Stopping TSC Onset and Progression 2: Epilepsy Prevention in TSC Infants
Phase: PHASE1
Conditions: Tuberous Sclerosis Complex, Epilepsy
Sponsor: Children's Hospital Medical Center, Cincinnati

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Protocol Title 
 
 
 
Stopping TSC Onset and Progression 2A: Epilepsy Prevention in TSC Infants 
 
 
 
Protocol Version: 7.0 
 
Protocol Date: May 11, 2022 
 
IND# 145820 
 
IND Sponsor/Lead Principal Investigator: Darcy A. Krueger, M.D. Ph.D. 
Cincinnati Children’s Hospital  
3333 Burnet Avenue 
Cincinnati, OH 45229  
Phone: 513.636.4222 
Fax: 513.636.1888 
Darcy.Krueger@cchmc.org  
 
NCT# 04595513 
 
 
 
   
 
 
 

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LEAD PRINCIPAL INVESTIGATOR:  
 
Darcy Krueger, M.D., Ph.D. 
Cincinnati Children’s Hospital  
 
 
CO- INVESTIGATORS:  
 
David Neal Franz, M.D. 
Cincinnati Children’s Hospital 
 
Hans Greiner, M.D. 
Cincinnati Children’s Hospital 
 
David M. Ritter, M.D. 
Cincinnati Children’s Hospital  
 
Jamie K. Capal, M.D. 
University of North Carolina at Chapel Hill 
 
Alexander A. (Sander) Vinks, Ph.D., Pharm.D., FCP 
Cincinnati Children’s Hospital 
 
Simon Warfield, Ph.D. 
Boston Children’s Hospital  
 
Paul S. Horn, Ph.D. 
Cincinnati Children’s Hospital 
 
 
 
INDEPENDENT MEDICAL MONITOR: 
 
Katie Holland, M.D. Ph.D. 
Cincinnati Children’s Hospital 
 
 
INDEPENDENT DOSING PHYSICIANS: 
 
Carlos Prada, M.D. 
Lurie Children’s Hospital 
 
Kelly Kremer, M.D. 
Cincinnati Children’s Hospital 
 
 

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TAVT-18 (SIROLIMUS) POWDER FOR ORAL SOLUTION SUPPLIER: 
 
Tavanta Therapeutics, Inc. 
101 E. Baltimore Ave, #602 
Media, PA  19063, USA 
 
 

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DISCLOSURE STATEMENT 
 
Restricted Distribution of Documents 
 
This document contains information that is confidential and proprietary to the Lead PIs. This 
information is being provided to you solely for the purpose of evaluating and/or conducting a 
clinical study for the Lead PIs. You may disclose the contents of this document only to study 
personnel under your supervision, institutional review boards (IRBs)/independent ethics 
committees (IECs), or duly authorized representatives of regulatory agencies for this purpose 
under the condition that they maintain confidentiality. The contents of this document may not be 
used in any other clinical study, disclosed to any other person or entity, or published without the 
prior written permission of the Lead PIs. The foregoing shall not apply to disclosure required by 
any regulations; however, you will give prompt notice to the Lead PIs of any such disclosure. All 
other nonpublic information provided by the Lead PIs, as well as any information that may be 
added to this document, also is confidential and proprietary to the Lead PIs and must be kept in 
confidence in the same manner as the contents of this document. 
 
 

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V. 7.0 SPONSOR SIGNATURE 
 
 
I have read and approve this protocol. My signature, in conjunction with the signature of the 
investigator, confirms the agreement of both parties that the clinical study will be conducted in 
accordance with the protocol and all applicable laws and regulations including, but not limited 
to, the International Conference on Harmonisation Guideline for Good Clinical Practice (GCP), 
the Code of Federal Regulations (CFR), the ethical principles that have their origins in the 
Declaration of Helsinki, and applicable privacy laws. 
 
 
 
 
_________________________________ 
________________________ 
Sponsor Signature 
 
 
 
 
Date 
 
 
 
___________________________ 
Sponsor Name and Title (Print) 
 
 

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V. 7.0 INVESTIGATOR SIGNATURE 
 
 
I have read and understand this protocol. My signature, in conjunction with the signature of the 
sponsor, confirms the agreement of both parties that the clinical study will be conducted in 
accordance with the protocol and all applicable laws and regulations including, but not limited 
to, the International Conference on Harmonisation Guideline for Good Clinical Practice (GCP), 
the Code of Federal Regulations (CFR), the ethical principles that have their origins in the 
Declaration of Helsinki, and applicable privacy laws. 
 
Nothing in this document is intended to limit the authority of a physician to provide emergency 
medical care under applicable regulations. 
 
 
 
 
_________________________________ 
________________________ 
Investigator Signature  
 
 
Date 
 
___________________________ 
Investigator Name and Title (Print) 
 
___________________________ 
Institution (Print) 
 
 
 
 
 

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TABLE OF CONTENTS 
 
1 ABSTRACT ................................................................................................................. 9 
2 BACKGROUND & RATIONALE................................................................................ 10 
3 PRELIMINARY STUDIES .......................................................................................... 13 
4 STUDY OBJECTIVES AND OUTCOME MEASURES .............................................. 16 
4.1 Primary Endpoints .............................................................................................................. 16 
4.2 Secondary Endpoints ........................................................................................................... 16 
5 STUDY DESIGN AND ORGANIZATION ................................................................... 17 
6 BENEFITS AND RISKS ............................................................................................. 18 
6.1 Risk and Benefit Analysis ................................................................................................... 18 
6.2 Potential Benefits ................................................................................................................ 18 
6.3 Potential Risks .................................................................................................................... 18 
7 STUDY DURATION ................................................................................................... 18 
8 SELECTION AND WITHDRAWAL OF SUBJECTS .................................................. 18 
8.1 Inclusion Criteria ................................................................................................................ 19 
8.2 Exclusion Criteria ............................................................................................................... 19 
8.3 Subject Withdrawal ............................................................................................................. 20 
9 STUDY TREATMENT AND DOSING ........................................................................ 20 
10 STUDY DRUG SUPPLY .......................................................................................... 23 
10.1 Description of Study Drug ................................................................................................ 23 
10.2 Study Drug Labelling and Packaging ............................................................................... 23 
10.3 Study Drug Administration, Compliance and Accountability .......................................... 24 
10.4 Study Drug Distribution, Return, and Destruction ........................................................... 24 
11 STUDY PROCEDURES ........................................................................................... 25 
11.1 Subject Numbering ........................................................................................................... 25 
11.2 Initial Open-label PK Study (Stage 1) .............................................................................. 25 
11.3 Interim Analysis and DSMB Determination of Study Continuation ................................ 25 
11.4 Treatment Assignment and Randomization (Stage 2) ...................................................... 26 
11.5 Study Visit Schedule ......................................................................................................... 26 
11.6 Visit Procedures ................................................................................................................ 28 
12 ASSESSMENT OF SAFETY ................................................................................... 32 
12.1 Adverse Events, Safety Evaluations, and Reporting ........................................................ 32 
12.2 Serious Adverse Events, Safety Evaluations, and Reporting ........................................... 33 
12.3 General Guidelines for Management of Adverse Events ................................................. 34 
12.4 Specific Guidelines for SELECTED Treatment-related AE ............................................ 35 
13 CONCOMITANT ADMINSTRATION OF MEDICATIONS ....................................... 37 
14 DATA AND SAFETY MONITORING BOARD ......................................................... 39 
15 DATA AND MONITORING PLAN ............................................................................ 39 
15.1 Data Management ............................................................................................................. 39 
15.2 Data Quality Control ......................................................................................................... 40 
15.3 Study Monitoring and Auditing ........................................................................................ 41 
16 STATISTICAL ANALYSIS PLAN ............................................................................ 41 
16.1 Data Analysis .................................................................................................................... 41 
16.2 Study Size and Power Calculations .................................................................................. 44 
 

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17 HUMAN SUBJECT PROTECTION .......................................................................... 44 
17.1 Privacy and Confidentiality .............................................................................................. 45 
17.2 Informed Consent Process ................................................................................................ 45 
18 FUNDING SOURCES .............................................................................................. 46 
19 SUBJECT COMPENSATION .................................................................................. 46 
20 PUBLICATION PLANS ............................................................................................ 46 
21 REFERENCES ......................................................................................................... 47 
 

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1 ABSTRACT 
 
Tuberous Sclerosis Complex (TSC) is caused by genetic mutation in TSC1 or TSC2, resulting in 
dysregulation of the mechanistic target of rapamycin (mTOR) signaling pathway.  mTOR 
inhibitors such as everolimus and sirolimus have been shown to be effective and well-tolerated 
for treatment of multiple clinical manifestations of TSC, including brain and renal tumors, lung 
disease, and most recently, medically-refractory partial complex epilepsy.  Over the past decade, 
we have led successful efforts in the clinical development of mTOR inhibitors to treat TSC, with 
FDA and/or EMA-approval for subependymal giant cell astrocytoma (SEGA), angiomyolipoma, 
lymphangioleiomyomatosis (LAM), and partial seizures.   
 
In all instances, treatment has been initiated after the development and progression of clinical 
disease manifestations.  Given that the underlying genetic defect of TSC driving mTOR 
abnormal mTOR activation is present from birth, preventative treatment with everolimus or 
sirolimus before the onset of clinical symptoms could prove superior for optimizing outcomes 
and changing the course of the overall disease.  This is particularly important for prevention of 
epilepsy, which affects more than 80% of individuals overall.  Onset for the vast majority is in 
the first year of life, with more than 50% refractory to all currently available anticonvulsant 
medications.  Those with early onset epilepsy are at greatest risk for lifelong developmental and 
cognitive impairment.   
 
Our overall hypothesis is that early treatment with sirolimus is safe and effective for preventing 
epilepsy and associated developmental and cognitive delay in this high-risk population of TSC 
infants.  This phase I clinical trial will evaluate sirolimus treatment in TSC infants 0-12 months 
of age, when onset of clinical seizures is highest and preventative treatment offers the greatest 
potential to protect long-term neurological outcome.   Our primary aims are: 
 
Safety: To demonstrate safety and tolerability of sirolimus in infants with TSC that are 0-12 
months of age. 
 
The Hypothesis is that sirolimus will be safe and well tolerated in infants with TSC that are 
0-12 months of age. Safety is defined as the frequency of severe/life-threating adverse events 
(grade 3, Common Terminology Criteria for Adverse Events, CTCAE v5.0) in infants treated 
with sirolimus compared. Tolerability is defined as the percentage of subjects that discontinue 
treatment or reduce dose because of an adverse event or serious adverse event (AE/SAE). We 
will also assess the number of days treatment is held but not discontinued because of an 
AE/SAE. 
 
Efficacy: To demonstrate that sirolimus prevents or delays epilepsy in infants with TSC that are 
0-12 months of age.   
The Hypothesis is that infants treated with sirolimus before the onset of clinical seizures and 
continued until 12 months of age.  The primary endpoint for efficacy will be time to seizure 
onset.  We will assess efficacy with regards to age at time of seizure onset, seizure type(s), and 
seizure frequency at the end of treatment (12 months of age) as additional secondary outcome 
measures, which also have previously been shown to directly correlate with long-term epilepsy 
severity and neurodevelopmental outcome in TSC.   
 
 
Additional secondary objectives of the study are:  

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(1) To assess the effect of early sirolimus treatment in TSC infants 0-12 months of age on 
neurodevelopment and behavior, which closely associate with epilepsy in TSC.    
(2) To assess the effect of early sirolimus treatment in TSC infants 0-12 months of age on TSC-
associated electrophysiological (EEG) biomarkers of neuronal connectivity and explore 
whether normalization of biomarkers is associated with epilepsy prevention and structural 
biomarkers of neuronal connectivity measured by diffusion MRI (dMRI).   
(3) To optimize treatment with sirolimus in TSC infants 0-12 months of age, identifying dosing 
that maintains sirolimus trough levels (Cmin) where intolerable side effects are minimized 
while preserving treatment benefit.  
 
 
2 BACKGROUND & RATIONALE 
 
A key intracellular signaling pathway regulated by the mechanistic target of rapamycin (mTOR), 
essential for normal cell growth, differentiation, metabolism, function, and survival is 
responsible for many of the clinical manifestations of Tuberous Sclerosis Complex (TSC).1  In 
the brain, subependymal giant cell astrocytomas (SEGA) arise from subependymal nodules in 
10-15% of children with TSC and if untreated, can cause obstructive hydrocephalus.2  Even more 
common in TSC is epilepsy, affecting 80-90% of affected individuals.3  Seizures often present 
before 1 year of age as infantile spasms or focal seizures and too often is refractory to all 
available treatments and interventions.3  Seizures in general and infantile spasms particularly 
have additional devastating impact on neurodevelopment and long-term cognitive and behavioral 
outcomes.3-5  This is consistent with preclinical mouse models of TSC, in which seizures begin 
early and gradually worsen over time, to the point of intractability and early demise.6  TSC 
mouse models also demonstrate cognitive and behavioral deficits similar to the human disease.  
In each case, deficits could be reversed and/or prevented with preemptive everolimus or 
sirolimus (rapamycin) treatment, small molecule pharmacological inhibitors of mTOR.7-10   
 
Recent data from the NIH-funded TSC Autism Centers of Excellence Network (TACERN) not 
only confirms that 70% of diagnosed infants will develop seizures in the first year of life, but 
also that standardized, validated assessment tools at 12 month of age are able to identify 
measurable deficits in learning and behavior linked to early onset epilepsy in this population.4, 11, 
12  Furthermore, infants who do not develop seizures or whose seizures are completely or 
relatively controlled by 12 months of age are much more likely to develop normally through 24 
months of age and beyond.   Unfortunately, such infants are the minority in TSC.  The 
cumulative preclinical and clinical evidence strongly support targeted anti-epileptogenic 
therapies for TSC and such disease modifying, preventative treatment should be initiated before 
the onset of seizures in the first year of life before epilepsy becomes refractory to conventional 
treatment and before epilepsy-associated neurocognitive and behavioral deficits take hold. 
 
As evidence emerged in the early 2000s that TSC1 or TSC2 mutations allow mTOR activity to go 
unchecked, we began to assess the effect of pharmacological inhibitors that rectify mTOR 
activity in patients with TSC.  The first human TSC clinical experience with mTOR inhibitors 
was first reported in 2006, where sirolimus was found to be effective for reducing SEGA tumor 
volume in as little as 2 months.13  Prospective clinical trials with sirolimus and everolimus, an 
ethyl-ester derivative of sirolimus, began in 2007.  In 2010, the FDA and EMA approved 
everolimus for the treatment of SEGA in TSC.14-19   Regulatory approval of everolimus for 

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angiomyolipoma and sirolimus for lymphangioleiomyomatosis (LAM) in TSC followed in 2012 
and 2015, respectively.20-23   Meanwhile, case reports emerged of sirolimus and/or everolimus 
reducing seizure frequency in TSC patients with refractory epilepsy.24-26  After observing similar 
improvement in TSC patients treated for SEGA,19 we initiated the first prospective multicenter 
clinical trial (Phase I/II) for everolimus specifically to treat refractory epilepsy in pediatric TSC 
patients 2-21 years of age.  Following 3 months of treatment in which concurrent antiseizure 
medications remained unchanged, median seizure frequency was reduced 73%.27  Furthermore, 
follow-up for an additional four years revealed the improved seizure frequency was sustained 
with continued treatment.28  These pilot study results were confirmed in EXIST-3,29, 30 an 
international multicenter phase III randomized, double-blind, placebo-controlled clinical trial 
leading to  EMA (2017) and FDA (2018) approval of everolimus for the treatment of partial 
seizures in TSC.   
 
This will be the first study to truly evaluate a targeted, disease-modifying drug therapy for 
preventing epilepsy in TSC using a rational, mechanism-based therapeutic approach.  Clinical 
development of sirolimus and everolimus in TSC has been driven primarily by commercial and 
market exclusivity considerations by their respective manufacturers, limiting opportunities for 
direct comparison of the two mTOR inhibitors.  To date, neither everolimus or sirolimus has 
demonstrated superiority over the other with regard to safety or efficacy in TSC and both are 
used interchangeably in clinical practice.1  Safety in infants and toddlers is of particular concern, 
as all clinical trials in TSC have limited study to children > 2 years of age and adults; none have 
evaluated efficacy or safety of sirolimus in infants or toddlers and none have initiated treatment 
before clinical symptoms and disease progression are manifest.  In older children and adults, the 
vast majority (>90%) of side effects are mild or moderate in severity (CTCAE grade 1 or 2), with 
stomatitis and lipidemia most prevalent.  We identified 45 TSC infants 0-24 months of age (11.6 
 7.6 months) from 19 TSC clinics treated with everolimus or sirolimus since 2010 for clinical 
indications.31  Overall, treatment-related adverse events were common (78%) but as is the case in 
older populations the majority were mild or moderate in severity.  However, the study was 
limited by its retrospective design and lack of control group for comparison.  Well-designed, 
prospective studies are needed to adequately ensure there are no new adverse events or increased 
severity unique to the infant TSC population that would outweigh the potential benefit of 
epilepsy prevention in this population.   
 
Incorporation of biomarkers of pharmacodynamic response to demonstrate drug-specific 
treatment effects would further advance development of sirolimus as a preventative, disease-
modifying therapy in TSC.  As our understanding of TSC increases, it is becoming increasingly 
clear that non-tuber abnormalities are strongly associated with neurological outcome10, 32, 33. We 
can measure potential treatment-related changes noninvasively with electroencephalography 
(EEG) and diffusion magnetic resonance imaging (dMRI).  Both are routinely acquired as 
standard of care for TSC patients in this age range.34  We have found conventional EEG is highly 
sensitive and specific identifying TSC infants at greatest risk for newly developing clinical focal 
seizures and/or infantile spasms.12  In addition, quantitative EEG demonstrates abnormalities 
both regional and global connectivity and high frequency oscillations in TSC that may reflect 
changes in epileptogenicity and synaptic functionality.35, 36  EEG assessment of functional 
connectivity is further reinforced by similar demonstration of structural connectivity in TSC, 
measured via dMRI.  With dMRI, we have identified abnormalities in network organization and 
structural integrity associated with language deficits and autistic behaviors in TSC.37, 38   
Furthermore, dMRI can differentiate between typically developing children, children with TSC 

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alone, and those with both TSC and ASD.39  Animal models of TSC demonstrate reduced 
myelination in white matter tracts, which could account for the increased diffusion observed in 
patients with the disorder.9  Most relevant to this clinical trial, we have identified multiple dMRI 
measures of microstructural integrity of the corpus callosum, internal capsule, and 
geniculocalcarine tracts improve in SEGA patients treated with everolimus for 12-36 months.40, 
41  Thus, inclusion of EEG and dMRI as markers of target engagement represent a critical 
advancement over prior TSC clinical trials with mTOR inhibitors with the potential to provide 
important links between the molecular consequences of mTOR dysregulation and malleable 
brain networks amenable to treatment with mTOR inhibition.  These same biomarkers 
potentially could be further developed as surrogates for target organ engagement by sirolimus 
and correlated with epilepsy prevention in TSC infants. 
 
Preclinical studies suggest that the patient population most likely to benefit from treatment are 
young children in the critical period when epilepsy and neurobehavioral symptoms first emerge 
and synaptic plasticity is most robust.42, 43  This is also supported by evidence from EXIST-3, 
where treatment was stratified by age and younger patients (< 6 years of age) were significantly 
more likely to reduce seizure frequency compared to older children and adults.30  Younger 
patients also were more likely to achieve target dosing, and those with higher treatment exposure 
demonstrated the greatest age-associated improvement.44   Yet as previously mentioned, safety 
and efficacy for mTOR inhibitors in younger children is limited, especially in those under the 
age of 2 years.  Likewise, appropriate pharmacokinetic (PK) and pharmacodynamic (PD) 
characterization relating CNS kinetics to epilepsy outcomes in this age group is lacking.   While 
high doses of mTOR inhibitors can prevent epilepsy and associated behaviors in TSC mouse 
models10, 45, 46, few studies have attempted to define practical, clinically-relevant treatment 
protocols that could be translated into preventative therapy in TSC patients. To date, sirolimus 
and everolimus dosing in TSC clinical trials has been arbitrarily based on dosing to achieve 
target trough levels commonly used in solid organ transplantation (5-15 ng/ml)19, 21, 27, 30, 47. PK 
and PD studies in animal models and patients were primarily carried out during its clinical 
development for cancer and solid organ transplantation48 and need to be validated in TSC, where 
the brain is the intended site of action. We have generated a preliminary population PK model 
for neonates and infants with vascular anomalies collected a patients using sirolimus data 
collected at Cincinnati Children’s.49  A secondary aim of the current study will be to update this 
PK model for TSC infants treated with a novel formulation of sirolimus (TAVT-18) and extend 
this to the primary and secondary outcome measures for PD analysis that determines optimal 
sirolimus dosing that maintains therapeutic benefit for epilepsy prevention without more 
exposure than necessary so as to minimize toxicity. 
 
The proposed Phase I clinical trial is the first clinical trial to evaluate the potential of this mTOR 
inhibitor for preventing seizure onset and epilepsy progression in high-risk TSC infants. A 
previous version of this clinical trial protocol included a planned second stage, Phase IIb clinical 
trial comparing TAVT-18 to placebo in a randomized, double-blinded, placebo-controlled 
design.  The latter has since been replaced by a stand-alone, Phase IIb clinical trial comparing a 
currently FDA-approved formulation of sirolimus with matching placebo known as the STOP2B: 
Sirolimus TSC Epilepsy Prevention Study (TSC-STEPS; clinicaltrials.gov NCT05104983; 
CCHMC IRB#2021-0438) made possible by separate funding from the FDA Office of Orphan 
Products Development (R01-FD007275).   
 
 

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3 PRELIMINARY STUDIES  
 
Everolimus for treatment of refractory epilepsy in TSC:  Preclinical studies and early human 
case reports have demonstrated beneficial effects of mTOR inhibitors on seizures.6, 9, 25, 50  We 
reported in 2013 the first prospective, multicenter, open-label, phase I/II human clinical trial 
designed to directly assess the benefit of everolimus on seizure control in patients with TSC 
(NCT01070316, N=20).27  Overall, treatment was well-tolerated and seizures were reduced in 17 
of 20 (85%) by a median of 73% (p<0.001).  Improvement in seizure control was accompanied 
with improvement in multiple parent-reported measures of behavior and cognition assessed using 
the Nisonger Child Behavior Rating Form (NCBRF) and Quality of Life for Children with 
Epilepsy (QOLCE).  Initial responders continued treatment up to an additional 48 months (n=18) 
and improved seizure control compared to baseline was maintained in the majority (14 of 18, 
78%), with longer treatment resulting in greater efficacy over time.27, 28    A follow-up Phase III 
randomized, placebo-controlled, double-blind clinical trial was initiated in 2012 comparing low-
dose exposure (3-7 ng/mL) and high-dose exposure (9-15 ng/mL) with placebo (EXIST-3, 
n=366).30  Upon completion of the main study phase (3 months), 28.2% and 40.0% of the low- 
and high-dose everolimus-treated groups reported 50% reduction in seizure frequency, 
compared to 15.1% in the placebo group (p=0.0077 and p<0.0001, respectively).  The median 
response rate for the two everolimus dosing groups combined was 31% after 3 months but 
improved to 47% after 12 months.51 In both epilepsy studies, the tolerability and safety profile of 
everolimus compared with placebo were similar to previous clinical trials for SEGA or renal 
angiomyolipoma in TSC.14, 21    
 
Sirolimus for treatment of refractory epilepsy in TSC: Sirolimus is FDA approved for the 
treatment of LAM,22, 23, 52 a progressive lung disease largely seen in adult women with TSC.  
Sirolimus has also been shown to be effective for treatment of TSC-associated SEGA,24, 52 
angiomyolipoma,22, 52, 53 cutaneous hamartomas,54, 55 retinal hamartomas,56 and cardiac 
rhabdomomas.57-60    Yet despite robust preclinical studies demonstrating reduced seizures in 
TSC animal models treated with sirolimus,6, 50, 61 clinical development of mTOR inhibitors for 
the treatment of epilepsy in patients has almost exclusively focused on everolimus.  Case reports 
and retrospective studies have reported reduced seizure frequency following the initiation of 
treatment with sirolimus,24, 25 but to date there has been only one prospective clinical trial.62     
Twenty-three children with TSC ages 1.8-10.9 years were treated with open-label sirolimus for 6 
months.  Half were randomized to treatment immediately, the remainder to treatment 6 months 
later.  Sirolimus treatment reduced seizure frequency 41% compared to standard care, greatest in 
those achieving a target trough level of 5-10 ng/mL, and 3 patients became seizure-free.  The 
trial was limited, however, by failing to reach its inclusion goal of 30 children. 
 
Safety of mTOR inhibitors in TSC Infants: Multiple prospective clinical trials have 
demonstrated safety and tolerability of mTOR inhibitors generally in TSC, including sirolimus16, 
19, 21-23, 27, 30, 52. Because treatment in each of the trials was initiated after the onset of clinically 
significant symptoms, nearly all study participants were over the age of 2 years; safety in 
younger infants that would be ideally targeted prior to emergence of first seizures remains 
inadequately studied. There are increasing number of published case reports of successful 
treatment of TSC infants treated for other indications,63-72 but no prospective studies to date.  As 
part of an international collaboration of TSC specialty clinics, we collected retrospective safety 
data from TSC infants treated with everolimus (n=39) or sirolimus (n=11) for clinical indications 
since 2010,31 when everolimus was first approved for treatment of SEGA.  In this cohort, infants 

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treated with everolimus started as early as the first month of life; 18 started treatment between 0-
12 months and 27 between 13-24 months.  The average duration of treatment 27.3 ± 24.7 
months.  At least one treatment-related adverse event (AE) was reported in 78% of subjects (84% 
in those treated with everolimus compared to 63% for sirolimus).  The most common AE 
reported was infections (URI, sinusitis, otitis, gastroenteritis, other infection types, ranging in 
frequency from 20-69%.  All but 9% of infections were mild or moderate in severity.  The next 
most common AE type were aphthous ulcers/stomatitis (31%), similarly mild or moderate in all 
but one case.  The most common laboratory abnormality was hypercholesterolemia with or 
without hyperlipidemia, reported in 14%, and again mild or moderate in severity in all but one 
case.  This profile of AE, both in type and severity, is consistent with TSC clinical trials with 
everolimus and sirolimus in older children and adults treated for SEGA, angiomyolipoma, LAM, 
and refractory epilepsy. In most instances, AE were managed by temporarily suspending 
treatment until AE resolved.  However, 23% stopped everolimus because of adverse events, 
which is higher than that reported for older children and adults in published studies to date 
(typically between 4-6%).27  Although the study was not designed to evaluate efficacy, treating 
clinicians reported that 29 of the 45 (64%) subjects demonstrated at least partial benefit.  Of the 
remaining 16 subjects, 8 (18%) were unsure or undetermined benefit, and 8 did not improve or 
respond to treatment at time of data cut-off.  Given that the type and severity of AE in this infant 
cohort was no different and response is similar to that of older children with TSC, it more likely 
parent and/or clinician discomfort with continuing treatment in the context of an AE rather than 
the AE type or severity itself.  In other words, discontinuation seems to be driven more by the 
lack of evidence-based treatment guidance for this specific age group than unique tolerability or 
benefit experience in TSC infants.   Thus, establishing a definitive safety profile through a well-
designed, prospective clinical trial with randomized, placebo-controlled, double-blind design 
remains a critical need for clinical decision making and future clinical trials in this population.  
 
Sirolimus Dosing for Infants in TSC: Lack of focused PK/PD studies is a major reason many 
promising preclinical treatments fail during later clinical development in human studies73 and 
there is renewed emphasis for inclusion of the same throughout therapeutic drug development for 
prevention treatments in CNS disorders.61, 74, 75  While high doses of mTOR inhibitors can 
prevent epilepsy and autism-associated behaviors in TSC mouse models,6, 10, 50 few studies have 
attempted to define practical, clinically-relevant treatment protocols of mTOR inhibitors that 
could be translated into preventative therapy in TSC patients.  Sirolimus dosing in TSC clinical 
trials to date has been based on dosing to achieve target trough levels commonly used for solid 
organ transplantation (Cmin 5-15 ng/ml).22, 23, 52, 53  The assumption is that PK/PD characteristics 
for sirolimus in TSC are the same, although this has never been verified.  Relevant to the current 
study, there is particular deficiency for very young children, where drug clearance can vary 
significantly due to developing organ function.76  Sirolimus has been used successfully to treat 
congenital vascular anomalies at our center,77-79 which can occur in patients with TSC.80   
Collaboration in these trials by the NIH-funded Pediatric Pharmacology Research Unit (PPRU) 
and the Laboratory of Applied Pharmacokinetics and Therapeutic Drug Monitoring at Cincinnati 
Children’s has allowed us to develop age-appropriate precision sirolimus dosing for pediatric 
patients with congenital vascular anomalies.81  More recently, we were able to extend our 
findings to neonates and infants.82  For the current study, these same models will be validated for 
TSC and used to describe sirolimus concentrations relative to primary and secondary efficacy 
and safety outcome measures and identify the optimal dosing range that preserves treatment 
effect while minimizing the risk of adverse events. 
 

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TAVT-18, a novel formulation of sirolimus with improved bioavailability and reduced 
inter-patient variability:  Dissolution properties of sirolimus are generally accepted to be a rate 
limiting factor of oral absorption.  Currently, two formulations, oral suspension and oral tablets, 
are FDA-approved, both marketed under the trade name of Rapamune™ (Pfizer, Inc.) and used 
off-label for the clinical treatment of infants with TSC.31  However, the systemic bioavailability 
is low, estimated to be 14% and 18%, respectively, for the Rapamune™ oral suspension and 
tablets.83  TAVT-18 is a novel powder formulation of sirolimus being clinically developed by 
Tavanta Therapeutics, Inc. that improves sirolimus absorption from the GI tract.  Only the active 
ingredient (sirolimus) is absorbed for TAVT-18, so there are no identified toxicities from TAVT-
18 to date that differ from existing formulations of sirolimus.83  In preclinical studies, TAVT-18 
demonstrated significantly improved maximal plasma concentration (Cmax, increased 3.7-fold) 
and exposure (AUCinf, increased 2.0-fold) compared to Rapamune™, while reducing tmax nearly 
10-fold (Table 1). As a result, less TAVT-18 is needed compared to Rapamune™ to achieve 
comparable therapeutic target drug levels.   
 
Table 1: PK parameters following oral administration of Rapamune™ or 
TAVT-18 in fasted rats (N=4) at 1.0 mg/kg/dose 
Test compound 
Cmax 
(ng/ml) 
tmax 
(h) 
AUCinf 
(ng/ml*h) 
Frel 
(%) 
Rapamune® 
6.9±0.3 
4.8±0.4 
144±14 
 
TAVT-18 
25.9±9.0* 
0.5±0.0** 
307±59* 
209 
       *: p < 0.05 **:; **: p < 0.005 
 
 
A Phase 1 clinical trial with TAVT-18 has also been conducted to evaluate the safety, PK and 
food effect of single doses oral doses of 0.5, 2 and 10 mg (fasted) and 40 mg (fasted and fed). 
TAVT-18 was well tolerated in this study, with no severe adverse events (AEs) reported, and no 
subject withdrawn as a result of an AE. The majority of AEs reported were mild in severity and 
considered unrelated to TAVT-18.  Inter-individual variability also is reduced with TAVT-18 
and therapeutically relevant plasma concentrations (Cmax) and exposures (AUC0-48h) are dose-
proportional up to 10 mg in healthy adults (Figure 1, n=32).84   
 
 

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The lower overall dosing that is needed to achieve therapeutic sirolimus levels, combined with 
less inter-patient variability, supports TAVT-18 is an attractive alternative to conventional 
sirolimus formulations such as Rapamune™ for preventative epilepsy treatment in TSC infants.   
 
Alternative Strategies for Epilepsy Prevention in TSC: In 2010, Bombardieri et al. published 
a case series of 10 TSC children demonstrating the benefits of early recognition of seizures and 
treatment with the anticonvulsant vigabatrin, which inhibits GABA transaminase to increase 
GABAnergic signaling at the neuronal synapse,85 was associated with more favorable long-term 
neurological outcome.86  Shortly thereafter, Jóźwiak et al. demonstrated treatment with 
vigabatrin before the onset of clinical seizures in TSC infants was associated with improved 
neurological outcome when compared to historical controls treated after the onset of clinical 
seizures.87  Prospective open-label (EPISTOP, NCT02098759) and randomized, double-blind, 
placebo-controlled (PREVeNT, NCT02849457) are underway in Europe and the United States, 
respectively, but results are not yet known.  Our investigator team leads the PREVeNT study and 
have purposely designed this clinical trial with matching enrollment criteria, visit schedules, 
assessment procedures, and outcome measures to allow direct comparison between these two 
studies of preventative treatment for TSC infants that utilize distinct mechanisms of action.   
 
 
4 STUDY OBJECTIVES AND OUTCOME MEASURES 
 
4.1 Primary Endpoints 
 
1. Safety: The primary endpoint will be the percentage of subjects reporting severe (CTCAE 
v5.0 grade 3) adverse event (AE) or serious adverse event (SAE), when treated with sirolimus 
(TAVT-18).  Additional safety-related endpoints include: 
a. Percentage of subjects that reduce or discontinue treatment due to an AE or SAE (any 
grade). 
b. Number of days treatment is withheld due to an AE or SAE (any grade). 
 
 
2. Efficacy: The primary endpoint for efficacy will be time to seizure onset, when treated with 
sirolimus (TAVT-18).  Additional efficacy-related endpoints include: 
a. Age at time of seizure onset 
b. Percentage of subjects with infantile spasms (past or current) at the end of the 
treatment period (12 months of age). 
c. Seizure frequency at the end of the treatment period (12 months of age).  
 
 
4.2  Secondary Endpoints  
 
1. To evaluate the effect of early sirolimus (TAVT-18) treatment in TSC infants on epilepsy-
associated neurodevelopment outcomes using the TSC-associated Neuropsychiatric Disorders 
(TAND) Checklist, Vineland Adaptive Behavioral Scales (VABS), Bayley Scales of Infant and 
Toddler Development (Bayley-4), Preschool Language Scale, Fifth Edition (PLS-5), and Autism 
Diagnostic Observation Schedule, Second Edition (ADOS-2). 
 

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2.  To evaluate the effect of early sirolimus (TAVT-18) treatment in TSC infants on 
electrophysiological biomarkers of neuronal connectivity with EEG, we will measure frequency 
of interictal and ictal epileptiform activity, mean coherence, average path length, clustering 
coefficient, and global efficiency.  We also will explore if these EEG biomarkers of functional 
connectivity correlate with white matter tracts associated with neurodevelopmental and/or 
neurocognitive impairment in TSC39 and treatment with mTOR inhibitors in TSC.40, 41 
 
3. To develop a predictive dosing model for early sirolimus (TAVT-18) treatment in TSC infants 
using TAVT-18, we will measure steady-state blood trough concentration (ng/mL) 
corresponding to actual and dose-normalized sirolimus dose (mg/m2/day).   
 
 
5 STUDY DESIGN AND ORGANIZATION 
 
This trial originally planned to use a two stage, phase I clinical trial design, with the first stage to 
employ an open-label clinical trial design to verify dosing for TAVT-18 (sirolimus) powder for 
oral solution in TSC infants (N=5) that would then be carried forward to inform appropriate 
initial dosing, dosing frequency, and dosing adjustments for the second stage—a randomized, 
double-blind, placebo-controlled multi-site trial design—to evaluate the safety and efficacy of 
early sirolimus treatment to prevent epilepsy in TSC infants until 12 months of age (N=60).  
However, with the elimination of the planned second stage which has now been replaced by 
STOP2B: TSC-STEPS, the study design now consists of a single stage, phase I clinical trial 
design only.  Subjects will be between 0-6 months of age at time of treatment initiation and meet 
clinical and/or genetic diagnostic criteria for TSC and have no prior history of clinical seizures at 
time of enrollment.   Treatment will be continued until subjects reach 12 months of age.  The 
TSC Clinic at Cincinnati Children’s Hospital Medical Center (CCHMC) will serve as the single 
clinical site.   
 
Additional key investigators of the study: 
 
• Dr. Hans Greiner (CCHMC) will direct EEG acquisition and data transfer quality 
control, processing, and blinded central analysis 
• Dr. Jamie Capal (UNC, Chapel Hill) will direct neuropsychological assessments and 
data transfer quality control, processing, and blinded central analysis  
• Dr. Alexander (Sander) Vinks (CCHMC) will direct PK/PD sample acquisition and 
quality control, processing, and blinded central analysis 
• Dr. Simon Warfield (Boston Children’s Hospital) will direct dMRI acquisition and 
data transfer quality control, processing, and blinded central analysis 
• Dr. Paul Horn (CCHMC) will serve as study biostatistician 
 
Operations will be managed through the Clinical Coordinating Center (CCC) and Data 
Management Center (DMC) at CCHMC to ensure the optimal scientific rigor, efficient execution 
and management of the study, and analyses.   
 
An independent medical monitor (MM) and Data Safety Monitoring Board (DSMB) will be 
established to ensure patient safety is appropriately monitored and prioritized throughout the 
study. 
 

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6 BENEFITS AND RISKS 
 
6.1 Risk and Benefit Analysis 
This study is greater than minimal risk, but with the potential for direct benefit.   
 
6.2 Potential Benefits 
Potential Benefits to Subjects and Others 
There may be some benefit to research subjects from the therapeutic intervention and evaluations 
as part of this research.  When available and as long as disclosure does not have the potential to 
impact the accuracy of future assessments of the subject during the course of the study, results of 
research-specific procedures and assessments performed during the course of this study may be 
provided to parents and clinicians.  
 
Importance of the Knowledge to be Gained 
The most important information to be gained from this research will be the possibility of 
developing a targeted, disease-modifying drug therapy to prevent seizure onset and epilepsy 
progression in infants with TSC.   
 
6.3 Potential Risks 
EEGs are routine clinical tests that are considered safe and carry negligible risk.  EEGs have a 
minor risk of skin irritation due to adhesive used for sensor attachment but are routinely 
performed as part of clinical care for subjects with TSC in this age group.    
 
MRIs are routine clinical tests that are considered safe and carry negligible risk.  For subjects 
with TSC in this age group, the MRI performed yearly as part of clinical care routinely includes 
sedation.  This sedation will be extended during the research portion of the MRI for no more than 
15 minutes.   
 
For blood sample collection to measure sirolimus levels and laboratory studies, there is a minor 
risk of pain, bleeding, bruising, or infection.  When possible, blood draws will be combined with 
venipuncture already being performed for clinical purposes. 
 
As part of this study there is a minor risk for a loss of confidentiality.  Good clinical practice 
standards and institutional rules will be observed throughout all aspects of the study to maintain 
subject confidentiality.  No individually identifiable subject data will be distributed to non-
research personnel.     
 
 
7 STUDY DURATION 
 
The trial is for 3 years.  Subject recruitment will occur during year 1 and completion of 
scheduled clinical visits and data analysis will occur in years 2-3.    
 
 
8 SELECTION AND WITHDRAWAL OF SUBJECTS 
 
Evaluable subjects are those who have initiated treatment with sirolimus, complete the initial 

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follow-up visit 1 month after initiating treatment, and complete the final assessment at 12 months 
of age.   
 
Male and female TSC infants 0-6 months of age will be enrolled.  There will be no exclusion 
based on race or sex.   
 
Subjects will be recruited through the TSC clinics which are geographically distributed to allow 
nationwide recruitment, supplemented by and in partnership with the advocacy organization 
Tuberous Sclerosis Alliance (TS Alliance) website, Perspective magazine, and social media 
efforts (Facebook and Inspire, online community support page).  We will continue existing 
strategies to improve recruitment and retention that have been successful in our TACERN and 
PREVeNT studies of TSC infants, which have been able to recruit a similar number of TSC 
infants under 12 months of age over a similar time period proposed for the current study.  
Successful recruitment strategies utilized in the past and continued here include leveraging 
existing outreach and clinical support programs at each center, financial support when available 
for qualified travel expenses, scheduling visit times and places that accommodate the needs of 
the family, providing regular feedback to families about the ongoing progress of their children, 
and optimization of overall TSC clinical medical care.  
 
We may modify recruitment strategies as needed if the current pandemic or other events affect 
the ability for subjects to travel or willingness to be seen at a research site on schedule or if 
protocol-required assessments/procedures cannot be performed in a validated manner.  
Telehealth for clinical assessment of subjects, local collection of sirolimus levels and safety 
laboratory studies, and increased use of parent-reported measures or personal protective 
equipment/physical distancing-friendly tools are such strategies in current use by other TSC 
studies during the COVID-19 pandemic.   
 
 
8.1 Inclusion Criteria 
1. 0-6 months of age at the time of enrollment (subject must be <7 months of chronological 
age at time of randomization and treatment initiation).  Corrected age must be at least 39 
weeks (calculated by subtracting the number of weeks born before 40 weeks gestation 
from the chronological age).  
2. Has a confirmed diagnosis of TSC based on established clinical or genetic criteria88 
 
8.2 Exclusion Criteria 
1. Prior history of seizures (clinical or electrographic) at the time of enrollment or identified 
on baseline EEG 
2. Has been treated in the past or is currently being treated at the time of enrollment with 
conventional anticonvulsant medications (AEDs), systemic (oral) mTOR inhibitors (such 
as rapamycin, sirolimus, or everolimus), ketogenic-related special diet, or another anti-
seizure therapeutic agent, device, or procedure  
3. Has taken any other investigational drug as part of another research study, within 30 days 
prior to the baseline screening visit  
4. Has a significant illness or active infection at the time of the baseline screening visit  
5. Has a history of significant prematurity, defined as gestational age <30 weeks at the time 
of delivery, or other significant medical complications at birth or during the neonatal 
period that other than TSC would convey additional risk of seizures or 

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neurodevelopmental delay (i.e. HIE, severe neonatal infection, major surgery, prolonged 
ventilatory or other life-saving supportive care or procedures) 
6. Abnormal laboratory values at baseline (i.e., renal function, liver function, or bone 
marrow production) that are in the opinion of the investigator clinically significant and 
may jeopardize the safety of the study subject 
7. Prior, planned or anticipated neurosurgery within 3 months of the baseline visit  
8. Has a TSC-associated condition for which mTOR treatment is clinically indicated (i.e. 
SEGA or AML) 
9. Subjects who are, in the opinion of the investigator, unable to comply with the 
requirements of the study 
 
 
8.3 Subject Withdrawal 
Subjects may be withdrawn from the study for any of the following reasons: 
• Excessive toxicity, prolonged interruption in treatment with study drug, or emergency 
unblinding due to an adverse event (see section 12)   
• Non-compliance with study procedures or reporting  
• Non-compliance with study drug dosing 
• Withdrawal of consent 
• Subjects lost to follow up, with documentation of due diligence 
• Any unforeseen event that in the opinion of the treating physician and/or the PI, will 
prevent the research subject from taking part in this study 
 
 
9 STUDY TREATMENT AND DOSING  
 
9.1 STUDY MEDICATION (TAVT-18 SIROLIMUS) 
The half-life of sirolimus (TAVT-18) is estimated to be >30 hours,84 allowing for convenient 
twice daily oral dosing.  Medication should be taken in the fed state, defined as within 30 
minutes of feeding.  An individualized PK model-informed age-adjusted dosing scheme with a 
starting dose based on age at the time of enrollment (see Table 2) will be utilized, which is based 
on previous experience and simulation analysis of data obtained from our previous studies 
treating infants with congenital vascular anomalies with RapamuneTM 49, 77, 82 and preclinical and 
human studies with TAVT-18.83, 84  These targeted doses are estimated based on the assumption 
that the oral bioavailability of TAVT-18 is 2-times higher compared to RapamuneTM.  The target 
pre-dose whole blood trough sirolimus concentration (Cmin) will be 10 ng/mL with an upper 
tolerance range of 10-15 ng/mL. This target is consistent with prior published experience from 
infants treated with sirolimus for clinical indications31 and previous clinical trials in TSC patients 
treated for SEGA or epilepsy.24, 31, 62  
 
Table 2: Estimated sirolimus (TAVT-18) starting doses for the indicated target 
concentration range82 
Age group 
(months) 
Dosing for target concentration range = 10-15 ng/ml 
0-1 
0.2 mg/m2/dose, administered twice daily (total daily dose = 0.4 mg/m2) 
1-2 
0.25 mg/m2/dose, administered twice daily (total daily dose = 0.5 mg/m2) 
2-3 
0.3 mg/m2/dose, administered twice daily (total daily dose = 0.6 mg/m2) 
3-4 
0.35 mg/m2/dose, administered twice daily (total daily dose = 0.7 mg/m2) 

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4-6 
0.45 mg/m2/dose, administered twice daily (total daily dose = 0.9 mg/m2) 
 
 
Steady state whole blood trough levels should be drawn in the morning, approximately 24-hours 
since last dose of study medication, after the subject has been on continued dosing for 7-14 days.  
Sirolimus trough level may be drawn at the participating study center or drawn locally and sent 
to the reference laboratory, whichever is easier for the subject.  Subjects for which treatment is 
held temporarily due to an AE but resumed at same dosing as prior to the AE (see section 12) do 
not require a repeat sirolimus whole blood trough level to be checked when resuming treatment 
after the AE has resolved. 
 
Whole blood sirolimus trough levels will be assessed at defined intervals after the initial dose 
(+1, +3, +6, +24 hours).  Infants will continue daily dosing at the same dose, orally twice/daily 
within 30 minutes of feeding, for an additional 6 days (±1 day), when the steady state sirolimus 
whole blood trough levels will be assessed at defined intervals of +1, and +3 hours post-dose.  
Based on resultant steady-state measured trough level at day 7, sirolimus dosing will be adjusted 
per protocol (see next paragraph) to achieve the desired precision dosing target of 10 ng/ml.  
Treatment at the adjusted dosing will continue an additional 6 days (±1 day), after which the 
steady state sirolimus trough level will be measured again (day 14).  Subject recruitment and 
participation is an essential component to the success of the overall study, but it is recognized 
enrollment is unlikely unless given opportunity to continue treatment beyond 14 days given the 
potential for direct benefit (see section 6.2 above) provided no individual- or group-level safety 
concerns are encountered.  Accordingly, after the day 14 sirolimus trough level, participants can 
elect to continue open-label treatment with TAVT-18 (sirolimus) up to 12-months of age, 
providing additional extended exposure dosing and safety data for TAVT-18.  For additional 
details, see section 11.2 below.   
 
During open-label treatment with TAVT-18 (sirolimus), participants will have already had their 
first steady sirolimus whole blood trough concentration measured at 7 and 14 days after initiating 
treatment and subsequent dosing will be individually adjusted using real-time drug concentration 
measurements in combination with a Bayesian population model-based target optimization 
approach.124  Sirolimus trough levels also will be obtained in conjunction with safety labs (CBC 
with differential, comprehensive metabolic panel, lipid profile, amylase, and lipase) drawn at 
each clinical follow-up visit (1, 3, 6, 9, and 12 months). Patients will keep a diary of dosing 
information recording exact dosing times, time of last feeding, and dosing amount administered.  
Any missed doses will be reviewed at each visit to document adherence. Sirolimus 
concentrations will be determined at the CLIA-certified laboratory located at Cincinnati 
Children’s using a validated tandem mass spectrometry assay performed using electrospray on a 
Waters Quattro Micro API triple quadrupole mass spectrometer interfaced with an Acquity Ultra 
Performance Liquid Chromatography instrument (Water Corporation, Milford, MA). The 
dynamic range of the assay is 0.5–100.0 ng/mL.  As we did previously,89 a central physician not 
involved in patient care or study assessments will monitor sirolimus results and provide protocol-
specified dosing adjustments in real time Patients may continue treatment clinically (non-
research) with sirolimus after the 12-month follow-up visit if clinically indicated. However, 
research study medication will not be provided beyond the final follow-up visit, so sirolimus 
must be sourced through normal clinical supply channels in such instances. 
 

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For subjects who are unable to tolerate the protocol-defined dosing schedule, dose adjustments 
are permitted following guidelines in Table 4 (section 12) in order to keep the subject on study 
drug.  If study drug is interrupted due to toxicity (AE), study drug should not be resumed until 
recovery to grade ≤ 1 is achieved.  Depending on AE type and grade, study drug may be re-
introduced at the initial dose or a lower dose level (see Table 4).  Any changes must be recorded 
on the appropriate CRF.  Additionally, if any surgery is planned, study drug should be 
interrupted for one week prior to surgery and be re-started as soon as possible following wound 
healing (default is 2 weeks post-procedure, but may be shortened to 1 week for minor procedures 
and extended as far as 4 weeks under special circumstances).   
 
Treatment compliance will be monitored via patient diaries and drug accountability procedures.  
Treatment compliance will be reviewed at each clinical follow-up visit and calculated as the ratio 
of actual drug taken/expected drug taken.  For calculation of treatment compliance, days 
expected will be corrected to account for days when subject is instructed by study staff to hold 
medication due to an AE.  Subjects unable to provide verification of study dosing compliance via 
medication diaries and/or drug accountability procedures may be removed from the study due to 
noncompliance.  Likewise, subjects repeatedly with a corrected treatment compliance ratio <75% 
or >125% despite retraining may also be removed from the study due to noncompliance. 
 
 
9.2 CONCURRENT MANAGEMENT OF EPILEPSY 
The purpose of the study is to determine if sirolimus is safe and effective for prevention of 
epilepsy in at-risk infants diagnosed with TSC.  The primary endpoint for efficacy epilepsy 
prevention is time to first seizure (seizure onset).  However, subjects treated with sirolimus may 
still develop seizures if (1) our primary hypothesis is incorrect and sirolimus is not preventative 
or (2) our hypothesis is correct and seizure onset is delayed but sirolimus does not fully eliminate 
seizures from ever occurring.  It is this very reason that our study will evaluate additional 
secondary efficacy disease-modifying outcome measures relating to epilepsy (seizure type and 
seizure frequency) and neurodevelopment at 12 months of age.   
 
Accordingly, new onset of seizures (clinical or electrographic) does not require discontinuation 
of study medication.  New onset of seizures should be evaluated and treated with conventional 
anticonvulsant medications (note that mTOR inhibitors are excluded) according to recommended 
clinical practice guidelines and the managing clinician’s best judgement.  In most instances, this 
will be initiation of vigabatrin, recommended first line therapy for infantile spasms in TSC and 
an effective treatment for focal epilepsy which is also common at this age.12, 34  Rescue 
medications are also allowed.  In all instances, prescribed treatment for seizures (medication, 
diet, and/or procedures) will be recorded in the appropriate CRF, including 
medication/treatment/procedure name, start/end dates used, total daily dose prescribed (including 
dosage adjustments, when applicable).  Medications temporarily utilized or prescribed for use on 
as needed basis (PRN) will be recorded and include the date/time/dose for each use.   
 
Another clinical scenario with relevance to the current study is the potential for off-label, 
prophylactic treatment with vigabatrin in TSC infants who have not yet experienced clinical or 
electrographic seizures.  Off-label prophylactic treatment with vigabatrin has the potential to 
directly interfere with primary and indirectly affect secondary outcome measures of this study 
evaluating the preventative benefit of sirolimus. Jóźwiak et al (2011) published a case series of 
14 TSC infants prophylactically treated with vigabatrin following abnormal EEG, compared to 

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historical controls treated conventionally with vigabatrin after the onset of clinical seizures.87  In 
that study, the pre-emptive vigabatrin treatment did not always prevent seizures from occurring 
but still resulted in favorable seizure control and developmental outcomes at 24 months of age.  
Some patients since 2011 as a result have been treated with prophylactic vigabatrin in the 
absence of clinical or electrographic seizures.  However, the Jóźwiak study results have yet to be 
replicated and validation efforts using prospective, randomized, double-blind clinical trials 
currently are underway in Europe (EPISTOP) and the United States (PREVeNT).  Until then, 
off-label prophylactic treatment with vigabatrin is not recommended in current international 
guidelines nor considered current standard of care.34  Accordingly, such prophylactic treatment 
with vigabatrin (or any other anticonvulsant medication or anti-seizure therapy prescribed for the 
same purpose of epilepsy prevention) before the onset of first seizure is specifically prohibited.  
To be clear, this restriction does not apply to vigabatrin or any other anticonvulsant or anti-
seizure treatment(s) after the onset of first clinical seizure (see above), as withholding such 
treatment would be unethical and contrary to current treatment guidelines.34    
 
 
10 STUDY DRUG SUPPLY 
 
10.1 Description of Study Drug  
The investigational drug product to be used in this study is TAVT-18, a proprietary formulation 
of sirolimus in clinical development, by Tavanta Therapeutics, Inc.   It is provided in powder 
formulation consisting of 16.7% sirolimus as active ingredient along with 50.0% Povidon K90 
and 33.3% sodium lauryl sulfate as excipients.  The excipients ensure that sirolimus disperses 
instantaneously in water, which is then administered as an oral solution.  Both excipients used 
are pharmaceutical grade and are listed on the FDA Inactive Ingredients Used in Approved Drug 
Products list.90   TAVT-18 will be supplied from the manufacturer in powder form in pre-
measured vials.  The central investigational pharmacy at Cincinnati Children’s will then oversee 
the labeling of the TAVT-18 in pre-measured vials containing 500 ug of TAVT-18 (sirolimus) 
for single use.  TAVT-18 is stable in powder form for at least 12 months when stored at 2-8 °C.  
  
Printed instructions and supplies will be provided to the parent for TAVT-18 preparation and 
administration.  When not in use, TAVT-18 (sirolimus) will be kept in the refrigerator.  At time 
of administration, the parent/caregiver will add 20 ml water and invert the vial 2-3 times to 
reconstitute the oral solution with a concentration of 0.025 mg/ml.   The reconstituted solution is 
ready for administration right after the reconstitution and is stable at room temperature for at 
least 2 hours.  Sirolimus stability is known to be reduced at lower pH (e.g. pH <3) that is 
ameliorated by raising pH by as little as 1-2 points.91   Stomach pH in infants typically ranges 
between 2-592 and although there was little difference between fasted and fed states with regard 
to mean tmax (< 1 hr) in adults treated with TAVT-18 (sirolimus),84 we want to reduce this 
potential added source of absorption variability to the present study.  Accordingly, TAVT-18 
(sirolimus) will be administered to infants in the fed state (within 30 minutes of feeding), where 
breastmilk or formula (pH 7.0-7.4)93 is sufficient to sufficiently raise stomach pH above the 
minimum desired threshold (pH > 4).91   
 
10.2 Study Drug Labelling and Packaging  
TAVT-18 will be packaged and labeled per institutional guidelines.  Study medication labels will 
be labeled as “Sirolimus (TAVT-18) for Oral Solution” and include all additional required 
labeling as an investigational product, including source (Cincinnati Children’s Hospital), 

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quantity, administration instructions, storage conditions, Lot#, Expiration date, Name of Clinical 
Trial, PI Name, and FDA IND#.   
 
10.3 Study Drug Administration, Compliance and Accountability  
Medication will be dispensed to subjects at each visit, with enough supply to cover the visit 
window time period.  Subjects will be instructed on how to prepare and administer study drug in 
accordance with the protocol.  Dispensing of study drug will only be done by designated and 
qualified individuals at that site location. The study drug is to be taken as a suspension only.  For 
PK/PD analyses, time and dose amount will be captured via CRF when corresponding blood 
trough levels are obtained (see section 9 above regarding dosing and blood trough level 
monitoring).  An IRB-approved Dosing and Administration instructions for use will be provided 
to subject families that outlines specific instructions for preparation and use.   
 
If the subject misses a dose (scheduled dose not administered within 12 hours of expected 
timing), the dose will be skipped.  The missed dose will be recorded as not taken in the subjects’ 
medication diary.  If the dose is missed/held due an AE, that will be recorded in the subject’s 
medication diary also.  Study drug compliance will be assessed by the investigator and/or study 
team designee at each visit. Parents/LARs will be expected to return both unused and used study 
drug to the site at each scheduled visit.  All doses taken and any adjustments in doses are to be 
captured on the drug diary CRF.   
 
Subjects who take 75-125% of their drug, excluding days in which they are instructed to 
temporarily hold study medication by study investigators due to an AE (see section 12), will be 
considered compliant.  Subjects who take <75% or > 125% of their drug, excluding days in 
which they are instructed to temporarily hold study medication by study investigators due to an 
AE (see section 12), or subjects for which drug compliance cannot be verified, may be 
withdrawn from the study (see section 8.3 above). 
 
Upon withdrawal from or completion of the study, any unused study medication is to be returned 
by the subject. 
 
10.4 Study Drug Distribution, Return, and Destruction  
The CCHMC Investigational Pharmacy will serve as central pharmacy and be responsible for 
providing the site with a pharmacy binder and applicable training documents for site staff to 
review before the initial shipment of drug dispensed.  The pharmacy binder will include (1) 
dispensing guidelines, (2) enrollment logs, (3) pharmacy personnel and training logs, (4) study 
medication shipment and receipt forms, (5) site master inventory logs, (6) physician ordering 
templates, (7) study medication resupply forms, and (8) study medication return forms.   
 
 
All medication provided to the site from the central pharmacy will be used only for this trial and 
accountability logs will be maintained at the site.  CRFs will be completed each time study 
medication is received or dispensed.  At the conclusion of the trial and at appropriate times 
throughout duration of the trial, accountability will be reconciled (monitored).  Accountability 
logs may need to be faxed or emailed to the central pharmacy or the sponsor when requested for 
overall study medication reconciliation. 
 
The central pharmacy will keep an expiration log for all study medication.   

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11 STUDY PROCEDURES 
  
11.1 Subject Numbering  
Each subject will be assigned a unique study ID when the subject is first enrolled and remains 
the identifier for the study duration.  Study IDs will not include protected health information 
(PHI) or PHI-derived identifiers nor elements that could be used to determine randomization 
assignment.  
 
11.2 Initial Open-label PK Study (Stage 1) 
Five infants will be enrolled for detailed TAVT-18 (sirolimus) dosing and pharmacokinetic (PK) 
analysis and preliminary safety profile.  Open-label, non-randomized treatment initially will be 
for 14 days, during which sirolimus trough levels and safety labs will be collected at baseline and 
at defined intervals along with continuous AE/SAE reporting.   
 
Following verification of baseline safety laboratory studies (CBC with differential, complete 
metabolic panel, lipid profile, amylase, and lipase), initial dosing will be based on age at the time 
of enrollment (see Table 2), dosed orally within 30 minutes of feeding, twice/daily (see section 
9.1).  Whole blood sirolimus trough levels will be assessed post-dosing at defined intervals (+1, 
+3, +6, +24 hours) on day 1.  Infants will continue daily dosing at the same dose, orally 
twice/daily within 30 minutes of feeding, for an additional 6 days (±1 day), when the steady-state 
sirolimus whole blood trough level will again be assessed at +1 and +3 hours post-dose.  Based 
on resultant steady-state measured trough level at day 7, sirolimus dosing will be adjusted per 
protocol to achieve the desired precision dosing target of 10 ng/ml (see section 9.1).  Dosing will 
continue for an additional 7 days and the final PK assessment for Stage 1 analysis will be 
assessed on day 14 (±1 day).  Safety labs will be repeated at the +7 days and +14 days 
assessment visits.  In addition, AE and SAE safety data will be collected throughout.    
 
Subjects with no significant AE/SAE during the initial 14-day treatment period will be allowed 
to continue open-label treatment so as to allow collection of additional extended exposure safety 
data until 12 months of age, provided sirolimus trough levels within the target range are able to 
be achieved and maintained (see section 9.1 above).   
 
11.3 Interim Analysis and DSMB Determination of Study Continuation 
After the last (5th) subject completes the 14-day open-label treatment study visit, a detailed PK-
dosing and preliminary safety analysis report will be prepared by the study team for review by 
the study sponsor, drug supplier, and DSMB.  Specific criteria for continuation of the study 
(Go/No-Go criteria) are not specified for this Phase I study, but the report must address the 
following key questions to the DSMB’s satisfaction: 
(1) Is 0.2-0.45 mg/m2 TAVT-18 (sirolimus) dosed orally 2x/day appropriate for initial 
dosing in TSC infants 0-6 months of age to achieve a target sirolimus trough levels 
between 5-15 ng/ml? 
(2) Does the proposed real-time, individualized PK model-based precision-dosing 
strategy for TAVT-18 (sirolimus) in TSC infants perform adequately in order achieve 
the target steady-state sirolimus trough level of 10 ng/ml? 

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(3) Are there any unique safety events or related concerns that have emerged in TSC 
infants that were not anticipated which significantly alter the potential benefit-to-risk 
profile for TAVT-18 (sirolimus) in this population? 
(4) Have any practical issues with the planned study design been identified which were 
not anticipated that could impact the feasibility or successful completion of the 
primary objectives of the study? 
 
The DSMB may request additional information or analysis from the investigators, modification 
to the study design, or study discontinuation.   
 
 
11.4 Treatment Assignment and Randomization (Stage 2)  
 
This section of the protocol has been deleted, as the Phase IIb (Stage 2) portion of the study has 
been replaced by STOP2B: TSC-STEPS operating under a separate protocol (CCHMC IRB# 
2021-0438).  
 
11.5 Study Visit Schedule  
A summary of study visit schedule and study procedures is summarized in Table 3.  
 
Baseline Visit (Screening/Treatment Initiation)  
To be eligible, infants 0-6 months of age must have a confirmed diagnosis of TSC based on 
established clinical and/or genetic criteria.88  During the baseline visit, eligibility criteria will be 
verified, baseline medical history/demographics, vital signs, and any existing laboratory or 
diagnostic testing results will be collected.  A clinical examination along with a routine video-
EEG and safety laboratory tests (with option for additional blood samples to be collected at the 
same time and stored at the TSC Biorepository located at the Van Andel Research Institute for 
future genetic and/or molecular studies) will be performed.  Dispensation of study drug will 
occur following confirmation of eligibility.  Genetic mutation information will be collected, but 
genetic testing will not be required to be positive if clinical criteria are fulfilled since up to 15% 
of subjects will clinically-definite TSC have no mutation identified through conventional genetic 
testing.88, 94, 95   
 
Follow-up Visits 
In-person study visits will occur at screening/baseline, Day 7, +1 month following treatment 
initiation, and then at defined intervals thereafter according to subject’s chronological age: 3 
months, 6 months, 9 months, and 12 months.  Visit schedule windows are +/- 2 weeks from the 
scheduled visit date, and if the +1 month follow-up visit and the next defined age interval follow-
up visits are within 4 weeks of each other, they may be combined into a single in-person study 
visit.  At each visit, a clinical examination with interval medical history that includes 
concomitant medications and any additional interventional therapies received (including type of 
intervention and average hours/week of each), safety laboratory studies including sirolimus level, 
optional biorepository samples, EEG, and study drug accountability will be completed.  Seizure 
diaries and adverse event monitoring and reporting will also be maintained continuously 
throughout the study and reviewed at each visit.  At the in-person follow-up visit at 12 months of 
age, dMRI, EEG, TAND Checklist, VABS, and Bayley-4 will be performed.  To verify 
durability of treatment effect, at the in-person follow-up visit at 24-months of age, repeat 
developmental assessment with the addition of the PLS-5 and ADOS-2, accompanied by clinical 

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examination and an interval medical history that will include any additional treatment 
interventions, epilepsy history, and therapies, will also be performed. 
 
Between in-person study visits, interim phone visits will be conducted as often as needed, but not 
less frequently than 1x/month throughout the entire length of study.  Phone visits will occur more 
frequently for patients enrolling and initiating treatment as follows: 1) for those enrolling 
between 0-3 months of age, phone calls will occur weekly the first month of treatment and every 
other week thereafter until the patient is at least 3 months of age, then monthly thereafter; 2) for 
those enrolling between 4-6 months of age, phone calls will occur weekly the first month of 
treatment and then monthly thereafter.  Phone visits will consist of update of medical history, 
discovery and documentation of any interval AE not previously reported, review of seizure and 
drug diaries, and preparations for next scheduled study visit.  If a new or worsening AE with 
severity grade 3 is revealed during an interim phone visit (or other communication between 
study team and subject parent/caregiver), study medication must be held until subject is able to 
undergo appropriate clinical evaluation by qualified medical professional and cleared by study 
investigators to resume treatment.  All AE and stopping/resuming study medication will be 
reported using the appropriate CRF and reporting requirements outlined in Section 12.    
 
After treatment initiation, follow-up PK assessment and dose-adjustment visits will take place at 
defined intervals.  During Stage 1, scheduled follow-up PK assessment and dose-adjustment 
visits will occur on day 7 and day 14.  Thereafter, PK assessment and dose-adjustment visits will 
in conjunction with in-person clinic visits (+1 month after treatment initiation and then according 
to chronological age (3, 6, 9, and 12 months)).  During Stage 2, scheduled follow-up PK 
assessment and dose-adjustment visits will occur 7-14 days after treatment initiation then in 
conjunction with in-person clinic visits (+1 month after treatment initiation and then according to 
chronological age (3, 6, 9, and 12 months)).  Scheduled PK assessment and dose-adjustment visit 
windows 7-14 days after treatment initiation are +/- 1 week.  All other scheduled PK assessment 
and dose-adjustment visit windows are +/- 2 weeks from the scheduled visit date, and if the +1 
month PK-a visit and the next defined age interval follow-up visits are within 4 weeks of each 
other, they may be combined into a single study visit.  For both Stage 1 or Stage 2, unscheduled 
PK assessment and dose-adjustment visits will occur 7-14 days after TAVT-18 (sirolimus) dose 
is adjusted in accordance to protocol to achieve target blood trough level of 10 ng/ml (see section 
9.1 above) or due to AE/SAE (see section 12 below).     
TABLE 3: Schedule of Study Procedures/Events 
Procedure 
Screening/Baseline 
(0-6 months of age) 
+7-14 
days 
+1 
month 
Age: 3 
months 
Age: 6 
months 
Age: 9 
months 
Age: 12 
months 
Age: 24 
months 
Eligibility/ Informed 
Consent 
X 
 
 
 
 
Baseline 
History/Demographics 
X 
 
 
 
 
Interval Medical History 
 
X 
X 
X 
X 
X 
X 
Safety Laboratory tests1  
X 
 
X 
X 
X 
X 
X 
 
Sirolimus level2  
 
X 
X 
X 
X 
X 
X 
 
Vital Signs 
X 
 
X 
X 
X 
X 
X 
X 
Clinical Exam 
X 
 
X 
X 
X 
X 
X 
X 
Adverse Event Review 
X 
 
X 
X 
X 
X 
X 
 
Seizure Diary Review 
 
 
X 
X 
X 
X 
X 
 
EEG3 
X 
 
X 
X 
X 
X 
X 
X 
dMRI4 
 
 
 
 
 
 
X 
X 

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End of Treatment   
At the end of the treatment period (when each subject reaches 12 months of age), participants 
will stop taking the study drug (TAVT-18).  Due to the extended half-life of sirolimus, gradual 
weaning is not necessary.  In the absence of significant complications or contraindications, 
parents who wish to pursue continued treatment with sirolimus after their final study visit as an 
off-label clinical treatment using commercially-available, FDA-approved medication may do so 
through consultation with the primary TSC clinician.  However, such is not part of the current 
research study and no research study medication will be provided after completion of the final 
study visit at 12 months of age.      
 
Post-treatment follow-up 
A follow-up assessment will occur 30 days after the end of treatment visit by phone, which will 
include questions about any new or persistent side effects after discontinuing treatment.   We are 
interested in correlating primary and secondary outcome measures at 12 months (this study) with 
potential longer-term epilepsy-related outcomes.  Thus, enrolled subjects will repeat 
developmental assessment (TAND Checklist, VABS, Bayley-4, PLS-2 and ADOS-2) at 24 
months, along with collection of interval medical history related to epilepsy (seizure types and 
frequency, epilepsy and cognitive/behavior/developmental treatment(s), etc.  In addition, as long 
as the current study protocol remains active and provided proper subject consent, subjects may 
be contacted annually to obtain any new additional follow-up clinical history, lab results, EEG or 
brain imaging source data and reports, and other clinical data pertinent to epilepsy or 
neurodevelopmental outcomes beyond 24 months of age. 
 
 
11.6 Visit Procedures  
Clinical Evaluations  
The following clinical data specifically will be collected: Basic demographics, medical/family 
history, vital signs, physical and neurological examination, current seizure history (type and 
frequency), prior and concomitant medications, adverse events, interventional therapies.  Seizure 
diaries will be given to parents/guardians to record seizure type and frequency following 
randomization, and these will be returned at each visit.  A study drug diary will also be given to 
parents/guardians to record treatment administration and these likewise be returned to the sites at 
Neuropsych assessment5 
 
 
 
 
 
 
X 
X 
Dispense Study Drug 
X 
 
X 
X 
X 
X 
 
 
Interim phone vists6  
 
 
 
 
 
 
 
 
 
Subjects may be enrolled into the study at any time between the ages of 0-6 months and will receive TAVT-18 (sirolimus) until 12 months of age.  
Visit window for follow-up visits is ± 2 weeks. 
 
1Includes option for additional bloodwork for exploratory measures; subjects not taking study medication within the previous 48 hours of the 
study visit due to AE or other reasons will not have sirolimus level assessed. 
2Sirolimus trough levels should be drawn in the morning, approx. 24hrs after last dose of study medication.  The initial level will be drawn 7-14 
days after subject has been on steady dosing and in conjunction with safety labs at each clinic follow-up visit (1,3,6,9,12 mths).  Similarly, trough 
levels will be drawn at 7-14 days after any dose modification, until target concentration is reached.  For convenience, levels can be drawn at the 
study center or drawn locally and sent to the reference laboratory. 
3Routine EEG (60 minutes duration).  EEG acquisition schedule for study is consistent with current TSC clinical guideline recommendations 
4dMRI is 15-minute add-on sequence to conventional MRI that is recommended clinically every 1-3 years in TSC.   
5Developmental assessment consists of TAND Checklist, VABS, and Bayley-4 at the 12 months of Age visit and TAND Checklist, VABS, 
Bayley-4, PLS-5, and ADOS-2 at the 24 months of Age visit 
6Monthly calls will occur in between in-person visits.  During the first month in the study, phone calls will occur weekly. 

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each visit.  Outside test results or specialist evaluation notes obtained as part of the subjects’ 
clinical care may be included in the research medical/family history, including but not limited to 
clinical imaging studies, laboratory tests, genetic testing results, and medical procedures.   
 
Laboratory Evaluations 
Laboratory evaluations will be done at baseline, 1 month, 3 months, 6 months, 9 months, and 12 
month visits. These are standard of care laboratory assessments for this population, including: 
CBC with differential, comprehensive metabolic panel, lipid profile, amylase, lipase and 
concurrent anticonvulsant levels (if any).  Sirolimus trough level measured in whole blood (Cmin) 
will also be determined for any follow-up visit if patient has taken study medication within the 
previous 48 hours, utilizing a central laboratory in order to maintain treatment assignment 
blinding (CCHMC).  At each blood draw, the time/amount of last medication(s) dose, medication 
preparation procedures, time since last feeding, and any other identifiable parameters with 
potential impact on testing results will be captured via CRF.  
 
Opportunity to collect biological tissue for future research from well-characterized patients with 
rare diseases such as TSC is extremely limited.  Accordingly, we will include the option for 
participants in this study to provide blood and tissue for future genetic and molecular studies, as 
we have done in all previous NIH-funded TSC clinical trials conducted by our clinical research 
consortium.  During time of scheduled research or clinical blood draws, extra blood may be 
collected for this purpose.  Likewise, when tissue specimens left over from clinical procedures 
that would otherwise be discarded may be collected. The TSC Biorepository is funded by the TS 
Alliance and physically located at the Van Andel Research Institute (VARI) under the direction 
of Dr. Scott Jewell and accredited by the Biorepository Accreditation Program of the College of 
American Pathologists (#8017856).  Providing blood or biological specimens is optional, will not 
require any additional effort on the part of the patient, and will not interfere with any required 
clinical or study procedures.  Collection and shipping kits are provided by the TSC 
Biorepository, and at all times accompanying demographic and accompanying phenotypic data is 
devoid of any protected health information so as to maintain patient confidentiality at all times. 
Following established protocols and procedures, specimens are prepared at shipped overnight to 
VARI.  Blood is separated into white blood cells and plasma, from which DNA and RNA are 
isolated.  Other tissue samples are stored as either fresh frozen or preservative-fixed specimens. 
 
When blood is drawn, the sirolimus trough will be done first, followed by safety testing, 
followed by optional biorepository specimens. Drawing of the blood tests will be ordered in this 
way to ensure the most important samples for patient dosing and safety are collected first, while 
not exceeding institutional limits.  Total blood draw volume over the 12 month study period is 
likely to range from 20-40mL.  
 
Clinically significant abnormalities prior to initiating treatment with study medication that are 
not exclusionary will be recorded as part of the medical history and current medical conditions in 
the source documents and CRFs. New significant abnormalities identified after the start of study 
medication will be recorded as adverse events in the source documents and CRFs. All laboratory 
reports will be retained in the source documents in the subject charts. 
 
Neurodevelopmental/Behavioral Evaluations 
A comprehensive neuropsychological and behavioral assessment battery providing an 
abbreviated global assessment, using the TAND Checklist, VABS, and Bayley-4 will be 

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performed at the end of treatment (12 months of age).  The same neuropsychological and 
behavioral assessment battery will be performed at 24 months to assess durability of treatment 
effect.  Components of the TAND Checklist capture achievement of major developmental 
milestones and presence/absence of early problem behaviors.  Components of the VABS assess 
adaptive behaviors.  Components of the Bayley-4 include measurements of motor, cognitive, 
language, social-emotional, and adaptive behavior development.  Components of the PLS-5 
assess language skills for children.  Components of the ADOS-2 assess children for autism 
spectrum disorder (ASD).  Both the TAND and VABS are administered through parent interview 
or automatic capture (e.g., iPAD) and reviewed with the parent at time of collection.  The 
Bayley-4 and PLS-5 are a combination of parent interview and child observation.  The ADOS-2 
is conducted through child interaction and observation.   
 
TAND Checklist: The TAND Checklist consists of a set of questions that can be used to guide a 
15-minute conversation between the healthcare provider and a parent, caregiver, or individual 
with TSC. The checklist captures basic developmental milestones, current behavior, psychiatric 
diagnosis, perceived intellectual disability, scholastic difficulties, neuropsychological skills, and 
psycho-social functioning. It also includes parent/caregiver/self-rating and healthcare provider 
ratings of the overall impact of TAND.  As a screening tool, the TAND Checklist has been 
shown to have face validity, content validity, and transferability for capturing essential and 
relevant TAND features in different populations of TSC96.  Domain scores correlated strongly 
with the Strength and Difficulties Questionnaire and BRIEF behavior rating index, two 
additional standardized parent-report measures.  (Administration time: approximately 15 
minutes) 
 
Vineland Adaptive Behavioral Scales (VABS): VABS will be administered at the end of 
treatment visit when subjects are 12 months of age.  The VABS is a caregiver-interview that 
assesses social, communication, motor, and daily living schools.4  Test booklets with scores will 
be maintained with the source documents.  Raw and age equivalency adaptive behavior 
composite (ABC) and 4 subscale scores will be entered in the CRFs.  (Administration time: 
approximately 25 minutes)    
 
Bayley Scales of Infant and Toddler Development, Fourth Edition (Bayley-4): The Bayley-4 
includes a core battery of five scales: adaptive behavior, cognitive, language, motor, and social-
emotional.  The Bayley-4 is a combination of parent/caregiver interview/input along with 
observation of the child performing activities114.  Test booklets with scores will be maintained 
with the source documents.  Subtest level raw and scaled scores, domain composite scores, and 
percentile ranks will be entered into the CRFs.  (Administration time: approximately 30-70 
minutes) 
 
Preschool Language Scale, Fifth Edition (PLS-5: Zimmerman, 2011): The Preschool 
Language Scale will be completed at the 24-months of Age visit.  This interactive, play-based 
assessment provides information about language skills for children birth through age 7. 
(Administration time: approximately 10-30 minutes) 
 
Austism Diagnostic Observation Schedule, Second Edition (ADOS-2; Lord, 2000): ADOS-2 
will be completed at 24-months of Age visit.  The ADOS-2 is a semi-structured, interactive 
observation schedule designed to assess individuals who may have an ASD and consists of 5 
modules.  The specific module to be used at each time point is determined by the ADOS 

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administrator at the time of these assessment.  The Toddler Module is for infants between 12-30 
months of age who do not consistently use phrase speech, whereas Module 1 is for children 31 
months or older who do not consistently use phrase speech.  Module 2 is for children of any age 
who use phrase speech but not verbally fluent.  The revised diagnostic algorithms will be 
computed and the established cut-off scores used to differentiate ASD and non-ASD children 
and can be compared across modules.  It is routine practice for ADOS-2 assessments to be 
digitally recorded and later reviewed by the research psychologist team members for scoring, 
standardization, and quality assurance purposes.  (Administration time: approximately 60 
minutes) 
 
SPECIAL LANGUAGE CONSIDERATIONS FOR DEVELOPMENTAL 
ASSESSMENTS:  TAND Checklist, VABS, Bayley-4, PLS-5, and ADOS-2 should be done in 
the subject’s native language (defined as primary spoken language in the subject’s home) by 
qualified administrator fluent in the subject’s native language.  In non-native English speakers 
where this is not available, these can be administered in English if parent is fluent in the same or 
can be administered through a qualified medical interpreter in the parent’s native language, but 
noted as such on the corresponding CRF.  Inability to obtain a specific developmental 
assessment due to language barrier is not a reason for exclusion from study participation, but any 
developmental assessments not performed should be recorded as a procedural study deviation on 
the appropriate CRF. 
 
Encephalography (EEG) 
Encephalography (EEG) with video is recommended at the time of TSC diagnosis and as 
clinically indicated thereafter for surveillance of seizure risk and response to treatment.34  EEG 
(60 minutes, included extended epochs of both wake and sleep states) are scheduled to be 
acquired at every visit, but at minimum will be performed at baseline and at end of treatment (12 
months).  Sites in this network will utilize identical EEG acquisition protocols and procedures 
established by the TSC Clinical Research Consortium that are designed to yield comparable 
results across different equipment platforms.12  Recordings will utilize 21 gold-plated electrodes 
placed according to the International 10-20 system with a digital sampling rate at a rate of 
2000Hz with no filters, displayed at an effective time scale of 30 mm/sec with 1Hz low 
frequency and 70Hz high frequency display filters on the left screen, and on the right screen a 
maximum time scale of 100 mm/sec, 30Hz low frequency filter (high pass) and 100Hz high 
frequency filter (low pass). These parameters were designed to yield comparable data on Stellate, 
Nihon-Kohden, XLTEK/Natus EEG systems throughout the consortium.  Any additional EEG 
obtained for clinical purposes between scheduled visits will also be collected for research 
analysis.  The digitized EEG source data will be transferred to CCHMC for central processing 
and analysis.  
 
Diffusion MRI (dMRI)  
Brain MRI is recommended in TSC infants annually as standard clinical care to monitor for 
developing or progressing SEGA.97  We have developed a diffusion MRI (dMRI) protocol,98 that 
is an optimally distributed set of gradient directions and strengths, and an algorithm that 
identifies diffusion tensor (DTI) and diffusion compartment (DCI) parameters at every voxel 
from the same acquisition.99, 100  Each year during clinical MRI, we will include this research 
dMRI sequence (scan acquisition time 15 minutes). The TSC Clinical Research Consortium 
uses human phantoms as well as ACR phantoms to align the parameters for collection of 
diffusion MRI data at participating sites. Such an approach has allowed us to obtain high 

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reproducibility across sites in previous multicenter TSC studies, including TACERN.101 
Additionally, if a clinical MRI scan with DTI is performed prior to enrollment in the study, these 
scans may also be included in the planned analysis.   
 
 
12 ASSESSMENT OF SAFETY  
 
Safety will be monitored using laboratory and clinical parameters at each visit and periodic 
phone calls as indicated in the Study Schedule (Table 3).  Data will be reviewed regularly by an 
independent medical monitor who has no other involvement in study execution or analysis or 
TSC patient clinical care. In addition, a dedicated Data Safety and Monitoring Board (DSMB) 
will be established to protect and safeguard the interests of all study patients and to oversee trial 
progress.  The DSMB board composition at minimum will include separate clinical specialists 
with experience in pediatric epilepsy, TSC clinical care, and treatment with mTOR inhibitors.  
The independent medical monitor also will review any serious adverse events and determine if 
unblinding and reporting to the FDA and DSMB is required.  The DSMB will receive regular 
reports from the trial on any injuries or adverse events and any developments that jeopardize the 
continued success of the trial and integrity of the data. The DSMB will meet twice yearly to 
examine study data and additionally may meet on an ad hoc basis as needed. The DSMB will be 
provided with a summary report of all AEs, deviations and SAEs as well as safety laboratory 
evaluations for review during the meetings.  
 
12.1 Adverse Events, Safety Evaluations, and Reporting  
Baseline conditions (e.g. an elevated laboratory value) at study entry will be noted and graded 
per the CTCAE criteria.  For the purposes of this study, an adverse event (AE) is the appearance 
or worsening of any undesirable sign, symptom, or medical condition occurring after beginning 
the study drug, whether or not considered drug related.  Medical conditions/diseases present 
before beginning study drug are only considered adverse events if they worsen after starting 
study drug.  Epilepsy and seizures as primary outcome of interest will not be reported as an AE 
unless accompanied by additional symptoms or events not ordinary in the course of epilepsy 
management in patients with TSC.  Out of range lab results that are considered clinically 
significant, induce clinical signs or symptoms, or require concomitant intervention or changes in 
study treatment also will be reported as adverse events.  
 
Following informed consent, all AEs will be captured, graded per the specified parameters, and 
assigned causality.  Adverse events will be assessed in accordance with The Common Toxicity 
Criteria for Adverse Events (CTCAE v5.0).  If the event is not found in the CTCAE criteria, the 
event will be captured in the “other” category of CTCAE.  The occurrence of adverse events 
should be sought by non-directive questioning of the subject at each visit throughout the study.  
Adverse events may also be detected when they are volunteered by the subject during or between 
visits, though physical examination, laboratory tests, or other assessments.  Each event should be 
evaluated to determine: 
1. Severity grade: CTCAE 1-5 
2. Relationship to study drug: suspected/not suspected 
3. Duration: start and end dates (or ongoing at the time of study completion) 
4. Action taken: no action taken, study drug dosage adjusted/interrupted, study drug 
permanently discontinued, concomitant medication taken, non-drug therapy given, 
hospitalization/prolonged hospitalization 

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5. Whether it is a serious adverse event (SAE) as defined by the FDA and described below 
in section 12.2. 
 
All adverse events should be treated appropriately.  If any concomitant medication or non-drug 
therapy is given as a result, these should be recorded on the appropriate CRF.   
 
Once an adverse event is detected, it should be followed until resolution, with an assessment 
made at each study visit to make note of any changes in severity, suspected relationship to study 
drug, interventions require, and the outcome.  In addition, all adverse events will be recorded and 
subjects will be followed for 30 days after the last dose of study drug.  At the end of the 30-day 
period, the Principal Investigator will determine if the patient is stable and the tracking of 
ongoing AE’s can be discontinued.  New AEs will not be captured beyond the 30-day period. At 
the end of the 30-day period, AEs that have not resolved (e.g. returned to at least baseline) will 
be documented as ongoing.                                                                                                           
 
Periodic summary reports of AEs will be provided to the independent medical monitor, DSMB, 
and Tavanta Therapeutics, Inc. —the supplier for TAVT-18 for this study.   Patient 
confidentiality will be maintained at all times.  No PHI will be included in AE summary reports.  
 
All adverse events are to be reported as follows, unless they meet the definition of a Serious 
Adverse Event described in section 12.2: 
• FDA Reporting:  Annually  
• DSMB:  Per DSMB Charter  
• IRB:  Per IRB requirements 
• Study sponsor, independent medical monitor, and drug supplier: Monthly 
 
12.2 Serious Adverse Events, Safety Evaluations, and Reporting 
For the purpose of this study, a serious adverse event (SAE) is defined by the FDA as one which: 
• Is fatal or life-threatening 
• Results in a persistent or significant disability/incapacity  
• Constitutes a congenital anomaly/birth defect  
• Requires inpatient hospitalization or a prolongation of an existing hospitalization (greater 
than 24 hours) unless the hospitalization is for: 
o Routine treatment or monitoring of the studied indication, not associated with any 
deterioration in condition  
o Elective or pre-planned treatment for a pre-existing condition that is unrelated to 
the indication under study and has not worsened since signing the informed 
consent  
o Treatment on an emergency outpatient basis for an event not fulfilling any of the 
definitions of an SAE given above and not resulting in a hospital admission  
o Social reasons and respite care in the absence of any deterioration in the patient’s 
general condition  
 
Every SAE, regardless of suspected causality, occurring after the subject has provided informed 
consent until 30 days after treatment has stopped must be reported to the sponsor within 24 hours 
of learning of its occurrence.  SAEs will also be reported within 24 hours of learning of its 
occurrence to the drug supplier and medical safety monitor.  The medical monitor will determine 

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if steps to identify and treat the SAE by study investigators are appropriate, if additional 
investigations are required, and if treatment unblinding or treatment discontinuation is necessary. 
 
Any SAEs occurring after the 30-day period following end of treatment should only be reported 
to the sponsor and medical safety monitor if the investigator suspects a causal relationship to the 
study drug.   
 
SAEs that are considered to be unexpected and at least possibly related to study drug are required 
to be reported to the FDA within 7 calendar days of the sponsor’s initial receipt of the 
information if characterized as fatal or life-threatening.  Non-fatal or non-life-threatening events 
must be reported no later than 15 calendar days after the sponsor determines that the serious 
suspected adverse reaction (SSAR) or other information qualifies for reporting.  
 
All SAEs are to be reported to the IRB and the DSMB as per policy and Tavanta Therapeutics, 
Inc.  Patient confidentiality will be maintained at all times when reporting SAE.  
 
12.3 General Guidelines for Management of Adverse Events 
Adverse events most frequently observed with sirolimus are rash, stomatitis/oral 
mucositis/aphthous ulcers, fatigue, headache, anorexia, nausea, vomiting, diarrhea, and 
infections.  Non-infectious pneumonitis, although rare, has also been reported with this class of 
medications.  The most frequently observed laboratory abnormalities include neutropenia, 
thrombocytopenia, hypercholesterolemia, and/or hypertriglyceridemia.  The majority (>95%) of 
these AEs have been of mild to moderate severity (CTCAE grade 1-2).  General 
recommendations for management of adverse events are provided in Table 4, separated 
according to CTCAE grade.  
 
Table 4: Criteria for dose medication management in case of toxicity suspected to be related to study 
treatment 
AE CTCAE Grade 
Actions 
CTCAE Grade 1 
(mild) 
No specific action required.  However, physicians should always 
manage patients according to their medical judgement based on the 
particular circumstances.  May consider temporary interruption of 
therapy, in which case restart study drug at same dose after 
symptoms improve/resolve.  
 
CTCAE Grade 2 
(moderate) 
If toxicity is tolerable, no dose adjustment required. Initiate 
appropriate medical therapy and monitor.  
 
If toxicity becomes intolerable, temporary dose interruption until 
recovery to grade ≤1. Re-start study drug at same dose unless AE 
is recurrent, in which case consider re-starting study drug at lower 
dose.  
 
CTCAE Grade 3 
(severe) 
Interrupt study drug until symptoms resolve to grade ≤1.  Initiate 
appropriate medical therapy and monitor.  Consider re-starting 
study drug at a lower dose, unless AE is recurrent, in which case 
re-start study drug at a lower dose or consider discontinuation. 
 
 
CTCAE Grade 4 
(life-threatening) 
Temporary dose interruption until recovery to grade ≤1.  Initiate 
appropriate medical therapy and monitor. Consider discontinuation 
or re-start study drug at a lower dose.  If toxicity recurs at Grade 4, 
discontinue study drug. 

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Subjects with frequent and/or severe AE may require reduction in treatment medication at the 
discretion of the study investigator.  Recommendations by the independent physician monitoring 
whole blood trough results to increase dosing may also be deferred at the discretion of the study 
investigator if history of current or higher dosing previously attempted during the course of the 
study was associated with significant and/or recurrent AE.  Reasons for dosing reductions due to 
an AE and/or deferment of dosing recommendations to increase dosing under such circumstances 
should be clearly documented in the research chart using the provided CRF. 
 
12.4 Specific Guidelines for SELECTED Treatment-related AE 
Infections 
Sirolimus is a mild immunosuppressant, and therefore subjects who take study drug may at an 
increased risk of infection, including bacterial and viral pneumonias.  Opportunistic infections 
have not been reported in TSC clinical trials with sirolimus (or everolimus).  Otitis media, upper 
respiratory infections, and gastroenteritis are most common.  Investigators should be aware of 
the increased risk of infection and should warn subjects and their caregivers to be vigilant for 
signs/symptoms of infection and to seek medical attention should signs/symptoms occur.  Should 
an infection occur, subjects should be evaluated clinically by their pediatrician or similarly 
qualified medical professional.  Upon confirmation of infection, anti-infectives should be 
prescribed as appropriate and consideration be given to withholding study medication until 
infection is resolved.    
 
Stomatitis/Oral mucositis/Mouth ulcers  
Stomatitis/oral mucositis/mouth ulcers due to sirolimus is the most commonly reported 
treatment-related side effect in prior TSC clinical trials and should be treated using appropriate 
locally available supportive care.  Please note that investigators in earlier trials have described 
the oral toxicities associated with mTOR inhibitors as mouth ulcers, rather than mucositis or 
stomatitis. If examination reveals mouth ulcers rather than a more general inflammation of the 
mouth, the adverse event will be classified as such.  
1. For mild toxicity (grade 1 or asymptomatic occurrences): No symptomatic treatment may be 
needed, but study medication may be held temporarily until resolution.  Dosage reductions 
upon re-start may be required if recurrence of any grade, including grade 1, is frequent. 
2. For more severe toxicity (grade 2 in which case patients have pain but are able to maintain 
adequate oral alimentation, or grade 3 in which case patients cannot maintain adequate oral 
alimentation), treatment medication should be held until recovery to grade ≤1.   In addition, 
symptomatic treatment to alleviate symptoms may be considered and include any or all of the 
following: 
a. Oral sulcrafate (i.e. Carafate®), 5-10 ml applied to discrete aphthous ulcers (or oral 
swish & spit, but OK if swallowed) up to 5x/day.   
b. Topical corticosteroids, such as 0.1% triamcinolone oral paste (i.e., (Kenalog in 
Orabase®), applied directly to discrete aphthous ulcers 1-4x/day.  Mucosal surface to 
which the paste is to be applied must be dried of saliva for medication to adhere and 
be absorbed.  Alternative topical oral steroids (i.e. 0.5 mg/5ml oral dexamethasone 
solution) can also be used in older populations as swish and spit (in this population-
direct aerosolized spray to mucosal surface may be more appropriate) treatment up to 
4x/day.  However, the infant population of the current study makes such swish and 
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c. Local topical analgesic mouth treatments (i.e., local anesthetics such as benzocaine, 
butyl aminobenzoate, tetracaine hydrochloride, menthol, or phenol).  Should be 
applied directly to discrete lesions rather than swallowed.  
3. Subjects experiencing frequent mouth sores during treatment may benefit from prophylactic 
daily intake of supplemental amino acid L-lysine.  Standard dosing for L-lysine has not been 
established, but typical dosing in infants would be 125 mg 1-2x/day.   
4. Agents containing hydrogen peroxide, iodine, and thyme derivatives may tend to worsen 
mouth ulcers.  It is preferable to avoid these agents.  Some foods which are spicy or acidic 
may also exacerbate symptoms. 
 
Hyperlipidemia/hyperglycemia  
Grade 3 hyperglycemia has been observed in patients receiving sirolimus therapy and is the most 
common laboratory-related AE reported in previous TSC clinical trials.  In almost all cases the 
affected patients had an abnormal fasting glucose at baseline. Based on this finding, it is 
suggested that optimal glucose control should be achieved before starting a patient on study 
drug, and that glucose control should be monitored during the trial.  Management of 
hyperlipidemia should take into account the pre-treatment status and dietary habits of the patient.  
For example, breast milk is high in cholesterol and is critical to brain development; long-term 
breastfed babies fare better than others when it comes to healthy hearts.  Infant formulas, on the 
other hand, are low in cholesterol but many include supplemental fatty acids to partially 
compensate for the difference.  To minimize immediate feeding effects on circulating blood 
levels, blood tests to monitor hyperlipidemia must be taken in the fasting state when possible 
(minimum 4 hours since last breastfeeding or 6 hours since last formula feeding, infant cereals, 
or baby food) for infants under 1 year of age.  Cholesterol and triglyceride results drawn in non-
fasting states is non-standardized and cannot be reliably used for clinical decision making or AE 
reporting.   For the purposes of the current study, upper limit of normal (ULN) in fasting infant 
for total cholesterol is 200 mg/dL (5.18 mmol/L) and total triglyceride is 150 mg/dL (1.69 
mmol/L).  Non-fasting cholesterol or triglyceride levels > 4X ULN should be rechecked in the 
fasting state.  As for all AE involving laboratory values, Grade 1 AE is 1X ULN.  Grade 2 AE 
is  2.5X ULN.  Grade 3 AE is  5X ULN.  Grade 4 AE is   10X ULN.  Grade 1 and 2 AE for 
cholesterol or triglycerides do not require any specific intervention, but dietary modification may 
be considered.  In addition to diet modification if possible, Grade 3 hypercholesterolemia or 
hypertriglyceridemia should be treated by lowering daily dose of treatment medication.  Grade 4 
hypercholesterolemia or hypertriglyceridemia should prompt holding study medication 
temporarily until levels normalize and then can be resumed at a lower daily dose.  Although 
sirolimus-associated hyperlipidemia/hypercholesterolemia can be treated with HMG-CoA 
reductase inhibitors in older children and adult patients, such treatment is not recommended for 
the 0-12 month-old infant population of the current study.   
 
Non-infectious pneumonitis 
Pneumonitis is a recognized adverse effect of rapamycin derivatives (i.e. everolimus, sirolimus) 
in adults.  In human clinical trials for TSC to date, rates of non-infectious pneumonitis are low 
(<1%), but in oncology studies frequency has been reported as high as 14%.  Individuals 
participating in this trial will be questioned at each study visit as to the presence of new or 
changed pulmonary symptoms consistent with lung toxicity.  If an investigator suspects a subject 
may be developing pneumonitis, other potential mimics should first be excluded (viral URI, 
reactive airway disease, pneumonia).  In unresolved cases when other causes are determined not 

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to be responsible, study medication should be temporarily withheld while investigations such as 
CT chest and/or referral to a pulmonologist are considered. 
 
 
13 CONCOMITANT ADMINSTRATION OF MEDICATIONS 
 
With the exception of experimental therapies, use of most concomitant medication/therapy 
deemed necessary for the care of the subject is allowed (see special considerations regarding 
concurrent anticonvulsant treatments in section 9.2 above).  The investigator should instruct the 
subject family to consult with the study investigator prior any new medications he/she takes after 
the start of the study drug, including natural supplements (nutraceuticals) and over-the-counter 
medications.  All medications (other than study drug) and significant non-drug therapies 
(including physical therapy and blood transfusions) administered within 30 days of starting study 
drug, throughout the entire study period, and up to 30 days after study drug discontinuation must 
be listed on the appropriate CRF.   
 
Investigational or commercial anti-proliferative and immunosuppressive agents other than study 
drug (including other mTOR inhibitors, e.g., everolimus, temsirolimus) are prohibited. 
 
Sirolimus is metabolized by isozyme CYP3A4 and P-glycoprotein (PgP).  Co-administration 
with moderate or strong inducers/inhibitors/substrates of CYP3A4 or PgP should be avoided 
(refer to Table 5).  Exception is use of anti-epileptic medications that are clinically-indicated.  If 
a subject is treated long-term with one of these medications (anticipated or actual duration ≥2 
weeks) a sirolimus whole blood trough level should be repeated.  
 
Seville orange, star fruit, grapefruit and their juices affect CYP3A4 and PgP activity should be 
avoided. 
 
Sirolimus may affect the response to vaccinations, making the response to the vaccination less 
effective.  Recombinant and inactive vaccinations may be given at any time during the course of 
the study, including annual non-live influenza vaccination that is recommended by the CDC for 
at-risk populations that include infants diagnosed with TSC.  However, live vaccines should be 
avoided while patient is treated with sirolimus.  As current CDC recommendations do not 
recommend any live vaccines (MMR, Varicella) before the age of 12 months, this should not be 
impacted by participation in this study.  However, if there is reason for live vaccine to be 
administered, it should be administered 1-2 weeks prior to  initiation of sirolimus or delayed until 
1-2 weeks after sirolimus is discontinued upon study completion at 12 months of age.  If live 
vaccination must be administered while taking sirolimus, then study medication should be 
discontinued 1-2 weeks prior to vaccination with the live vaccine and restarted 1-2 weeks 
afterward.  
 
 
 
 
 
  
 

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Table 5: Clinically-relevant Drug Interactions with Sirolimus: Substrates, Induces and Inhibitors of 
CYP3A and/or PgP 
CYP3A4 INDUCERS 
 
Strong inducers: avasimibe, carbamazepine,enzalutamide, mitotane, phenobarbital, phenytoin, rifabutin, 
rifampin (rifampicin), St. John's wort (Hypericum perforatum)  
 
Moderate inducers: bosentan, efavirenz, etravirine, genistein, lersivirine, lopinavir, modafinil, nafcillin, 
ritonavir,semagacestat, talviraline, thioridazine, tipranavir  
 
Weak inducers: amprenavir, aprepitant, armodafinil (R-modafinil), bexarotene, 
boceprevir,brivacetam,clobazam, danshen, dexamethasone, Echinacea, eslicarbazepine, garlic (Allium sativum), 
gingko (Ginkgo biloba), ginseng, glycyrrhizin, methylprednisolone, nevirapine, oxcarbazepine, pioglitazone, 
prednisone, pleconaril, primidone, quercetin, raltegravir, ritonavir,rufinamide, sorafenib, Stribild (combo of 
elvitegravir, cobicistat, emtricitabine, and tenofovir), sulfinpyrazone,telaprevir, 
terbinafine,ticagleror,ticlopidine,topiramate, troglitazone, vemurafenib, vicriviroc/ritonavir, vinblastine 
CYP3A4 INHIBITORS 
Strong inhibitors: boceprevir, clarithromycin, cobicistat, 
conivaptan,danoprevir/ritonavir,eltegravir/ritonavir,elvitegravir,grapefruit juice, indinavir,indinavir/ritonavir, 
itraconazole, ketoconazole, lopinavir/ritonavir, mibefradil, nefazodone, nelfinavir, posaconazole, ritonavir, 
saquinavir, saquinavir/ritonavir, telaprevir, telithromycin, tipranavir/ritonavir, troleandamycin, voriconazole  
 
Moderate inhibitors: Amprenavir, aprepitant, atazanavir, atazanavir/ritonavir,casopitant, cimetidine, 
ciprofloxacin, crizotinib, cyclosporine, darunavir, darunavir/ritonavir, diltiazem, dronedarone, erythromycin, 
fluconazole, fosamprenavir, grapefruit juice (Citrus parasidi fruit juice), imatinib,lomitapide, 
netupitant,nilotinib,Schisandra sphenanthera, tofisopam, verapamil  
 
Weak inhibitors: almorexant, alprazolam, alprazolam, amiodarone, amlodipine, amlodipine, atorvastatin, 
azithromycin, berberine, bicalutamide, bicalutamide, blueberry juice, cilostazol, cilostazol, cimetidine, 
clotrimazole, clozoxazone, cranberry juice, cyclosporine, delavirdine, everolimus, fluoxetine, fluvoxamine, 
fosaprepritant, ginkgo, goldenseal, isoniazid, isoniazid, ivacaftor, lacipidine, linagliptin, nilotinib, oral 
contraceptives, pazopanib, peppermint oil, propiverine, ranitidine, ranitidine, ranolaxine, ranolazine, resveratrol, 
roxithromycin, Seville orange, simeprevir, sitaxentan, tabimorelin, tacrolimus, teriflunomide, ticagrelor, 
tipranavir/ritonavir, tolvaptan, zileuton 
 
Dual  PgP/CYP3A4 INHBITORS 
amiodarone, azithromycin, captopril, carvedilol, clarithromycin, conivaptan, diltiazem, dronedarone, elacridar, 
erythromycin, felodipine, fluvoxamine, ginkgo (Ginkgo biloba), indinavir, indinavir/ritonavir, itraconazole, 
mibefradil, milk thistle (Silybum marianum), nelfinavir, nifedipine, nitrendipine, paroxetine, quercetin, 
quinidine, ranolazine, rifampin, ritonavir, saquinavir/ritonavir, Schisandra chinensis, St John’s wort (Hypericum 
perforatum), talinolol, telaprevir, telmisartan, ticagrelor, tipranavir/ritonavir, tolvaptan, verapamil 
PgP INDUCERS 
avasimibe, carbamazepine, efavirenz, genistein, phenytoin, quercetin, rifampin, St John’s wort 
PgP INHIBITORS 
alogliptin,canaglifozin, cremophor RH40, curcumin, ketoconazole, lapatinib, lopinavir/ritonavir, mirabegron, 
propafenone, simepravir, valspodar, vandetanib, voclosporin 
PgP SUBSTRATES 

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afatinib, alfuzosin, aliskiren, alogliptin, ambrisentan, apixaban, apremilast, aprepitant, atorvastatin acid, 
atorvastatin, azithromycin, boceprevir, bosentan, carvedilol, caspofungin, ceritinib, cerivastatin, citalopram, 
colchicine, CP-481,715, cyclosporine, dabigatran, digoxin, docetaxel, domperidone, doxepin, doxorubicin, 
eribulin, everolimus, fentanyl,fexofenadine, fidaxomicin, fluvastatin, fosamprenavir, gatifloxacin, idelalisib, 
iloperidone, indacaterol,indinavir, irbesartan, lacosamide, lapatinib, levetiracetam, levofloxacin, linagliptin, 
linezolid, loperamide, losartan, maraviroc, mirabegron, moxifloxacin, naloxegol, nateglinide, nevirapine, 
nintedanib, lodaterol, paclitaxel, pantoprazole, paroxetine, pazopanib, phenytoin, posaconazole, pravastatin, 
proguanil, quinidine, quinine, ranolazine, riociguat, risperidone, ritonavir, rivaroxaban, saquinavir, silodosin, 
simeprevir, simvastatin, sirolimus, sitagliptin, sofosbuvir, sorafenib, tacrolimus, telaprevir, tenofovir, ticagrelor, 
tipranavir, tolvaptan, topotecan, umeclidinium, valsartan, vardenafil, vincristine, voclosporin, voriconazole 
 
Reference: Internal Clinical Pharmacology Drug-drug interaction (DDI) memo, updated April 2015, which 
summarizes DDI data from three sources including the FDA’s “Guidance for Industry, Drug Interaction 
Studies”, the University of Washington’s Drug Interaction Database, and Indiana University School of 
Medicine's Drug Interaction Table." 
 
 
 
14 DATA AND SAFETY MONITORING BOARD 
 
A Data and Safety Monitoring Board will be established to protect all study subjects, monitor the 
overall conduct of the trial, advise the investigators in order to protect the integrity of the trial, 
and supervise the conduct and analysis of all interim analyses.  DSMB membership may include 
members from the same institution but none may be otherwise involved or affiliated with the 
study nor have direct clinical or scientific collaboration with a member of the study team.  
Composition of the DSMB will be determined by the DSMB chair in accordance with the DSMB 
charter, but must include at least one or more each of the following:  biostatistician, child 
neurology and/or epilepsy specialist, TSC clinician with experience prescribing/managing 
mTOR inhibitors, pharmacologist, and general pediatrician. 
 
Initially, the DSMB will review the protocol and will have the opportunity to request changes or 
clarifications in the study design and conduct prior to study start.  The DSMB will meet prior to 
study initiation to review the protocol and confirm the adequacy of safety monitoring.  During 
the study, the DSMB will review cumulative study data to evaluate safety, study conduct, and 
scientific validity and integrity that might jeopardize the continued success of the trial and 
integrity of the data.  This includes mandatory review of Stage 1 PK analysis and preliminary 
safety report (see section 11.3 above) before enrollment is allowed to begin for Stage 2 of the 
study.   
 
The DSMB charter outlines the membership, responsibilities, frequency of meetings, and the 
process for review of study data at selected intervals.  Additionally, the charter includes the 
format of the formal report that will be provided by the DSMB chair to the study sponsor 
outlining the conclusions and recommendations of the DSMB following each meeting.  
 
 
 
15 DATA AND MONITORING PLAN 
 
15.1 Data Management  
The Data Management Center (DMC) at Cincinnati Children’s will provide full data 
management support to the project.  The DMC has dedicated space within the Division of 

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Biostatistics and Epidemiology (DBE) and was formed in 2002.  The DMC currently consists of 
three Managers of Data Management operations and 25+ staff members (Clinical Research Data 
Specialists, Clinical Research Database Programmers and Data Coordinators), six of which are 
Certified Clinical Data Managers.  DMC staff are active members of the Society of Clinical Data 
Management, the Drug Information Association, and the Society of Clinical Trials and subscribe 
to Good Clinical Data Management Practices.  Data management support services include grant 
review, budgeting and resourcing for data management operations, protocol review, case report 
form design and development, database development using Medidata Rave ®, documentation, 
data cleaning and preparation for analysis.    
 
The project will use Medidata Rave ® as its Electronic Data Capture (EDC) software.   Medidata 
Rave® is a robust EDC platform for capturing, managing and reporting clinical research data. As 
a single platform, Medidata Rave® combines easy-to-use EDC and advanced clinical data 
management capabilities.  Rave’s® extensive capabilities — including wide support of industry 
data standards, flexibility to implement any data management workflow and a rich set of on-
demand data extraction and ad hoc reporting tools — provide a robust platform to manage site-, 
patient- and lab-reported data from EDC and other third party systems via smooth integrations, 
and rapidly make it available for analysis and submission. The early visibility to reliable trial 
data enables study teams to safely and quickly make sound decisions and bring life-enhancing 
treatments to patients earlier.   
 
The Rave® system includes a robust query management system based on the data quality checks 
identified in the Data Quality Plan and programmed during database design. Values that are 
considered potentially inaccurate are flagged by the system and a query is created and sent to the 
site, all within the Rave® interface.   All queries and data changes are documented in the audit 
trail and available for reporting purposes, such as identifying common data queries and query 
rates per site.  In addition, the data management team will provide frequent monitoring, 
described as process control, of the database throughout the study to assure completeness and 
accuracy of the data.  This will allow corrective action to be taken quickly during the course of 
the study if problems with the data collection process are identified. 
 
Rave® allows for seamless uploads of external data sources into the system to eliminate the need 
to enter data that is already available in electronic formats and integrates this additional clinical 
data for data cleaning and quality control.  Documented procedures will be developed for the 
collection, transfer, loading, and validation of any external data.  Written specifications will 
identify mandatory fields including the appropriate variables needed to merge data.  
 
Rave® provides 42 standard reports that will be available to investigators at any time.  This 
allows investigators to track their progress on such key statistics such as enrollment, data entry, 
query status and audit trails.   
 
15.2 Data Quality Control  
All the developmental assessments and secondary outcome measured described above have been 
previously performed by the collaborative research team.  Quality control is the highest priority 
in data collection; therefore, as in previous TSC Clinical Research Consortium studies including 
TACERN, RDRCN-DSC, and PREVeNT, we will take multiple steps to ensure data collected is 
of the highest quality and fidelity.  This includes all personnel performing assessments be 

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professionals trained and certified in the appropriate use and administration of each 
neuropsychological instrument.   
 
 
15.3 Study Monitoring and Auditing 
Monitoring will be performed to ensure the study is conducted, documented, and reported in 
accordance with the IRB approved protocol, the International Conference on Harmonization 
(ICH) Good Clinical Practice (GCP) Guidelines, and applicable FDA regulatory requirements.  
 
Targeted on-site monitoring will occur at least annually, with the schedule for monitoring at each 
site to be determined by the overall risk level of the study, identified site-level risks, and issues 
that may arise during the course of the study.   
 
On-site monitoring will include source data verification and source data review as specified in 
the Monitoring Plan.  The study monitor will perform verification and/or review of critical site 
processes as indicated, including: 
• Eligibility of enrolled research subjects 
• Protocol adherence and appropriate reporting of protocol deviations 
• Study drug accountability  
• Safety information and reporting  
• Consent process and documentation 
• Record keeping of essential documents 
• Completeness and accuracy of data entry and data query resolution 
• Investigator oversight 
 
 
 
16 STATISTICAL ANALYSIS PLAN 
 
 
  
16.1 Data Analysis  
 
Primary Endpoint Analysis and Statistical Considerations (Safety):  
The hypothesis is that sirolimus will be safe in infants with TSC up to 12 months of age. We 
predict that most AE/SAE will be mild/moderate (CTCAE grade 1 or 2) and as was the case for 
the treatment of SEGA and epilepsy in TSC,30, 47. Descriptive statistics (percentages and 90% CI 
based on Newcombe’s modification of Wilson scores102) will be used to describe the frequency 
of individual AEs by type and severity (CTCAE grade). Treatment tolerability will also be 
measured as a safety-related endpoint.  Tolerability is distinct in that it represents the patient’s 
ability to continue treatment despite the presence of one or more significant or recurrent AEs 
rather than a measure of the AE frequency or severity itself.  Tolerability will be measured as the 
percentage of subjects that permanently reduce or discontinue treatment because of an AE or 
SAE. We will also determine the number of days treatment is held because of an AE or SAE.  
We will also assess the number of days treatment is held but not discontinued because of an AE 
or SAE.  Since this measure of tolerability has no precedent, to our knowledge, there is no non-
zero value that we think should or should not be contained within the CI.  
 
There are methodological challenges in safety assessment from a statistical perspective in any 
clinical trial, especially those that are limited in size or duration.103  It is no different in TSC, 

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where every clinical trial evaluating mTOR inhibitors that has led to an FDA-approved 
indication has reported AE/SAE frequency in descriptive terms without accompanying analysis 
of statistical significance between groups.21, 30, 47  Individually and collectively, these studies also 
have shown that most treatment-related AE and SAE in TSC are mild or moderate in severity. 
For the current study, we likewise will report all treatment-related AE, by category and severity.   
 
Primary Endpoint Analysis and Statistical Considerations (Efficacy):  
The hypothesis is that sirolimus will prevent or delay seizure onset in infants with TSC up to 12 
months in age.  To evaluate efficacy, we will determine time to seizure onset after treatment 
initiation in infants treated with sirolimus.   
 
It was originally planned for this analysis to consist entirely of subjects enrolled into Stage 2 
(n=60), comparing time to seizure onset between the two groups (treatment vs. placebo).  With 
Stage 2 now eliminated from this protocol, we will instead use a contemporary, prospectively 
evaluated historical control group (n=32) from our TACERN/TSC-EBS natural history study for 
comparison (Wu et al. Epilepsia 2019. 60:2428-36), in which infants were similarly enrolled 0-6 
months of age and followed until 24 months of age. Instead of time to seizure onset for the 
comparative analysis, we will use age of seizure onset as the outcome of interest as there was no 
treatment in the TACERN/TSC-EBS studies to use as a start point.  The average age of seizure 
onset in the TACERN/TSC-EBS control group was 7.4 ±4.4 months.  For statistical significance, 
we will use t-test or Wilcoxon rank sum test for the differences, depending on distribution 
(parametric vs. nonparametric).  In addition, survival analysis will be conducted with statistical 
comparison between treatment groups utilizing the long-rank test.  Seizure frequency, and 
history of infantile spasms at 12 months of age have been shown to be predictive of long-term 
neurodevelopmental outcome and seizure control at 24-36 months of age.4  Therefore, we will 
similarly compare seizure frequency at 12 months of age using the t-test/Wilcoxon rank sum test 
and the proportion of subjects who develop infantile spasms (past or current) using Fisher’s exact 
test.   
 
Secondary Endpoint Analysis and Statistical Considerations: 
As described above for primary outcome measures, descriptive statistics will be determined for 
each composite and individual component measures of the TAND Checklist, VABS, Bayley-4, 
PLS-5 and ADOS-2 for neurodevelopment and behavior; EEG for electrophysiological 
connectivity; and dMRI for structural connectivity.    
 
EEG data for conventional analysis (interictal and ictal epileptiform activity) will be sampled at 
500 samples/channel/second, 0.5 Hz low pass and 100 Hz high pass filters, and a 60 Hz notch 
filter, with impedance less than 5 Kohm for all electrodes.  Persyst software (San Diego, CA) 
will be used to digitally view each tracing by a single central reader in the standard timescale of 
30 mm/sec and standard filter settings of 1 Hz low-frequency filter (high pass) and 70 Hz high 
frequency (low pass), along with a 60 Hz notched filter.  EEG will be classified according to 
age-appropriate norms, as either normal or abnormal.  Conventional EEG abnormalities will be 
further evaluated in terms of the presence or absence of background abnormalities, such as 
generalized or focal slowing, epileptiform discharges (focal, regional, bilateral, or generalized 
spike or spike and wave discharges), hypsarrhythmia (classic or modified), voltage attenuation, 
as well as clinical and/or electrographic seizures, in accordance with the NINDS common data 
element tools for epilepsy.  The association between epileptiform discharges and primary 
efficacy outcome measures will be analyzed using multiple methods, including time-to-event 

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survival analysis, multivariable Cox proportional hazard analysis to assess the contribution of 
concurrent clinical or genetic variables on the response to treatment, and logistical regression 
analysis to determine the strength of associations.   
 
EEG data for quantitative analysis (power, coherence, path length, clustering, and global 
efficiency) will be imported into Brain Vision Analyzer (BVA) software (Brain Products GmbH) 
to remove offsets, optimize scaling, and re-reference the data into the desired montage. The 
power spectral density of the artifact-free bipolar pair EEG data will be calculated using the fast 
Fourier transform (FFT) function. The 512-point FFT is calculated for artifact-free two-second 
epochs with a rectangular window, DC de-trending applied to each segment of data, 0.5 Hz 
overlap at the limits of the band, and yielding a frequency resolution of 0.5Hz. Power will be 
calculated in six frequency bands, corresponding to delta (0.5-4Hz), theta (4-8Hz), alpha (8-
12Hz), beta (12-20Hz), gamma (30-50Hz), ripple frequencies (100-250Hz), and fast ripple 
frequencies (250-500Hz).  
 
Supplementation of traditional DTI from dMRI data with DCI allows us to characterize changes 
in free water content, multiple oriented fascicles per voxel, and diffusivity parameters per 
fascicle,104-107 using the concepts of statistical modelling of infinitesimal microenvironments,108 
and the well-established minimum requirements for compartment models.109  DIAMOND99, 100 is 
a finite mixture model of compartments, where the signal arising from each of the compartments 
is represented by a statistical distribution of 3-dimensional infinitesimal microenvironments. Our 
model order selection algorithm determines from the dMRI data, exactly the number of 
compartments that are present at each voxel.110 DCI enables better delineation of white matter 
pathways relevant to CNS disease in TSC;111 allows measurement of the free water volume and 
improves compensation for partial volume averaging; provides increased sensitivity to detect 
loss of microstructural integrity; provides intra-voxel orientational heterogeneity and allows 
tractography of all fascicle orientations; and provides measures of diffusivities from the imaging 
data.  
 
Sirolimus (TAVT-18) dosing and corresponding trough levels for the sirolimus (TAVT-18) 
treatment group will be analyzed for dose-dependent relationships to primary efficacy and safety 
outcome measures. We will define the developmental trajectory of sirolimus (TAVT-18) in very 
young infants (‘projected model’ line) using actual and dose-normalized sirolimus (TAVT-18)  
dose and corresponding trough concentrations at each sampling time, as done previously in 
patients with congenital vascular anomalies49. We will then use validated population modeling 
approaches supported by the U.S. Food and Drug Administration to simulate drug-treated patient 
populations of interest.112, 113   Mixed (random and fixed) effects modeling approach where the 
data are pooled with individual subject characteristics and maintained during the analysis will be 
employed to capture both inter-patient and intra-patient (also known as residual) variability. 
Exploratory covariate analyses using PK/PD modeling approach will be performed with 
variables considered to include (but are not limited to) age, gender, ethnicity, total bodyweight 
(TBW), body mass index (BMI), body surface area (BSA), hematocrit, disease status, time since 
last feeding, and concomitant medications. The fit of the population PK and PK/PD models will 
be evaluated both graphically and statistically. The final model will then be developed by 
applying a direct-link model to describe sirolimus concentrations and changes in primary 
efficacy and safety outcome measures to identify optimal dosing range for preservation of 
observed treatment effect compared to treatment-associated risk of AE.  

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Our consortium is actively involved in the NIH-funded epilepsy prevention clinical trial 
evaluating the pre-emptive treatment with vigabatrin in TSC infants (PREVeNT).  The current 
study design is purposefully similar to that trial (age at time of enrollment, clinical epilepsy and 
neurodevelopment assessments between 0-12 months of age, timing of serial blood and EEG 
acquisitions).  The underlying premise of the two studies, however, is distinct.  PREVeNT 
specifically targets early epileptogenesis with a conventional anticonvulsant, vigabatrin, that is 
initiated after EEG abnormalities are identified.  In contrast, the present study initiates treatment 
after TSC diagnosis, as the proposed treatment (sirolimus) targets the underlying molecular 
defect caused by genetic mutation of TSC1 or TSC2 that is present from birth.  Thus, we will be 
able to directly compare outcome measures and biomarkers to explore the significance of timing 
(before vs. after EEG change) and mechanism (targeting the mTOR pathway vs. GABAnergic 
effect of vigabatrin) to prevent epilepsy onset and progression in TSC infants.    
 
16.2 Study Size and Power Calculations 
 
The original study was powered for the planned enrollment of Stage 2, in which 60 subjects were 
to be randomized 2:1 for treatment with TAVT-18 (sirolimus) vs. placebo.  These power 
calculations remain valid for STOP2B: TSC-STEPS (CCHMC IRB#2021-0438) that has 
replaced Stage 2 of the current study.  However, with enrollment under the current protocol now 
limited to Stage 1 only (n=5), this study is no longer powered for definitive analysis and 
becomes a true pilot study aimed at obtaining preliminary data with regard to potential treatment 
safety concerns and an estimation of patient variability in treatment response.  Analyses for 
statistical significance will still be carried out with the modifications as outlined above, but it is 
expected that unless the treatment effect size is very large compared to a similarly matched 
historical cohort from the TACERN/TSC-EBS study, statistical significance will not be achieved 
with such a low number of treated individuals in this study.  Nonetheless, descriptive analysis as 
a pilot study using sirolimus (TAVT-18) in a patient population (TSC infants 0-12 months of 
age) that has hereto never previously been studied in a prospective fashion still has immense 
scientific and clinical value.  Furthermore, should the TAVT-18 sirolimus formulation be further 
developed as a potential clinical treatment for this indication, the descriptive statistics will 
provide essential data for estimating potential treatment effect size and interpatient variability 
values that will prove essential for determining study size and study power. 
 
   
 
 
17 HUMAN SUBJECT PROTECTION   
 
Compliance with Good Clinical Practice (GCP) guidelines for the conduct and monitoring of this 
clinical trial will occur through observation of the ethical and regulatory requirements presented 
in ICH E6, Good Clinical Practice: Consolidated Guideline.  The study (protocol, informed 
consent, advertisements, subject information sheets and Investigator CV and credentials) should 
be reviewed and approved by the Institutional Review Board (IRB) or ethics committee. Changes 
to the protocol will be approved by the IRB.  Subjects must sign written informed consent prior 
to being screened, before undergoing any study procedures.  
 

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The investigators and institutions affiliated with this study will permit trial-related monitoring, 
audits, IRB/IEC review, and regulatory inspection(s) by providing direct access to source 
documents. 
 
17.1 Privacy and Confidentiality 
Subject confidentiality will be maintained by the investigator, the investigator’s associates and 
co-workers, and by all administrators who are part of the project.  Confidentiality will be 
maintained according to ICH E6; 4.8.10, part O: “Records identifying the subject will be kept 
confidential and, to the extent permitted by the applicable laws and/or regulations, will not be 
made publicly available.  If the results of the trial are published, the subject’s identity will remain 
confidential.” 
 
The investigator, his or her staff and associates, and the appropriate regulatory agencies may use 
the information included in this protocol as necessary for the conduct of the trial and the safety 
of subjects.  The subject/legal guardian may obtain the results of clinical labs, tests and 
procedures obtained for this research study.  
 
Subjects will be identified only by a unique identifier for research specimens collected and 
shipped to analysts outside the consortium.  Any publications will reflect only unique identifiers.  
All information related to this study will be kept in secure and locked offices.  
 
Clinical data on paper forms will be stored separate from the patient chart.  The data on paper 
will be kept locked.  Any data on computer will be accessible only by password access.  Only 
members of the research team will have access to these files.  
 
17.2 Informed Consent Process 
Informed consent is an ongoing process that includes the signing of an informed consent 
document.  Parents/LARs are required to sign an informed consent prior to being screened, and 
before undergoing any study procedures or assessments, in accordance with International 
Conference on Harmonisation (ICH) E6; 4.8, “Informed Consent of Trial Subjects.”  When 
substantial modifications are made to the informed consent, the DSMB or IRB may require that 
all subjects currently enrolled in the study will be re-consented; ICH E6; 4.8 guidelines would 
still apply.   
 
Parents/LARs will be provided with a copy of the informed consent that explains the purpose of 
the study, the study procedures, and assessments.  Parents/LARs will also be provided with the 
telephone numbers of the investigator and qualified personnel who can assist with their questions 
and concerns. 
 
The following is the consent process that will be used for this project: 
• Subjects are recruited from the patient populations at each participating center.  
• A copy of the informed consent is given to the parents/LARs before signing the consent.  
The content of these documents, and the nature of the study, is discussed with the 
parents/LARs before obtaining their signature.  If there are no questions regarding the 
studies or the content of the consent forms, the parent and/or guardian is requested to sign 
the consent in the presence of a member of the investigation team. 
• Parents/LARs are given copies of the consent with signatures to keep. 

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• For advertisements used for recruitment purposes for this study, prior approval will be 
obtained from the institutional review board (IRB).  
 
 
18 FUNDING SOURCES 
 
The primary source for funding this clinical trial is the Clack Foundation and private donations 
in smaller amounts from individual patients and families donating to general TSC research at 
Cincinnati Children’s Hospital.  This funding supports the necessary infrastructure and resources 
necessary for successful completion of the study, including all study visits and procedures for the 
primary safety, efficacy, developmental/behavioral assessment, and later PK/PD endpoint 
analyses.  Tavanta Therapeutics, Inc.  is providing TAVT-18 (sirolimus) drug supply for the 
entire study and supplemental funding to support study visits and procedures for the initial open-
label, detailed PK analysis portion of the study (Stage 1).  The TS Alliance, a national patient 
advocacy not-for-profit organization, provides funding for tissue and blood biosample 
acquisition, shipping, processing, and storage at the TSC Biorepository in Grand Rapids, 
Michigan.   
 
 
19 SUBJECT COMPENSATION   
 
Subjects will not be compensated for participating in this trial.  Limited travel reimbursement for 
qualifying expenses may be available.  Clinical procedures and tests described above that are 
clinically indicated (meaning they would be done even if the subject was not participating in this 
study) may be charged to the subject and/or their medical insurance.  Examples include but are 
not limited to EEGs, MRI, laboratory studies, clinical evaluations, and/or additional 
developmental assessments.  However, procedures and tests that would only be done because of 
participation in this research study, such as measurement of sirolimus levels, will not be charged 
to the subject and/or their insurance.   
 
 
20 PUBLICATION PLANS 
 
Manuscript(s) and abstract(s) prepared from the data collected during this trial will be prepared 
by the study investigators using standard publication guidelines. 
 
The investigators on the clinical trial will be given the first and exclusive opportunity to analyze, 
present and publish data collected from their investment of time and effort.  It is the obligation of 
the study investigators to disseminate results and it is expected that the investigators will write 
manuscripts including study design and primary results as well as other methodology and 
preplanned analyses of secondary outcomes.   

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