Appendix 1. 
Prior to conducting any study-related activities, written informed consent and the Health 
Insurance Portability and Accountability Act (HIPAA) authorization must be signed and dated 
by the subject.   
9.1 
Clinical Assessments 
9.1.1 Concomitant Medications 
All concomitant medication and concurrent therapies will be documented at Screening and at all 
Study Visits and at early termination, when applicable. In addition, the use of concomitant 
inhaled, oral, and IV antibiotics from 30 days prior to Screening through Visit 5 will be 
documented.  Dose, route, unit frequency of administration, and indication for administration and 
dates of medication will be captured. 
9.1.2 Demographics  
Demographic information (date of birth, sex, race, CF genotype) will be recorded at Screening. 
9.1.3 Medical History  
Relevant medical history, including history of current disease, other pertinent respiratory history, 
and information regarding underlying diseases will be recorded as noted in the Schedule of 
Events. 
9.1.4 Physical Examination 
A complete or abbreviated physical examination will be performed by a licensed professional 
[MD (either the investigator or a sub-investigator), NP, RN, PA] as noted in the Schedule of 
Events.  A complete physical includes examination of the following systems: head/neck/thyroid, 
EENT, respiratory, cardiovascular, lymph nodes, abdomen, skin, musculoskeletal, and 
neurologic. An abbreviated physical includes examination of the following systems: respiratory, 
cardiovascular and abdomen. 
After initiation of Study Drug, new clinically significant abnormal physical exam findings must 
be documented as an AE. 
9.1.5 Weight and Height   
Weight and height will be measured on the same scale and recorded as noted in the Schedule of 
Events. Subjects may remain in clothes (without shoes). A standing height will be measured and 
recorded. 
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9.1.6 Vital Signs 
Body temperature, blood pressure, pulse and respirations will be performed after resting for 
5 minutes as noted in the Schedule of Events. 
9.1.7 Oximetry 
Oximetry will be measured on room air with the subject at rest as noted in the Schedule of 
Events. 
9.1.8 Spirometry 
Spirometry will be performed as noted in the Schedule of Events and in accordance with the 
current American Thoracic Society recommendations for the performance and interpretation of 
tests. Predicted equations for the computation of FEV1 and FVC % predicted will utilize the 
reference equations by Hankinson (42).   
Subjects who routinely use bronchodilators should use them prior to spirometry as noted below:  
• 
Subjects who routinely use short acting inhaled bronchodilators should use them 15 
minutes to 2 hours prior to PFTs during study visits. 
• 
Subjects who routinely use long acting bronchodilator agents should use them 15 minutes 
to 6 hours prior to PFTs during study visits. 
9.1.9 CFRSD-CRISS and Subject Diary 
The subjects will be given a CF specific symptom diary called the CFRSD-CRISS.  This diary 
includes 8 questions and takes less than 5 minutes to complete.  The diary will be completed 
daily as noted in the schedule of Events. 
Subjects also will be given a diary to document date, start and stop times they take their study 
drug and any AEs from Day 1 through Day 5.  In addition, at least two (2) liters each day of fluid 
consumption from Day 1 through Day 8 will be documented. 
9.1.10 Adverse Events 
Information regarding occurrence of AEs will be captured throughout the study. Duration (start 
and stop dates), severity, outcome, treatment and relation to study drug will be recorded on the 
case report form (CRF). Subjects will be specifically instructed to report peri-oral tingling, 
paresthesia (pins and needles sensation) of the extremities, or muscle spasms.  If these symptoms 
are reported, calcium, BUN, and creatinine may be checked more frequently at the discretion of 
the investigator. 
If a subject has study drug discontinued because of an AE, the subject will be followed and 
treated by the site investigator until the abnormal parameter or symptom has resolved or 
stabilized.  Subjects who discontinue study drug early will be encouraged to return for an Early 
Discontinuation of Study Drug Visit (Refer to section 10.6) and to complete all remaining visits 
and procedures.   
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9.2 
Clinical Laboratory Measurements  
After initiation of Study Drug, new clinically significant abnormal laboratory findings must be 
documented as an AE. 
The collection of blood samples may occur via the study drug administration access point if 
study drug is not being administered. If study drug is being administered, blood collection must 
occur at a different access point.   
9.2.1 Hematology 
Blood will be obtained as noted in the Schedule of Events and sent to each site’s clinical 
hematology lab for a complete blood count with differential (i.e., hemoglobin, hematocrit, red 
blood cell count, white blood cell count, white blood cell differential, and platelet count). 
9.2.2 Serum Chemistry Profile 
Blood will be obtained as noted in the Schedule of Events and sent to each site’s clinical 
chemistry lab for determination of serum sodium, potassium, chloride, bicarbonate, random 
glucose, BUN, creatinine, calcium, ionized calcium, phosphate, magnesium, aspartate 
aminotransferase (AST/SGOT), alanine aminotransferase (ALT/SGPT), alkaline phosphatase, 
total bilirubin, direct bilirubin, gamma-glutamyl transferase (GGT), albumin and lactate 
dehydrogenase (LDH). 
Calcium, BUN, and creatinine may be checked more frequently at the discretion of the 
investigator. 
9.2.3 Pregnancy Test 
A serum or urine pregnancy test will be obtained from female subjects who are of childbearing 
potential as noted in the Schedule of Events. 
9.2.4  Urinalysis 
Urine will be obtained as noted in the Schedule of Events and sent to each site’s clinical 
laboratory for determination of color, specific gravity, pH, protein, glucose, ketones, and blood.  
9.3 
Pharmacokinetic Measurements 
Because of limited correlation between clinical efficacy and PK measurements done in the 
previous Phase 1b study in CF, only limited PK assessments will be made.  Expectorated sputum 
and blood (plasma) for determination of concentrations of gallium and iron will be collected pre-
dose and post-dose as detailed in the Table below: 
PK Collection Day 
Blood 
Sputum 
Day 1 
• 
Pre-dose 
• 
1hr (+/- 10 
minutes) post 
infusion start 
 
1 hr (+/- 10 minutes) 
post infusion start 
 
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PK Collection Day 
Blood 
Sputum 
Day 6 
Prior to infusion stop 
(+/- 10 minutes) 
 
Prior to infusion stop 
(+/-10 minutes) 
 
Day 14 
At visit 
At visit 
Day 28 
At visit 
At visit 
Day 56 
At visit 
At visit 
 
The blood will be processed for plasma as detailed in the Study Laboratory Manual.  All 
specimens will be labeled and placed immediately into a -70°C freezer.  All frozen specimens 
will be shipped at the specified time frames, as detailed in the Study Laboratory Manual, 
throughout the study to a central laboratory. 
 
Gallium and iron concentrations will be measured using inductively coupled plasma mass 
spectrometry (ICP-MS) done at a central laboratory.  
9.4 
Research Laboratory Measurements  
9.4.1 Sputum Culture 
Expectorated sputum will be collected for culture as noted in the Schedule of Events.  All 
sputum specimens should be collected in a sterile specimen cup, labeled, and shipped on ice 
overnight to a central laboratory for culture. Specimens will be processed within two (2) days of 
collection. Quantitative culture for typical P. aeruginosa and qualitative culture for other CF 
pathogens will be performed.  Detailed instructions for specimen collection, packaging, and 
shipping will be provided in the Study Laboratory Manual. 
9.4.1.1 Gallium Susceptibility Testing 
The CF pathogens (e.g., Haemophilus influenzae, Staphylococcus aureus, P. aeruginosa, 
Stenotrophomonas  maltophilia, and Achromobacter  xylosoxidans)  isolated from the subject’s  
sputum will be tested for susceptibility using Clinical and Laboratory Standard Institute (CLSI) 
broth microdilution methods.  Susceptibility will be performed using standard  low iron BM-2 
broth (for the Gram-negative organisms) or 1:8 diluted MHB (for the Gram-positive organisms).  
9.4.2 Plasma Collection for Assessment of Blood Cytokines and Chemokines  
Blood will be collected and processed for plasma as specified in the Schedule of Events. Detailed 
instructions will be provided in the Study Laboratory Manual.  The plasma aliquots will be 
placed immediately into a –70oC freezer for storage until shipment.  All frozen specimens will be 
shipped to a central laboratory at the specified time frames detailed in the Study Laboratory 
Manual throughout the study. 
 
A panel of cytokines and chemokines assays will be performed on plasma to evaluate 
inflammatory biomarkers in CF (e.g.,(43;44)(45) Granulocyte Colony Stimulating Factor 
(GCSF), Interleukin-1ra (IL1ra), IL6, Interleukin-8 (IL8), TNF-α, Transforming Growth Factor-
β1 (TGFβ1), Neutrophil elastase antiprotease complex  (PMNeL), highly sensitive C-Reactive 
Protein (hsCRP), Calprotectin, Arginase-1, and Serum Amyloid A (SAA)). 
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These assays will be performed at a central laboratory as specified in the Study Laboratory 
Manual. 
10 EVALUATIONS BY VISIT 
10.1 Screening/Baseline/Visit 1 (Day 1) 
Screening may occur on the morning of Day 1 prior to start of study drug. In this case, 
Screening, Baseline and Start of Treatment (Day 1) occur on the same day. Alternatively, 
Screening and Baseline/Day 1 may be separated into two visits as long as Screening takes place 
within 7 days of Baseline/Day 1.  
10.1.1 Visit 1 (Day 1) – Combined Screening / Baseline 
Screening/Pre-Dose Baseline (Day 1) 
1. 
Review the study with the subject (subject’s legal representative) and obtain written 
informed consent and HIPAA authorization. Ensure subject has opted in or out of CFF 
Registry ID collection. 
2. 
Assign the subject a unique subject number. 
3. 
Record demographics data. 
4. 
Record medical history, including a history of CF, diagnosis date, and prior CF treatments. 
5. 
Record concomitant medications. 
6. 
Administer CFRSD-CRISS. 
7. 
Record height and weight. 
8. 
Perform a complete physical examination.  
9. 
Perform and record vital signs. 
10. 
Perform and record oximetry. 
11. 
Collect blood for clinical laboratory tests (hematology and serum chemistry), pre-dose 
gallium and iron concentrations, cytokine and chemokine testing. 
12. 
Collect urine for urinalysis. 
13. Collect blood or urine for pregnancy test (if female of child-bearing potential).  
14. Perform and record spirometry. 
15. Collect baseline expectorated sputum for culture. 
16. Confirm all eligibility criteria when lab results received.  
17. Randomize subject. 
18. If existing long-term vascular access (e.g., a subcutaneous venous Port) is not available, 
place a midline catheter, PICC or peripheral IV. 
Post-Dose (Day 1) 
1. 
Initiate infusion and dispense study drug. 
2. 
Observe first six (6) hours of infusion. 
3. 
Administer and dispense subject diary. Dispense CFRSD-CRISS for Days 2-6. 
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4. 
Collect blood for gallium and iron levels one (1) hour (± 10 minutes) after initiation of 
study drug infusion.  
5. 
Collect expectorated sputum for gallium and iron levels one (1) hour (± 10 minutes) after 
initiation of study drug infusion. 
6. 
 Record any AEs. 
7. 
Instruct the subject to drink two liters of fluid per day during the infusion. 
8. 
Schedule subject for Visit 2 and remind them to return all study drug bags, the subject 
diary, and the CFRSD-CRISS at the next visit. 
10.1.2 Visit 1 (Day 1) – Separate Screening / Baseline  
Screening (-1 to -6 days) 
1. Review the study with the subject (subject’s legal representative) and obtain written informed 
consent and HIPAA authorization. Ensure subject has opted in or out of CFF Registry ID 
collection. 
2. Assign the subject a unique subject number. 
3. Record demographics data. 
4. Record medical history, including a history of CF, diagnosis date, and prior CF treatments. 
5. Record concomitant medications. 
6. Record height and weight. 
7. Perform a complete physical examination. 
8. Perform and record vital signs. 
9. Perform and record oximetry. 
10. Collect blood for clinical laboratory tests (hematology and serum chemistry)  
11. Collect urine for urinalysis. 
12. Collect blood or urine for pregnancy test (if female of child-bearing potential).  
13. Perform and record spirometry. 
14. Schedule subject to return to complete Visit 1. 
Pre-Dose Baseline (Day 1) 
1. Administer CFRSD-CRISS. 
2. Record interval medical history. 
3. Record concomitant medications. 
4. Record weight. 
5. Perform an abbreviated physical examination. 
6. Perform and record vital signs  
7. Perform and record oximetry. 
8. Collect blood for pre-dose gallium and iron concentrations, cytokine and chemokine testing. 
9. Collect blood or urine for pregnancy test (for female of childbearing potential). 
10. Perform and record spirometry. 
11. Collect baseline sputum for culture. 
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12. Confirm all eligibility criteria when lab results received.  
13. Randomize subject. 
14. If existing long-term vascular access (e.g., a subcutaneous venous Port) is not available, 
place a midline catheter, PICC, or peripheral IV. 
Post-Dose (Day 1) 
1. Initiate infusion and dispense study drug. 
2. Observe first six (6) hours of infusion. 
3. Administer and dispense subject diary. Dispense CFRSD-CRISS for Days 2-6 
4. Collect blood for gallium and iron levels one (1) hour (± 10 minutes) after initiation of study 
drug infusion.  
5. Collect expectorated sputum for gallium and iron levels one (1) hour (± 10 minutes) after 
initiation of study drug infusion.  
6. Record any AEs. 
7. Instruct the subject to drink two liters of fluid per day during the infusion. 
8. Schedule subject for Visit 2 and remind them to return all study drug bags, the subject diary, 
and CFRSD-CRISS at the next visit. 
10.2 Phone Call (Day 3) 
1. Review and record any AEs.  
2. Review subject’s fluid intake. 
3. Review the status of the subject’s study drug infusion and pump use. 
4. Remind the subject to return all study drug bags, the subject diary, and CFRSD-CRISS at the 
next visit. 
10.3 End of Treatment/Visit 2 (Day 6) 
With the exception of the CFRSD-CRISS administration and the blood and sputum samples for 
gallium and iron levels, the other Visit 2 procedures can be performed in any order in relation to 
the stop of the study drug infusion. 
1. If not already completed for the day, administer CFRSD-CRISS. 
2. Review subject diary. 
3. Collect and review CFRSD-CRISS from days 2-6. 
4. Record any AEs.  
5. Record changes to concomitant medications. 
6. Record weight. 
7. Perform abbreviated physical examination. 
8. Perform and record vital signs. 
9. Perform and record oximetry. 
10. Perform and record spirometry. 
11. Assess infusion of study drug and stop infusion. 
12. If applicable, remove the midline catheter, PICC, or peripheral IV.  
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13. Collect urine for urinalysis. 
14. Collect blood for laboratory tests (hematology and serum chemistry) and, within 10 minutes 
of the stop of the infusion, for gallium and iron levels. 
15. Collect expectorated sputum for gallium and iron levels within 10 minutes of the stop of the 
infusion. 
16. Collect returned study drug supplies and perform accountability 
17. Instruct the subject to drink two liters of fluid per day through Day 8. 
18. Dispense subject diary and remind subject to complete the diary through Day 8. 
19. Schedule subject for Visit 3. 
10.4 Visit 3 (Day 14 +/-2 days) 
1. Administer CFRSD-CRISS. 
2. Review subject diary. 
3. Record any AEs. 
4. Record changes to concomitant medications. 
5. Record weight. 
6. Perform abbreviated physical examination. 
7. Perform and record vital signs. 
8. Perform and record oximetry. 
9. Perform and record spirometry. 
10. Collect blood for clinical laboratory tests (hematology and serum chemistries) and for 
gallium and iron levels. 
11. Collect urine for urinalysis. 
12. Collect expectorated sputum for gallium and iron levels.   
13. Schedule subject for Visit 4 
10.5 Visit 4 (Day 28 +/- 3 days) 
1. Administer CFRSD-CRISS. 
2. Record any AEs. 
3. Record changes to concomitant medications. 
4. Record weight. 
5. Perform complete physical examination. 
6. Perform and record vital signs. 
7. Perform and record oximetry. 
8. Perform and record spirometry. 
9. Collect blood for clinical laboratory tests (hematology and serum chemistries), gallium and 
iron levels, and cytokine and chemokine testing. 
10. Collect urine for urinalysis.  
11. Collect blood or urine for pregnancy test (if female of child-bearing potential).  
12. Collect expectorated sputum for culture and gallium and iron levels. 
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13. Schedule subject for Visit 5. 
10.6 Visit 5 (Day 56 +/- 4 days) – Final Visit 
1. Administer CFRSD-CRISS. 
2. Record any AEs. 
3. Record changes to concomitant medications. 
4. Record weight. 
5. Perform complete physical examination. 
6. Perform and record vital signs. 
7. Perform and record oximetry. 
8. Perform and record spirometry. 
9. Collect blood or urine for pregnancy test (if female of child-bearing potential).  
10. Collect blood for gallium and iron levels, and  cytokine and chemokine testing. 
11. Collect expectorated sputum for culture and gallium and iron levels. 
10.7 Early Discontinuation of Study Drug  
With the exception of the CFRSD-CRISS administration and the blood and sputum samples for 
gallium and iron levels, the other procedures can be performed in any order in relation to the stop 
of the study drug infusion (if subject did not already stop infusion prior to visit). 
1. If not already completed for the day, administer CFRSD-CRISS. 
2. Review subject diary. 
3. Collect and review CFRSD-CRISS. 
4. Record any AEs.  
5. Record changes to concomitant medications. 
6. Record weight. 
7. Perform abbreviated physical examination. 
8. Perform and record vital signs. 
9. Perform and record oximetry. 
10. Perform and record spirometry. 
11. Assess infusion of study drug and stop infusion (if applicable). 
12. If applicable, remove the midline catheter, PICC, or peripheral IV. 
13. Collect urine for urinalysis. 
14. Collect blood for laboratory tests (hematology and serum chemistry) for gallium and iron 
levels (If infusion stopped at visit, collect within 10 minutes of the stop of the infusion. If 
infusion stopped prior to the visit, note the collection time). 
15. Collect expectorated sputum for gallium and iron levels (If infusion stopped at visit, collect 
within 10 minutes of the stop of the infusion. If infusion stopped prior to the visit, note the 
collection time). 
16. Collect returned study drug supplies and perform accountability. 
17. Instruct the subject to drink two liters of fluid per day for 2 more days. 
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18. Dispense subject diary and remind subject to complete the diary for 2 more days. 
19. Schedule subject for Visit 2 and proceed with the remaining study visits.  At Visit 2, conduct 
all procedures except for 10,11,15,16, and 17.   
11 ADVERSE EXPERIENCE REPORTING AND DOCUMENTATION 
11.1 Adverse Events 
An AE is any untoward medical occurrence in a clinical investigation of a patient administered a 
pharmaceutical product and that does not necessarily have a causal relationship with the 
treatment.  An AE is therefore any unfavorable and unintended sign (including an abnormal 
laboratory finding), symptom or disease temporally associated with the administration of an 
investigational product, whether or not related to that investigational product.  An unexpected 
AE is one of a type not identified in nature, severity, or frequency in the current Investigator’s 
Brochure or of greater severity or frequency than expected based on the information in the 
Investigator’s Brochure. 
The Investigator will probe, via discussion with the subject, for the occurrence of AEs during 
each subject visit and record the information in the site’s source documents.  AEs will be 
recorded in the patient CRF.  AEs will be described by duration (start and stop dates), severity, 
outcome, treatment, serious criteria, and relation to study medication. 
The investigator must continue to follow up on the AEs related to study drug until resolution or 
stability. 
AE Severity 
The National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE) 
Version 4.03, as modified for CF, should be used to assess and grade AE severity, including 
laboratory abnormalities judged to be clinically significant. The modified criteria can be found in 
the study manual.  If the AE is not covered in the modified criteria, the guidelines shown in 
Table 1 below should be used to grade severity.  It should be pointed out that the term “severe” is 
a measure of intensity and that a severe AE is not necessarily serious. 
Table 1.  AE Severity Grading 
Severity (Toxicity Grade) 
Description 
Mild (1) 
Mild; asymptomatic or mild symptoms; clinical or diagnostic 
observations only; intervention not indicated 
Moderate (2) 
Moderate; minimal, local or noninvasive intervention indicated; 
limiting age-appropriate Instrumental activities of daily living (e.g., 
preparing meals, using the telephone, managing money) 
Severe (3) 
Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; 
limiting self care activities of daily living (e.g., bathing, dressing, 
feeding self, using toilet, taking medications) 
Life-threatening (4) 
Life-threatening consequences; urgent intervention indicated 
Death (5) 
Death related to AE 
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AE Relationship to Study Drug 
The relationship of an AE to the study drug should be assessed using the following the guidelines 
in Table 2. 
Table 2.  AE Relationship to Study Drug 
Relationship 
to Drug 
Comment 
Definitely 
Previously known toxicity of agent; or an event that follows a reasonable temporal 
sequence from administration of the drug; that follows a known or expected response 
pattern to the suspected drug; that is confirmed by stopping or reducing the dosage of 
the drug; and that is not explained by any other reasonable hypothesis. 
Probably 
An event that follows a reasonable temporal sequence from administration of the 
drug; that follows a known or expected response pattern to the suspected drug; that is 
confirmed by stopping or reducing the dosage of the drug; and that is unlikely to be 
explained by the known characteristics of the subject’s clinical state or by other 
interventions. 
Possibly 
An event that follows a reasonable temporal sequence from administration of the 
drug; that follows a known or expected response pattern to that suspected drug; but 
that could readily have been produced by a number of other factors. 
Unrelated 
An event that can be determined with certainty to have no relationship to the study 
drug. 
11.2 Serious Adverse Experiences (SAE) 
An SAE is defined as any AE occurring at any dose that results in any of the following 
outcomes: 
• 
death 
• 
a life-threatening adverse experience 
• 
inpatient hospitalization or prolongation of existing hospitalization 
• 
a persistent or significant disability/incapacity 
• 
a congenital anomaly/birth defect  
Other important medical events may also be considered an SAE when, based on appropriate 
medical judgment, they jeopardize the subject or require intervention to prevent one of the 
outcomes listed.  
11.2.1 Serious Adverse Experience Reporting 
Study sites will document all SAEs that occur (whether or not related to study drug) on an SAE 
Report Form.  The collection period for all SAEs will begin after informed consent is obtained 
and end after procedures for the final study visit have been completed. 
All SAE Report Forms will be reviewed by the site investigator and sent to the TDNCC within 
one business day of the site learning of the event.  Sites will scan and email or fax the SAE 
report to: 
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Email address:  cfsaesfacsys@seattlechildrens.org 
Direct dial fax number:  206-985-3278 
The site will notify the TDNCC of additional information or follow-up to an initial SAE Report 
as soon as relevant information is available.  Follow-up information is reported on an SAE 
Report Form. 
SAEs will be reported to the DSMB in accordance with the Data Safety Monitoring Plan. 
In accordance with the standard operating procedures and policies of the local Institutional 
Review Board (IRB), the site investigator will report SAEs to the IRB.   
The Sponsor will report SAEs to the FDA in accordance with 21 CFR 312. 
11.3 Medical Monitoring 
The Medical Monitor for the TDNCC should be contacted directly at this number to report 
medical concerns or questions regarding safety. 
Pager : (800) 341-0961 
12 EARLY DISCONTINUATION OF STUDY DRUG, WITHDRAWAL AND 
REPLACEMENT OF SUBJECTS  
12.1 Discontinuation of Study Drug 
If a subject discontinues study drug early for any reason they should be encouraged to return for 
an Early Discontinuation of Study Drug Visit (Refer to section 10.6). Subjects will not be 
withdrawn from the study and will be encouraged to complete all remaining visits and 
procedures. 
If a subject discontinues study drug due to a related AE, the subject will be followed and treated 
by the Investigator until the abnormal parameter or symptom has resolved or stabilized.   
12.2 Withdrawal of Subjects from the Study 
All subjects are free to withdraw from participation at any time, for any reason, specified or 
unspecified, and without prejudice.  This may include subjects who discontinue study drug early 
and who decline to continue to come in for the remaining study visits 
Reasonable attempts will be made by the investigator to provide a reason for a subject’s 
withdrawal.  The reason for the subject’s withdrawal from the study will be specified in the 
subject’s source documents.  Subjects who withdraw from the study will be encouraged to come 
in for a final visit as follows: 
• If a subject withdraws prior to Day 6, they should come in for an Early Discontinuation of 
Study Drug Visit (Section 10.6). 
• If a subject withdraws on Day 6, they should come in for Visit 2 procedures (Section 10.2) 
• If a subject withdraws after Day 6, they should come in for Final Visit Procedures (Section 
10.5) 
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12.3 Replacement of Subjects 
Subjects who discontinue study drug early or withdraw from the study will not be replaced.   
13 PROTOCOL VIOLATIONS 
A protocol violation occurs when the subject, investigator or Sponsor fails to adhere to 
significant protocol requirements affecting the inclusion, exclusion, subject safety and primary 
endpoint criteria.  Protocol violations for this study include, but are not limited to, the following: 
• 
Failure to meet inclusion/exclusion criteria 
• 
Significant non-compliance with study drug regimen 
• 
Failure to perform spirometry at Day 1 or Visit 4 
• 
Use of a prohibited concomitant medication 
Failure to comply with Good Clinical Practice (GCP) guidelines will also result in a protocol 
violation. The lead Principal Investigator with consultation with the DSMB will determine if a 
protocol violation will result in withdrawal of a subject. 
When a protocol violation occurs, it will be discussed with the investigator and a Protocol 
Violation Form detailing the violation will be generated. This form will be signed by a Sponsor 
representative and the Investigator. A copy of the form will be filed in the site’s regulatory 
binder and in the Sponsor’s files.  The site will report the violation to their IRB in accordance 
with their IRB reporting requirements. 
14 DATA SAFETY MONITORING  
A DSMB will be established to monitor safety throughout the study, review interim safety 
analyses, and to ensure the continued scientific validity and merit of the study.  A DSMB Charter 
will be established for this protocol.  Summary reports tabulating SAEs by treatment group will 
be provided on a quarterly basis to the DSMB.  Comprehensive safety interim reports will be 
provided twice yearly to the DSMB and will include detailed summaries of all safety endpoints. 
The DSMB will recommend continuation or discontinuation of the study based on these interim 
reviews.   
15 STATISTICAL METHODS AND CONSIDERATIONS 
Prior to the analysis of the final study data, a detailed SAP will be written describing all analyses 
that will be performed.  The SAP will contain any modifications to the analysis plan described 
below.  Except where otherwise noted, all tests will be two-sided and statistical significance will 
be determined at the 0.05 level. 
15.1 Data Sets Analyzed 
Intent-to-Treat Population: All subjects who are randomized and has study drug infusion started 
will comprise the intent-to-treat (ITT) population.  The ITT population will be analyzed for the 
primary and secondary endpoint analyses and will comprise the safety population used for all 
safety analyses.   
Per Protocol Population: Subjects in the ITT population who have no protocol violations, 
received no bisphosphonates or inhaled chronic antibiotics from 7 days prior to Day 1 through 
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Day 28, and received gallium infusion for at least five sequential days. The per protocol 
population will be used in the sensitivity analyses of the primary and secondary endpoints. 
15.2 Demographic and Baseline Characteristics 
Treatment groups will be described and compared with respect to baseline demographic and 
clinical characteristics such as age, gender, race, ethnicity, genotype, height, weight, body mass 
index, microbiology, use of concomitant medications (hypertonic saline, dornase alpha, 
azithromycin) and pulmonary function.  Continuous measures will be analyzed using t-tests and 
categorical variables will be analyzed using chi-square,Fisher’s exact, or Cochran-Mantel-
Haenszel tests. 
15.3 Analysis of Primary Endpoint 
The primary endpoint is the difference between treatment groups in the proportion of subjects 
with a 5% or greater relative change from baseline to Day 28 of FEV1 measured in liters, 
calculated as: 
(Day 28 FEV1 – Day 1 FEV1)*100 
Day 1 FEV1 
To test the null hypothesis that there is no difference between the treatment groups, a two-sample 
test of proportions will be performed adjusted for baseline FEV1 strata.  The difference between 
treatment groups will be provided with associated 95% CI.  Additional analyses of the relative 
change in FEV1 through Day 56 will include the development of a mixed-effect model for 
repeated measures (MMRM). Adjusted means and 95% CIs will be presented for each visit.  
Treatment comparisons of the average response at each visit will be generated within the 
MMRM model based on the linear contrast of the average using the estimated least square means 
(LSMeans) at Days 14, 28, and 56. 
Missing data methods will be described in the SAP. 
15.4 Analysis of Secondary Endpoints 
Summary statistics (mean, standard deviation, median and range) of lung function parameters, 
sputum density, CFRSD-CRISS, and blood inflammatory markers for each visit and changes 
from baseline will be presented by treatment group.  Descriptive statistics will be used to 
summarize the proportion of subjects initiating acute antibiotics (by route) and differences in 
proportions between the study arms will be estimated with accompanying 95% CIs. 
 
Changes in lung function parameters (FVC in liters, FVC % predicted and FEV1 % predicted), 
sputum bacterial density, CFRSD-CRISS, and inflammatory markers will be analyzed using 
MMRM. Adjusted means and 95% CIs will be presented for each visit.  Treatment comparisons 
of the average response at each visit will be generated within the MMRM model based on the 
linear contrast of the average using the estimated LSMeans at Days 14, 28, and 56. 
A log transformation will be used in all analyses of quantitative sputum culture counts and blood 
inflammatory markers. Change in bacterial density will include only those subjects with the 
pathogen at baseline.  Additional descriptive analyses will be performed to summarize the 
disappearance and emergence of the pathogens and their susceptibility to gallium.   
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For those subjects randomized to receive IV gallium, we will determine of the Css and t1/2β by 
analyzing Days 1, 6, 14, 28 and 56. Clearance will be determined as the ratio of the infusion rate 
to the steady state concentration immediately prior to completion of the infusion.  The t1/2β  will 
be determined as 0.693/K where K is the elimination rate constant determined by the slope of the 
concentration/time curve after the infusion has been discontinued. To avoid unblinding, samples 
will only be assayed at the end of the completion of the trial. 
15.5 Analysis of Safety Endpoints 
All reported SAEs and AEs will be coded using MedDRA and grouped by body system.  SAEs 
and AEs will be tabulated by treatment group using standard coding terms sorted by body 
system.  The incidence of AEs in each treatment arm will be tabulated by seriousness, severity, 
and relationship to study drug.  If an AE is reported more than once during the study period for a 
given subject, the greatest severity and the worst-case relationship will be presented in tables.  
The number of SAEs and AEs will be summarized for each treatment group as follows: (i) The 
proportion of subjects with at least one (S)AE, (ii) The average number of (S)AEs per patient, 
and (iii) The rate of (S)AEs per patient week of follow-up.  Histograms showing the frequency of 
the number of (S)AEs in each treatment group will be included.  Rates of (S)AEs by System 
Organ Class (SOC) will be presented by treatment group.  Poisson regression modeling will be 
used to derive rate ratios and 95% CIs for each SOC.  The rate ratios will be compared using a 
two-sided 0.05 level test for Poisson count data.  
Safety lab data at each study visit and changes from baseline will be summarized by treatment 
group.  In addition, the following clinical laboratory summaries will be presented by treatment 
group: (i) the incidence of clinically significant abnormalities at each study visit; and (ii) tables 
summarizing the frequencies of subjects below, within, and above the normal reference ranges at 
baseline and end of study; and (iii) tables displaying baseline to end of study shifts in each 
laboratory value (shifts between below, within or above normal range).  
The proportion of subjects permanently discontinuing study drug will be tabulated by treatment 
group.  Drug discontinuation events will be categorized as:  (1) Permanently discontinued study 
drug and (2) Permanently discontinued study drug and withdrew from study. The reason for 
permanent drug discontinuation will be summarized.  
The number of hospitalization events and proportion of subjects hospitalized from baseline to 
Day 56 will be summarized and compared by treatment group.  Poisson regression modeling will 
be used to derive rate ratios and 95% CIs to compare hospitalization rates between treatment 
groups.   
15.6 Interim Analysis 
Comprehensive safety interim reports will be provided twice yearly to the DSMB, along with 
abbreviated quarterly reports.  Quarterly reports will include SAE tabulations by treatment 
group. Comprehensive, twice yearly safety reports will include detailed summaries of all SAEs, 
AEs, laboratory parameter listings, drug discontinuations and withdrawals as well as other 
pertinent safety data.  The DSMB will recommend continuation or discontinuation of the study 
based on these interim reviews.  Any interim analyses with respect to efficacy or futility will be 
outlined in the DSMB charter. 
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15.7 Sample Size and Randomization 
The primary endpoint is the difference between treatment groups in the proportion of subjects 
with a 5% or greater improvement in the relative change in FEV1 in liters from baseline to Day 
28.   A 5% or greater improvement in the relative change is well established as a minimum 
clinically important change by CF physicians based on the choice of the non-inferiority margin 
of 4% in a recent Phase 3 clinical trial (46) and the effect size of a number of key therapies 
utilized in CF (43;47-52). A responder-based endpoint is also an established approach for 
identifying efficacy on an individual patient level, as opposed to highly variable average changes 
across patients within a treatment group.  In the recently completed pilot study of gallium, 8 of 
11 (73%) experienced a 5% or greater relative change in FEV1 from baseline to Day 14 and 5 of 
11 (45%) experienced a 5% or greater relative change in FEV1 from baseline to Day 28.  There 
was no placebo group in the study; however, data from a completed randomized trial of 
azithromycin in subjects chronically infected with P. aeruginosa was used to estimate the 
expected responder rate among those receiving placebo (43).   In this study, the proportion of 
placebo subjects with a 5% or greater relative improvement in FEV1 ranged from 28% to 33% 
across study visits from Day 28 through Day 84.  Thus, the expected treatment difference in this 
study is between approximately 15% and 45% based on the observed response rates from the 
gallium pilot study.  However, it is felt that the minimum clinically important difference between 
groups is based on clinician opinion is 30% given the treatment burden of an intravenous therapy 
(e.g., increasing the responder rate from 30% to 60%).  With a sample size of 60 per group and 
assuming a responder rate of 30% in the placebo group, the study has 90% power to detect a 
28.3% or greater improvement in the responder rate.  Accounting for an attrition rate of 10% and 
interim analyses, the study will still have 90% power to detect a treatment difference of 30.0% or 
greater between groups.   
A key secondary endpoint is the difference between treatment groups in the average relative 
change in FEV1 from baseline (Day 1) to Day 28.  Based on estimates from prior CF clinical 
trials among CF patients chronically infected with P. aeruginosa, the expected standard 
deviation of the relative change over a 28 day period ranges from 9 – 23 (43;53).   A two-sided 
.05 level two-sample t-test will be used to test for differences between treatment groups with 
respect to the 28 day relative change.  With a sample size of 60 per group and a standard 
deviation as low as 9 or as high as 23, the study would have 90% power to detect a minimum of 
5.4% or 13.7% difference in the 28 day relative change between treatment groups, respectively. 
Additionally, the study has 90% power to detect a 0.78 log difference between treatment groups 
with respect to change in bacterial density assuming a standard deviation of 1.3 based on prior 
studies in CF(43). 
Study personnel at the investigative site will use the Medidata Rave® and Balance™ systems to 
randomize each subject. Medidata Balance™ is a dynamic randomization and trial supply 
management solution that is fully unified with the Rave® EDC system. An adaptive 
randomization (dynamic allocation based on minimization) (54) will be employed with the goal 
of ensuring equal representation in each study arm based on lung function (FEV1). Subjects will 
be randomly assigned in a 1:1 ratio to one of two arms: (1) IV placebo infusion, or (2) IV 
gallium nitrate solution.  Subject randomization will be stratified by baseline FEV1 group (FEV1 
< 50% of predicted, 50-70% of predicted and >70% of predicted).  The dynamic allocation 
algorithm seeks to optimize randomization balance by minimizing a weighted average of the 
marginal imbalance of treatment allocation for each factor and for the study overall (55). A 
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random element is added to the otherwise deterministic minimization algorithm to reduce 
allocation predictability by using a biased coin (56) to include a chance of allocation to a 
treatment arm other than the arm that optimizes balance.  Access to the randomization code will 
be strictly controlled and limited to select members of the Biostatistics and Clinical Data 
Management unit at the TDNCC and the central pharmacy.   
16   DATA COLLECTION, RETENTION AND MONITORING 
16.1 Data Collection Instruments 
An electronic data capture system will be utilized for collection of study data.  The Investigator 
will prepare and maintain adequate and accurate source documents designed to record all 
observations and other pertinent data for each subject who signs informed consent.   
Study personnel at each site will enter data from source documents corresponding to a subject’s 
visit into the protocol-specific CRFs when the information corresponding to that visit is 
available.  Subjects will not be identified by name in the study database or on any study 
documents to be collected by the sponsor (or designee), but will be identified by a site number, 
subject number and initials. 
 If a correction is required for a CRF, the time and date stamp tracks the person entering or 
updating CRF data and creates an electronic audit trail.   
The Investigator is responsible for all information collected on subjects enrolled in this study.  
All data collected during the course of this study must be reviewed and verified for completeness 
and accuracy by the Investigator.  A copy of the CRF will remain at the Investigator’s site at the 
completion of the study. 
16.2 Data Management Procedures 
The data will be entered into a validated database.  The Biostatistics and Clinical Data 
Management group will be responsible for data processing, in accordance with agreed 
procedures.  Database lock will occur once quality assurance procedures have been completed. 
All procedures for the handling and analysis of data will be conducted using good computing 
practices meeting FDA guidelines for the handling and analysis of data for clinical trials. 
16.3 Data Quality Control and Reporting 
After data have been entered into the study database, a system of computerized data validation 
checks will be implemented and applied to the database on a regular basis.  Queries are entered, 
tracked, and resolved through the EDC system directly.  The study database will be updated in 
accordance with the resolved queries.  All changes to the study database will be documented in 
an audit trail. 
16.4 Security and Archival of Data 
The EDC system is hosted by Medidata; the data are stored at Medidata’s primary data center in 
Houston, Texas, with fail-safe data centers in New Jersey.  Data are regularly backed up by 
Medidata and stored with Iron Mountain. 
Medidata maintains 21 CFR Part 11-compliant electronic systems, with procedures in place to 
safeguard against unauthorized acquisition of data.  Any authorized communication with the 
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Medidata servers at the Houston Data Center is conducted via SSL (128-bit) encryption.  Robust 
password procedures, consistent with 21 Part 11, are in place.  Robust physical security 
procedures are in place at the Houston Data Center to prevent unauthorized personnel physical 
access to the server rooms.  EDC account access is maintained and monitored by the Biostatistics 
and Clinical Data Management unit at the TDNCC 
Other databases will be stored on Seattle Children’s servers and are safeguarded against 
unauthorized access by established security procedures.  Network accounts are password 
protected and maintained and monitored by the Seattle Children’s Information Services group.  
Data is backed up regularly according to the Information Technology group’s procedures.  
16.5 Availability and Retention of Investigational Records 
The Investigator must make study data accessible to the monitor, other authorized 
representatives of the Sponsor (or designee), IRB, and Regulatory Agency (e.g., FDA) inspectors 
upon request.  A file for each subject must be maintained that includes the signed Informed 
Consent and HIPAA Authorization and copies of all source documentation related to that 
subject.  The Investigator must ensure the reliability and availability of source documents from 
which the information on the CRF was derived. 
All study documents (e.g., patient files, signed informed consent forms, copies of CRFs, Study 
Essential Documents) must be kept secured for a period of 2 years following marketing of the 
investigational product or for 2 years after centers have been notified that the IND has been 
discontinued.  There may be other circumstances for which the Sponsor is required to maintain 
study records and, therefore, the Sponsor should be contacted prior to removing study records for 
any reason. 
16.6 Monitoring 
Monitoring visits will be conducted by representatives of the Sponsor according to the U.S. CFR 
Title 21 Part 312 and ICH Guidelines for GCP (E6) and to ensure investigator compliance to 21 
CFR Parts 50, 56 and 312 and to GCP.  By signing this protocol, the Investigator grants 
permission to the Sponsor (or designee) and appropriate regulatory authorities to conduct on-site 
monitoring and/or auditing of all appropriate study documentation. 
16.7 Subject Confidentiality 
In order to maintain subject confidentiality, only a site number, subject number and subject 
initials will identify all study subjects on CRFs and other documentation submitted to the 
Sponsor.  If specific consent is given, the subject’s CFF patient registry number will also be 
collected.  Additional subject confidentiality issues (if applicable) are covered in the Clinical 
Study Agreement. 
17 ADMINISTRATIVE, ETHICAL, REGULATORY CONSIDERATIONS 
The study will be conducted according to the Declaration of Helsinki, Protection of Human 
Volunteers (21 CFR 50), Institutional Review Boards (21 CFR 56), and Obligations of Clinical 
Investigators (21 CFR 312). 
To maintain confidentiality, all evaluation forms, reports and other records will be identified by a 
coded number and initials only.  All laboratory specimens will be identified by a coded number. 
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All study records will be kept in a locked file cabinet and code sheets linking a patient’s name to 
a patient identification number will be stored separately in another locked file cabinet.  Clinical 
information will not be released without written permission of the subject, except as necessary 
for monitoring by the FDA.  The Investigator must also comply with all applicable privacy 
regulations (e.g., Health Insurance Portability and Accountability Act of 1996, EU Data 
Protection Directive 95/46/EC). 
17.1 Protocol Amendments 
Any amendment to the protocol will be written by the Sponsor. Protocol amendments cannot be 
implemented without prior written IRB approval except as necessary to eliminate immediate 
safety hazards to subjects.  A protocol amendment intended to eliminate an apparent immediate 
hazard to subjects may be implemented immediately, provided the IRBs are notified within five 
working days. 
17.2 Institutional Review Boards  
The protocol and consent form will be reviewed and approved by the IRB of each participating 
center prior to study initiation.  SAEs regardless of causality will be reported to the IRB in 
accordance with the standard operating procedures and policies of the IRB. The Investigator will 
keep the IRB informed as to the progress of the study.  The Investigator will obtain assurance of 
IRB compliance with regulations. 
Any documents that the IRB may need to fulfill its responsibilities (such as protocol, protocol 
amendments, Investigator’s Brochure, consent forms, information concerning subject 
recruitment, payment or compensation procedures, or other pertinent information) will be 
submitted to the IRB.  The IRB’s written unconditional approval of the study protocol and the 
informed consent form will be in the possession of the Investigator before the study is initiated.  
The IRB’s unconditional approval statement will be transmitted by the Investigator to the 
Sponsor prior to the shipment of study supplies to the site.  This approval must refer to the study 
by exact protocol title and number and should identify the documents reviewed and the date of 
review. 
Protocol and/or informed consent modifications or changes may not be initiated without prior 
written IRB approval except when necessary to eliminate immediate hazards to the subjects or 
when the change(s) involves only logistical or administrative aspects of the study.  Such 
modifications will be submitted to the IRB and written verification that the modification was 
submitted and subsequently approved should be obtained.   
The IRB must be informed of revisions to other documents originally submitted for review; 
serious and/or unexpected adverse experiences occurring during the study in accordance with the 
standard operating procedures and policies of the IRB; new information that may affect 
adversely the safety of the subjects or the conduct of the study; an annual update and/or request 
for re-approval; and when the study has been completed. 
17.3 Informed Consent Form  
Informed consent will be obtained in accordance with the Declaration of Helsinki, ICH GCP, US 
Code of Federal Regulations for Protection of Human Subjects (21 CFR 50.25[a,b], CFR 50.27, 
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and CFR Part 56, Subpart A), the Health Insurance Portability and Accountability Act (HIPAA, 
if applicable), and local regulations. 
The Investigator will prepare the informed consent form and HIPAA authorization and provide 
the documents to the Sponsor or designee for approval prior to submission to the IRB.  The 
consent form generated by the Investigator must be acceptable to the Sponsor and be approved 
by the IRB.  The written consent document will embody the elements of informed consent as 
described in the International Conference on Harmonisation and will also comply with local 
regulations. The Investigator will send an IRB-approved copy of the Informed Consent Form to 
the Sponsor (or designee) for the study file. 
A properly executed, written, informed consent will be obtained from each subject (or legal 
representative) prior to entering the subject into the trial.  Information should be given in both 
oral and written form and subjects (or their legal representatives) must be given ample 
opportunity to inquire about details of the study.  If a subject is unable to sign the informed 
consent form (ICF) and the HIPAA authorization, a legal representative may sign for the subject.   
A copy of the signed consent form will be given to the subject or legal representative of the 
subject and the original will be maintained with the subject’s records. 
During the course of the study, if modifications are made to the consent form that impact the 
subject, the subject will be re-consented as described above.  
17.4 Publications  
The preparation and submittal for publication of manuscripts containing the study results shall be 
in accordance with a process determined by mutual written agreement among the study Sponsor 
and participating institutions.  The publication or presentation of any study results shall comply 
with all applicable privacy laws, including, but not limited to, the Health Insurance Portability 
and Accountability Act of 1996.  
17.5 Investigator Responsibilities 
By signing the Agreement of Investigator form, the Investigator agrees to: 
1. Conduct the study in accordance with the protocol and only make changes after notifying 
the Sponsor (or designee), except when to protect the safety, rights or welfare of subjects. 
2. Personally conduct or supervise the study (or investigation). 
3. Ensure that the requirements relating to obtaining informed consent and IRB review and 
approval meet federal guidelines, as stated in § 21 CFR, parts 50 and 56. 
4. Report to the Sponsor or designee any AEs that occur in the course of the study, in 
accordance with §21 CFR 312.64. 
5. Ensure that all associates, colleagues and employees assisting in the conduct of the study are 
informed about their obligations in meeting the above commitments. 
6. Maintain adequate and accurate records in accordance with §21 CFR 312.62 and to make 
those records available for inspection with the Sponsor (or designee). 
7. Ensure that an IRB that complies with the requirements of §21 CFR part 56 will be 
responsible for initial and continuing review and approval of the clinical study. 
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8. Promptly report to the IRB and the Sponsor (or designee) all changes in the research activity 
and all unanticipated problems involving risks to subjects or others (to include amendments 
and IND safety reports). 
9. Seek IRB approval before any changes are made in the research study, except when 
necessary to eliminate hazards to the patients/subjects. 
10. Comply with all other requirements regarding the obligations of clinical investigators and all 
other pertinent requirements listed in § 21 CFR part 312. 
Reference List 
 
 
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(3)  Gibson RL, Burns JL, Ramsey BW. Pathophysiology and management of pulmonary 
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malignant lymphoma using gallium nitrate administered as a seven-day continuous 
infusion. Cancer 1983; 51(11):1982-1987. 
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clinical studies with gallium nitrate. Cancer Treat Rep 1978; 62(10):1449-1453. 
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 (25)  Watson ME, Jr., Burns JL, Smith AL. Hypermutable Haemophilus influenzae with 
mutations in mutS are found in cystic fibrosis sputum. Microbiology 2004; 150(Pt 
9):2947-2958. 
 (26)  Prunier AL, Malbruny B, Laurans M, Brouard J, Duhamel JF, Leclercq R. High rate of 
macrolide resistance in Staphylococcus aureus strains from patients with cystic fibrosis 
reveals high proportions of hypermutable strains. J Infect Dis 2003; 187(11):1709-1716. 
 (27)  Jackson K, Keyser R, Wozniak DJ. The role of biofilms in airway disease. Semin Respir 
Crit Care Med 2003; 24(6):663-670. 
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 (28)  Yee L, Binuraj A, Ohtake S, Saxena A, Pham B, Patzer E et al. Pharmacokinetics, acute 
inhalation toxicology, and bactericidal activities of anti-intective PANAECINTM 
(Gallium nitrate citrate). Pediatr Pulm 2010; S33:A368. 
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T-cell responses by transferrin-gallium and gallium nitrate. Blood 1996; 88(8):3056-
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B-lymphocyte lines in high versus low iron concentrations. Cancer Res 1990; 
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 (31)  Makkonen N, Hirvonen MR, Savolainen K, Lapinjoki S, Monkkonen J. The effect of free 
gallium and gallium in liposomes on cytokine and nitric oxide secretion from 
macrophage-like cells in vitro. Inflamm Res 1995; 44(12):523-528. 
 (32)  NIOSH. Registry of Toxic Chemical Substances. Registry of Toxic Effects of chemical 
Substances (RTECS).  2001.  
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of gallium nitrate. Cancer 1979; 44(5):1722-1727. 
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of cancer-related hypercalcemia: clinicopharmacological and dose response analysis. 
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inhibits calcium resorption from bone and is effective treatment for cancer-related 
hypercalcemia. J Clin Invest 1984; 73(5):1487-1490. 
 (39)  Chitambar CR, Zahir SA, Ritch PS, Anderson T. Evaluation of continuous-infusion 
gallium nitrate and hydroxyurea in combination for the treatment of refractory non-
Hodgkin's lymphoma. Am J Clin Oncol 1997; 20(2):173-178. 
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trial of gallium nitrate in patients with androgen-metastatic prostate cancer. Urol Int 
1999; 63(2):120-125. 
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 (41)  Chang AY, Reid R, Headlee D, Abornathy T, Horti J, Lush RM et al. Phase II trial of 
gallium nitrate, amonafide and teniposide in metastatic non-small cell lung cancer. An 
Eastern Cooperative Oncology Group study (E2588). Invest New Drugs 1995; 13(2):137-
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 (42)  Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of 
the general U.S. population. Am J Respir Crit Care Med 1999; 159(1):179-187. 
 (43)  Saiman L, Marshall BC, Mayer-Hamblett N, Burns JL, Quittner AL, Cibene DA et al. 
Azithromycin in patients with cystic fibrosis chronically infected with Pseudomonas 
aeruginosa: a randomized controlled trial. JAMA 2003; 290(13):1749-1756. 
 (44)  Ratjen F, Saiman L, Mayer-Hamblett N, Lands LC, Kloster M, Thompson V et al. Effect 
of azithromycin on systemic markers of inflammation in cystic fibrosis patients 
uninfected with Pseudomonas aeruginosa. Chest 2012. 
 (45)  Zemanick ET, Harris JK, Nikrad MP, Stewart A, Williams SA, Sagel SD et al. 
Identification of circulating biomarkers of pulmonary exacerbation using multiplex 
somamer assay. Pediatr Pulmonol 34, 241. 2011.  
 (46)  Assael BM, Pressler T, Bilton D, Fayon M, Fischer R, Chiron R et al. Inhaled 
aztreonam lysine vs. inhaled tobramycin in cystic fibrosis: a comparative efficacy 
trial. J Cyst.Fibros. (in press). 2012.  
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Effect of aerosolized recombinant human DNase on exacerbations of respiratory 
symptoms and on pulmonary function in patients with cystic fibrosis. The Pulmozyme 
Study Group. N Engl J Med 1994; 331(10):637-642. 
 (48)  Ramsey BW, Pepe MS, Quan JM, Otto KL, Montgomery AB, Williams-Warren J et al. 
Intermittent administration of inhaled tobramycin in patients with cystic fibrosis. Cystic 
Fibrosis Inhaled Tobramycin Study Group. N Engl J Med 1999; 340(1):23-30. 
 (49)  Elkins MR, Robinson M, Rose BR, Harbour C, Moriarty CP, Marks GB et al. A 
controlled trial of long-term inhaled hypertonic saline in patients with cystic fibrosis. N 
Engl J Med 2006; 354(3):229-240. 
 (50)  McCoy KS, Quittner AL, Oermann CM, Gibson RL, Retsch-Bogart GZ, Montgomery 
AB. Inhaled aztreonam lysine for chronic airway Pseudomonas aeruginosa in cystic 
fibrosis. Am J Respir Crit Care Med 2008; 178(9):921-928. 
 (51)  Retsch-Bogart GZ, Burns JL, Otto KL, Liou TG, McCoy K, Oermann C et al. A phase 2 
study of aztreonam lysine for inhalation to treat patients with cystic fibrosis and 
Pseudomonas aeruginosa infection. Pediatr Pulmonol 2008; 43(1):47-58. 
 (52)  Retsch-Bogart GZ, Quittner AL, Gibson RL, Oermann CM, McCoy KS, Montgomery 
AB et al. Efficacy and safety of inhaled aztreonam lysine for airway pseudomonas in 
cystic fibrosis. Chest 2009; 135(5):1223-1232. 
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 (53)  Ramsey BW, Pepe MS, Quan JM, Otto KL, Montgomery AB, Williams-Warren J et al. 
Intermittent administration of inhaled tobramycin in patients with cystic fibrosis. Cystic 
Fibrosis Inhaled Tobramycin Study Group. N Engl J Med 1999; 340(1):23-30. 
 (54)  Pocock SJ, Simon R. Sequential treatment assignment with balancing for prognostic 
factors in the controlled clinical trial. Biometrics 1975; 31(1):103-115. 
 (55)  Han B, Enas NH, McEntegart D. Randomization by minimization for unbalanced 
treatment allocation. Stat Med 2009; 28(27):3329-3346. 
 (56)  Brown S, Thorpe H, Hawkins K, Brown J. Minimization--reducing predictability for 
multi-centre trials whilst retaining balance within centre. Stat Med 2005; 24(24):3715-
3727. 
 
 
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18 APPENDIX 1.  SCHEDULE OF EVENTS 
Combined Screening/Baseline Schedule of Events  
Task/Procedure 
Visit 1a 
Day 1 
Phone Call 
Day 3 
Visit 2 
Day 6b 
Visit 3 
Day 14 
 (+/- 2 
days)  
Visit 4 
Day 28  
(+/- 3 days) 
Visit 5 
Day 56  
(+/- 4 days) 
(FINAL 
VISIT) c 
Early 
Discontinu
ation of 
Study 
Drug d 
Screening/ 
Pre-Dose 
Baseline 
Post-
Dose 
Follow-up 
Informed Consent 
X 
 
 
 
 
 
 
 
CFRSD-CRISS Administration e 
X 
 
 
X 
X 
X 
X 
X 
Medical History and Demographics 
X 
 
 
 
 
 
 
 
Adverse Events Review 
 
X 
X 
X 
X 
X 
X 
X 
Concomitant Medication Review 
X 
 
 
X 
X 
X 
X 
X 
Height 
X 
 
 
 
 
 
 
 
Weight 
X 
 
 
X 
X 
X 
X 
X 
Complete Physical Exam 
X 
 
 
 
 
X 
X 
 
Abbreviated Physical Exam 
 
 
 
X 
X 
 
 
X 
Vital Signs  
X 
 
 
X 
X 
X 
X 
X 
Oximetry 
X 
 
 
X 
X 
X 
X 
X 
Spirometry 
X 
 
 
X 
X 
X 
X 
X 
Serum chemistry and Hematology 
Performed at Site Lab 
X 
 
 
X 
X 
X 
 
X 
Blood Collection for Gallium and Iron 
Levels 
Xf 
Xf 
 
Xg 
X 
X 
X 
Xh 
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Task/Procedure 
Visit 1a 
Day 1 
Phone Call 
Day 3 
Visit 2 
Day 6b 
Visit 3 
Day 14 
 (+/- 2 
days)  
Visit 4 
Day 28  
(+/- 3 days) 
Visit 5 
Day 56  
(+/- 4 days) 
(FINAL 
VISIT) c 
Early 
Discontinu
ation of 
Study 
Drug d 
Screening/ 
Pre-Dose 
Baseline 
Post-
Dose 
Follow-up 
Blood Collection for Cytokines and 
Chemokines 
X 
 
 
 
 
X 
X 
 
Pregnancy Test (urine or serum) 
X 
 
 
 
 
X 
X 
 
Urine Collection for Urinalysis 
Performed at Site Lab 
X 
 
 
X 
X 
X 
 
X 
Collect Expectorated Sputum for 
Microbiology 
Xi 
 
 
 
 
X 
X 
 
Collect Expectorated Sputum for 
Gallium and Iron Levels 
 
Xf 
 
Xg 
X 
X 
X 
Xh 
Randomize subject 
X 
 
 
 
 
 
 
 
Obtain venous access j 
X 
 
 
 
 
 
 
 
Study drug administration k 
 
START 
 
STOP 
 
 
 
STOPl 
Six-Hour Observation 
 
X 
 
 
 
 
 
 
Dispense Subject Diary m 
 
X 
 
X 
 
 
 
X 
Review Subject Diary M 
 
 
 
X 
X 
 
 
X 
Review fluid intake and assess status 
of study drug infusion and pump use 
 
 
X 
 
 
 
 
 
Remove Venous Access 
 
 
 
X 
 
 
 
X 
Collect/Count Returned Study Drug 
Supplies 
 
 
 
X 
 
 
 
X 
 
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Separate Screening/Baseline Schedule of Events  
Task/Procedure 
Visit 1a 
(-1 to -6 days) 
Visit 1 
Day 1 
Visits 2 – Visits 5 & Early 
Discontinuation of Study 
Drug 
Refer to Combined 
Screening/Baseline 
Schedule of Events 
Screening 
Pre-Dose 
Baseline 
Post-
Dose 
Informed Consent 
X 
 
 
 
CFRSD-CRISS Administration e 
 
X 
 
 
Medical History and Demographics 
X 
Xn 
 
 
Adverse Events Review  
 
 
X 
 
Concomitant Medication Review 
X 
X 
 
 
Height 
X 
 
 
 
Weight 
X 
X 
 
 
Complete Physical Exam 
X 
 
 
 
Abbreviated Physical Exam 
 
X 
 
 
Vital Signs  
X 
X 
 
 
Oximetry 
X 
X 
 
 
Spirometry 
X 
X 
 
 
Serum Chemistry and Hematology 
Performed at Site Lab 
X 
 
 
 
Blood Collection for Gallium and Iron 
Levels 
 
Xf 
Xf 
 
Blood Collection for Cytokines and 
Chemokines 
 
X 
 
 
Pregnancy Test (urine or serum) 
X 
X 
 
 
Urine Collection for Urinalysis at 
Performed Site Lab 
X 
 
 
 
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Task/Procedure 
Visit 1a 
(-1 to -6 days) 
Visit 1 
Day 1 
Visits 2 – Visits 5 & Early 
Discontinuation of Study 
Drug 
Refer to Combined 
Screening/Baseline 
Schedule of Events 
Screening 
Pre-Dose 
Baseline 
Post-
Dose 
Collect Expectorated Sputum for 
Microbiology 
 
Xg 
 
 
Collect Expectorated Sputum for PK 
 
 
Xg 
 
Randomize subject 
 
X 
 
 
Obtain Venous Access 
 
X 
 
 
Study drug administration K 
 
 
START 
 
Six-Hour Observation 
 
 
X 
 
Dispense Subject Diary m 
 
 
X 
 
 
a Screening may occur on the morning of Day 1 prior to start of study drug. In this case, Screening, Baseline and Start of Treatment (Day 1) occur on the same day. Alternatively, 
Screening and Baseline/Day 1 may be separated into two visits as long as Screening takes place within 7 days of Baseline/Day 1.  
b Visit 2 should be scheduled at approximately the same time as Visit 1 as the study drug should be stopped at approximately the same time of day as it was started. 
c Subjects who withdraw from the study should be encouraged to come in for final visit procedures as described in section 12.2. 
d  Subjects who discontinue the study drug early, should be encouraged to come in for the Early Discontinuation of Study Drug Visit (Section 10.6) and then proceed with all the 
remaining study visits. At Visit 2, perform all study procedures except for stopping the study drug administration, dispensing the subject diary, and collecting/counting returned 
study drug supplies (as these procedures will be performed as part of the Early Discontinuation of Study Drug Visit). 
e The CFRSD-CRISS diary will be completed daily from Day 1 through Day 6 and then again at Visits 3, 4, and 5. 
f  Day 1 blood for gallium and iron levels: pre-dose, and 1 hour (+/- 10 minutes)  after initiating study drug infusion and Day 1 expectorated sputum for gallium and iron levels: 1 
hour (+/- 10 minutes) after initiating study drug infusion. 
g Day 6 blood and sputum for gallium levels: prior to infusion stop (+/- 10 minutes)    
h Early discontinuation of study drug for gallium and iron levels:  If infusion stopped at visit, collect within 10 minutes of the stop of the infusion. If infusion stopped prior to the 
visit, note the collection time. 
i Sputum for microbiology should be collected on Day 1 prior to the start of study drug. If Screening is done prior to Day 1, do not collect sputum for microbiology at Screening. 
j If existing long-term vascular access (e.g., a subcutaneous venous Port) is not available, place a midline catheter, peripherally inserted central catheter (PICC), or peripheral IV.   
k Study drug is initiated on Day 1 in clinic and will continue into Day 6 (for 5 full days of administration) in clinic or outpatient.   Whether inpatient, outpatient, or a combination of 
both, the infusion should continue for 5 days uninterrupted except for brief interruptions. The specifics of administration (pump type, bag vs. syringe, inpatient vs. outpatient) can 
be determined by each site according to institutional policy.  
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l If infusion was not stopped prior to the visit. 
m A Subject Diary will be maintained from Day 1 to 8.  Infusion start and stop times will be documented from Day 1 to Day 6. Fluid intake will be documented from Day 1 through 
Day 8.  
n Medical History review is performed at the pre-dose baseline portion of Visit 1. 
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