A Pilot Study of RNS60 in Amyotrophic Lateral Sclerosis (ALS)
Phase: PHASE1
Conditions: ALS
Sponsor: Sabrina Paganoni, M.D.

 
 
 
 
 
 
A PILOT STUDY OF RNS60 IN ALS 
 
 
 
 
 
NCT02525471  
 
 
 
 
 
Version 6.0 - May 5, 2016 

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A PILOT STUDY OF RNS60 IN ALS 
 
Investigators: 
Sabrina Paganoni, MD, PhD 
James Berry, MD, MPH 
Merit Cudkowicz, MD, MSc 
Nazem Atassi, MD, MMSc 
 
Massachusetts General Hospital  
Neurological Clinical Research Institute (NCRI) 
165 Cambridge St, Suite 600 
Boston, MA 02114 
 
Sponsor: 
 
 
MGH ALS Therapy Fund 
Study Product: 
RNS60 
 
 
Protocol Number: 
RNS60-01 
Draft or Version Number: 
6.0 
 
 
May 5, 2016 
 
 
 

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TABLE OF CONTENTS 
LIST OF ABBREVIATIONS ···································································································· 5 
PROTOCOL SUMMARY ······································································································· 7 
SCHEDULE OF ACTIVITES – CORE STUDY ·········································································· 11 
SCHEDULE OF ACTIVITES – OPTIONAL EXTENSION PHASE ················································· 13 
STUDY WORKFLOW ········································································································· 14 
1 
ETHICS/PROTECTION OF HUMAN SUBJECTS ······························································· 15 
1.1 
INSTITUTIONAL REVIEW BOARD (IRB) ............................................................................................................ 15 
1.2 
ETHICAL CONDUCT OF STUDY .......................................................................................................................... 15 
1.3 
SUBJECT INFORMATION AND CONSENT ............................................................................................................ 15 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3 
OBJECTIVES ············································································································· 23 
3.1 
STUDY OBJECTIVES ........................................................................................................................................... 23 
3.2 
STUDY OUTCOME MEASURES ........................................................................................................................... 23 
4 
STUDY DESIGN ·········································································································· 24 
4.1 
OVERALL STUDY DESIGN AND PLAN ................................................................................................................ 24 
4.2 
STUDY CENTERS ................................................................................................................................................ 24 
4.3 
STUDY DURATION .............................................................................................................................................. 24 
4.4 
PROTOCOL ADHERENCE ................................................................................................................................... 24 
5 
SELECTION AND WITHDRAWAL OF STUDY POPULATION ············································ 25 
5.1 
NUMBER OF STUDY SUBJECTS .......................................................................................................................... 25 
5.2 
INCLUSION AND EXCLUSION CRITERIA ............................................................................................................ 25 
5.2.1 
Inclusion Criteria ········································································································· 25 
5.2.2 
Subject Exclusion Criteria······························································································ 26 
5.3 
Withdrawal ················································································································ 27 
5.3.1 
Handling of Withdrawals ······························································································· 27 
5.3.2 
Termination of Study ···································································································· 27 
6 
TREATMENTS ADMINISTERED ··················································································· 28 
6.1 
TREATMENTS ..................................................................................................................................................... 28 
6.1.1 
Study Product Description ····························································································· 28 
6.1.2 
Treatments administered ······························································································· 28 
6.2 
RECEIVING, STORAGE, DISPENSING ................................................................................................................. 29 
6.2.1 
Receipt of Drug Supply ································································································· 29 
6.2.2 
Storage ······················································································································ 29 

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6.3 
MODIFICATION OF STUDY INTERVENTION/INVESTIGATIONAL PRODUCT FOR A SUBJECT ............................ 30 
6.3.1. 
Dosage Discontinuation ································································································· 31 
6.4 
ACCOUNTABILITY PROCEDURES ...................................................................................................................... 31 
6.5 
ASSESSMENT OF SUBJECT COMPLIANCE .......................................................................................................... 31 
6.6 
PRIOR AND CONCOMITANT THERAPY .............................................................................................................. 31 
6.6.1 
Prohibited Medications and Contraindications ···································································· 31 
6.7 
STATISTICAL CONSIDERATIONS ........................................................................................................................ 32 
7 
STUDY SCHEDULE ····································································································· 33 
7.1 
SCREENING VISIT .............................................................................................................................................. 33 
7.1.1 
Screen Failures ············································································································ 33 
7.2 
BASELINE VISIT ................................................................................................................................................. 34 
7.3 
WEEKLY STUDY VISITS (WEEK 1 THROUGH WEEK 10, WEEK 12 THROUGH WEEK 22, WEEK 24 THROUGH 34, 
AND WEEK 36 THROUGH 46) ...................................................................................................................................... 34 
7.4 
WEEK 11 VISIT .................................................................................................................................................. 35 
7.5 
WEEK 23 VISIT .................................................................................................................................................. 35 
7.6 
WEEK 35 VISIT .................................................................................................................................................. 36 
7.7 
WEEK 47 VISIT .................................................................................................................................................. 36 
7.8 
WEEK 28 OR 52 PHONE INTERVIEW ................................................................................................................. 36 
7.9 
FINAL SAFETY VISIT ......................................................................................................................................... 36 
7.10 
FOLLOW-UP .................................................................................................................................................. 37 
8 
CLINICAL ASSESSMENTS AND OUTCOME MEASURES ·················································· 38 
8.1 
CLINICAL VARIABLES ....................................................................................................................................... 38 
8.1.1 
Vital Signs, Height & Weight ·························································································· 38 
8.1.2 
Clinical Laboratory Assessments ····················································································· 38 
8.1.3 
Physical Examination ···································································································· 38 
8.1.4 
Neurological Examination ······························································································ 39 
8.1.5 
Adverse Events ············································································································ 39 
8.1.6 
ALSFRS-R ················································································································· 39 
8.1.7 
Pulmonary Function Testing ··························································································· 39 
8.1.8  
C-SSRS ····················································································································· 39 
8.1.9  
Upper Motor Neuron-Burden (UMN-B) ············································································ 40 
8.1.10 
Blood Biomarkers ········································································································ 40 
8.1.11 
Strength measurement (ATLIS)······················································································· 41 
8.1.12 
Neuroimaging ············································································································· 41 
9 
SAFETY AND ADVERSE EVENTS ················································································· 42 
9.1 
DEFINITIONS OF AES, SUSPECTED ADVERSE DRUG REACTIONS & SAES ...................................................... 42 
9.1.1 
Adverse Event and Suspected Adverse Drug Reactions ·························································· 42 
9.1.2 
Serious Adverse Events ································································································· 43 
9.2 
ASSESSMENT AND RECORDING OF ADVERSE EVENTS ..................................................................................... 44 
9.2.1 
Assessment of Adverse Events ························································································· 44 
9.2.2 
Relatedness of Adverse Event to Investigational Product························································ 44 
9.2.3 
Recording of Adverse Events ·························································································· 45 
10 
SAFETY MONITORING ······························································································· 46 
10.1 
SAFETY MONITORING .................................................................................................................................. 46 

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11 
DATA COLLECTION ··································································································· 47 
11.1 
ROLE OF DATA MANAGEMENT ...................................................................................................................... 47 
11.1.1 
Data Entry and Checks ································································································· 47 
11.1.2 
Data Lock Process ········································································································ 47 
11.1.3 
Data handling and record keeping ···················································································· 48 
11.2 
CONFIDENTIALITY .......................................................................................................................................... 48 
11.3 
RETENTION OF RECORDS................................................................................................................................ 48 
11.4 
PUBLICATIONS ............................................................................................................................................... 48 
12 
LITERATURE REFERENCES························································································ 49 
13 
APPENDICES ············································································································· 51 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 

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LIST OF ABBREVIATIONS 
 
AE 
Adverse Event/Adverse Experience 
ALS 
Amyotrophic Lateral Sclerosis 
ALSFRS-R 
Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised 
API 
Active Pharmaceutical Ingredient 
ATLIS 
Accurate Test of Limb Isometric Strength 
CFR 
Code of Federal Regulations 
CIB 
Clinical Investigator’s Brochure 
CNS 
Central Nervous System 
CRF 
Case Report Form 
CSF 
Cerebrospinal Fluid 
CSNs 
Charge-stabilized nanostructures 
C-SSRS 
Columbia Suicide Severity Rating Scale 
DBP 
Diastolic Blood Pressure 
EAE 
Experimental autoimmune encephalomyelitis 
eCRF 
Electronic Case Report Form 
EDC 
Electronic Data Capture 
FDA 
Food and Drug Administration 
FRAP 
Ferric Reducing Antioxidant Power 
FWA 
Federal-wide Assurance 
GCP 
Good Clinical Practice 
hCG 
Human Chorionic Gonadotropin 
HIPAA 
Health Insurance Portability and Accountability Act 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonization 
IDE 
Investigational Device Exemption 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
ITT 
Intent to treat 
IV 
Intravenous 
MGH 
Massachusetts General Hospital 
MOP 
Manual of Procedures 
MRI 
Magnetic Resonance Imaging 
N 
Number (typically refers to subjects) 
NDA 
New Drug Application 
NIH 
National Institutes of Health 
OHRP 
Office for Human Research Protections 

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OHSR 
Office of Human Subjects Research 
PET 
Positron Emission Tomography 
PHI 
Protected Health Information 
PHRC 
Partners Human Research Committee 
PI 
Principal Investigator 
QA 
Quality Assurance 
QC 
Quality Control 
ROI 
Region of Interest 
SAE 
Serious Adverse Event/Serious Adverse Experience 
SBP 
Systolic Blood Pressure 
SI 
Site Investigator 
SMC 
Safety Monitoring Committee 
SOP 
Standard Operating Procedure 
SVC 
Slow Vital Capacity 
Tregs 
T regulatory cells 
US 
United States 
VC 
Vital Capacity 
WOCBP 
Women of Childbearing Potential 

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PROTOCOL SUMMARY 
Study Title 
A PILOT STUDY OF RNS60 IN ALS 
 
Version Number 
6.0 
 
Protocol Number 
RNS60-01 
 
Study Indication 
Amyotrophic Lateral Sclerosis (ALS) 
 
Phase of Development 
IIa 
 
Rationale for the Study 
Amyotrophic lateral sclerosis (ALS) is a fatal, neurodegenerative disease for which there is no cure.  
  
A substantial body of evidence implicates the neuroimmune system and specifically activated 
microglia in ALS pathophysiology. Activated microglia are increased in postmortem brain and 
spinal cord tissue from patients with ALS compared to healthy controls, and the number of 
activated microglia correlates positively with faster rate of disease progression. In addition, studies 
of blood cells in people with ALS have shown an increased activation of two of the major 
inflammatory cell types in the body, monocytes and T cells. Among T cells, regulatory T cells 
(Tregs) have been recently proposed to play a role in ALS progression. Tregs and their FoxP3 
protein expressions were reduced in rapidly progressing ALS patients and inversely correlated with 
progression rates. A 3.5-year prospective study revealed that early reduced FoxP3 levels were 
predictive of future rapid progression and attenuated survival. These data suggest that Tregs may 
influence disease progression rates in ALS. 
 
 
 
 
 
 

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Study Design 
This is a single center, open label, pilot trial of RNS60 in people with ALS. Study participants will 
receive study drug for 24 weeks following the core study schedule of activities. Upon nearing 
completion of the core study, subjects will be given the option to continue to receive drug for 
approximately an additional 24 weeks, for a total of approximately 48 weeks on study drug, 
following the optional extension phase schedule of activities.  
 
 
Study Objectives and Endpoints  
The primary objectives of the study are to determine the preliminary safety and tolerability of 
RNS60 treatment in 18 people with ALS over 24 weeks.  We will measure the impact of RNS60 on 
blood biomarkers of inflammation. In addition, in a subgroup of  13 study participants (“Imaging 
group”), an additional primary objective is to measure the impact of RNS60 on [11C]-PBR28 uptake 
in the motor cortices and brain stem measured by positron emission tomography (PET) imaging.  

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We will also measure the effect of RNS60 on ALS clinical outcomes [ALS functional rating scale 
(ALSFRS-R), slow vital capacity (SVC), strength (measured by ATLIS- Accurate Test of Limb 
Isometric Strength)].  
For participants who elect to continue with the optional 24 week extension, safety parameters (labs, 
EKG, adverse events, C-SSRS) will continue to be monitored. We will also collect ALSFRS-R and 
SVC outcome measures. 
 
Study Location 
Massachusetts General Hospital (MGH) 
 
Number of Planned Subjects 
Up to 25 subjects will be screened for the study with the goal of enrolling 18 for treatment. All 18 
enrolled subjects will be given an opportunity to sign a consent form addendum during Weeks 18-
22 to receive approximately 24 additional weeks of drug treatment. 
 
Study Population 
This study will be conducted in subjects who meet the El Escorial criteria of possible, laboratory-
supported probable, probable, or definite criteria for a diagnosis of ALS.  At screening, eligible 
subjects must be at least 18 years old and must provide written informed consent prior to screening. 
Subjects on a stable dose of riluzole and those not taking riluzole, and women of child-bearing age 
at screening are eligible for inclusion as long as they meet specific protocol requirements.  Safety, 
tolerability, blood biomarkers, and clinical outcomes will be collected on all subjects. In a subgroup 
of 10 study participants (“Imaging group”) neuro-imaging will be performed. Detailed criteria are 
described in the body of the protocol. 
 
Treatment Plan 
RNS60 will be administered in two ways: by intravenous (IV) infusion one day a week (infusion 
dose: 375ml, infused over a 40-min period) and by inhalation (the remaining 6 days a week, 4 
ml/day) for 24 weeks or up to approximately 48 weeks. 
 
Duration of Treatment and Follow-up 
Subjects will remain on treatment in the core study for 24 weeks.  Each subject will also have a 
Week 28 Follow-up Telephone Interview to assess for adverse events (AEs), changes in 
concomitant medications and to administer the ALSFRS-R. After the completion of the trial, 
subjects will be called by phone approximately every 3 months to ascertain ALSFRS-R and vital 
status for up to 2 years. 
 
 
 

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Optional Extension Phase 
Upon nearing completion of the core study, subjects will be given the option to continue RNS60 
treatment for an additional 24 weeks of weekly infusions and daily inhalations. Subjects interested 
in continuing treatment in the extension phase will sign an additional IRB-approved consent 
addendum document with the physician-investigator during a clinic visit between Week 18 and 
Week 23.  Extension phase drug dispensing will occur at the Week 23 visit. Safety parameters such 
as blood work, urine samples, EKGs, and adverse event recording will continue to be monitored 
during the extension phase. ALSFRS-R and SVC outcome measures will be collected at two time 
points. Each subject will also have a Week 52 Follow-up Telephone Interview to assess for adverse 
events (AEs), changes in concomitant medications and to administer the ALSFRS-R. After the 
completion of the trial, subjects will be called by phone approximately every 3 months to ascertain 
ALSFRS-R and vital status for up to 2 years.  
 
Subjects may choose to discontinue RNS60 treatment at any point during the optional extension 
phase. 
 

 
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SCHEDULE OF ACTIVITES – CORE STUDY 
 
Screening 
Visit1 
 
Baseline 
Visit 
 
Weekly 
visits 
Week 1 
through 
Week 10 
Wk 11 
Visit 
Weekly visits 
Week 12 
through Week 
22 
Week 23 
Visit 
Week 
28 
Phone 
call  
Follow Up 
Chart Review 
/ Phone Call2 
Final Safety Visit 
(for early study 
drug 
discontinuation 
only)3 
Visit Window 
-42 days 
Day 0 
Day 7 ± 3 
Day 77 ± 3 
Day 84 ± 3 
Day 161 ± 3 
Day 196 
+ 5 
Every 3 
months 
 
Informed Consent  
X 
 
 
 
 
 
 
 
 
Eligibility Criteria 
X 
X 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
ALS History / ALS Diagnosis 
X 
 
 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
Blood sample for TSPO Affinity 
test† 
X 
 
 
 
 
 
 
 
 
12-lead ECG 
X 
X 
 
 
 
X 
 
 
X 
Safety Labs4 
X 
X 
 
X 
 
X 
 
 
X 
Vital Signs /Height and weight5 
X 
X 
X 
X 
X 
X 
 
 
X 
Neurological exam 
X 
 
 
 
 
X 
 
 
X 
Physical exam 
X 
 
 
 
 
X 
 
 
X 
[11C]PBR28-PET† 
 
X* 
 
 
X** 
 
 
 
 
ALSFRS-R 
 
X* 
 
X 
X** 
X 
X 
X 
X 
U Penn Upper Motor Neuron 
Burden6 
X 
X 
 
X 
 
X 
 
 
X 
Slow Vital Capacity 
 
X* 
 
X 
X** 
X 
 
X 
X 
Strength measurement (ATLIS)7 
X 
X 
 
X 
 
X 
 
 
X 
C-SSRS 
 
X 
 
X 
 
X 
 
 
X 
RNS60 infusion 
 
X 
X 
X 
X 
X 
 
 
 
RNS60 Dispensing (for inhalation) 
 
X 
X  (week 7) 
 
X  (week 15) 
 
 
 
 
RNS60 Accountability 
 
 
X 
X 
X 
X 
 
 
X 
AE review8 
X 
X 
X 
X 
X 
X 
X 
 
X 
Concomitant Meds 
X 
X 
X 
X 
X 
X 
X 
 
X 
Collection of blood biomarkers 
 
X 
 
X 
 
X 
 
 
X 
1 Screening procedures must be completed within 6 weeks prior to Baseline Visit. 

 
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2 Follow-up will continue every 3 months up to 2 years to collect data on SVC, ALSFRS-R, and survival status.  This information may be obtained 
via chart review and patient contact. 
3 Follow-up phone call to occur 28 +5 days after the last dose of study drug if a subject discontinues from the study prematurely. 
4 Safety labs include Hematology (CBC with differential), Complete Chemistry Panel, Liver Function Tests, Urinalysis, Urine pregnancy test 
(WOCBP). 
5 Vital signs include systolic and diastolic pressure in mmHg, respiratory rate/minute, heart rate/minute, temperature and weight.  Height measured 
at Screening Visit only. 
6 The Penn Upper Moter Neuron-Burden (UMN-B) includes testing of reflexes, the CNS Lability Scale (CNS-LS) and the Ashworth Spasticity 
Scale. 
7 If time permits, ATLIS will be performed at the screening visit.  
8 Adverse events that occur AFTER signing the informed consent form will be recorded. 
*Off treatment [11C]PBR28-PET will be performed one time only between the Screening and Baseline visit. ALSFRS-R and SVC will be repeated 
on the day of the scan. 
**On treatment [11C]PBR28-PET will be performed one time only between the Week 18 and Week 23 visits. ALSFRS-R and SVC will be 
assessed the day of the scan ONLY. 
†For subjects in the “Imaging group” only. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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SCHEDULE OF ACTIVITES – OPTIONAL EXTENSION PHASE 
 
 
Weekly visits 
Week 24 
through Week 
34 
 
Week 35 
 
Weekly visits 
Week 36 
through Week 
46 
Week 47 
Week 52 
Phone Call 
Follow Up Chart 
Review / Phone 
Call2 
Final Safety Visit 
(for early study 
drug 
discontinuation 
only)1 
Visit Window 
Day 168 ± 3 
Day 245 ± 3 
Day 252 ± 3 
Day 329 ± 3 
Day 364 ± 3 
Every 3 months 
 
12-lead ECG 
 
X 
 
X 
 
 
X 
Safety Labs3 
 
X 
 
X 
 
 
X 
Vital Signs / Weight4 
X 
X 
X 
X 
 
 
X 
Neurological exam 
 
 
 
X 
 
 
X 
Physical exam 
 
 
 
X 
 
 
X 
ALSFRS-R 
 
X 
 
X 
X 
X 
X 
Slow Vital Capacity 
 
X 
 
X 
 
X 
X 
C-SSRS 
 
X 
 
X 
 
 
X 
RNS60 infusion 
X 
X 
X 
X 
 
 
 
RNS60 Dispensing (for inhalation) 
X (week 30) 
 
X  (week 38) 
 
 
 
 
RNS60 Accountability 
X 
X 
X 
X 
 
 
X 
AE review3 
X 
X 
X 
X 
X 
 
X 
Concomitant Meds 
X 
X 
X 
X 
X 
 
X 
 
1 Follow-up phone call to occur 28 ± 5 days after the last dose of study drug if a subject discontinues from the study prematurely. 
2 Follow-up will continue every 3 months up to 2 years to collect data on SVC, ALSFRS-R, and survival status.  This information may be obtained via chart 
review and patient contact. 
3 Safety labs include Hematology (CBC with differential), Complete Chemistry Panel, Liver Function Tests, Urinalysis, Urine pregnancy test (WOCBP). 
4 Vital signs include systolic and diastolic pressure in mmHg, respiratory rate/minute, heart rate/minute, temperature and weight. 
 

 
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STUDY WORKFLOW
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 
 
            
  
 
 
 
 
 
 
 
 
        
 
 
 
 
 
 
 
 
 
           
 
 
Screening Period 
On Active Treatment 
Washout Period 
~ 25 Screened 
18 Subjects on RNS60; drug is administered by weekly 
IV infusions (infusions to occur at MGH) as well as by 
intranasal administration the remaining 6 days a week. 
6 weeks 
Subjects who discontinue from the study early will be asked to return to the study site for Final Safety assessments, and will be asked to have a final Follow-Up 
Telephone Call 28 days (+5 days) after taking their last dose of study drug. 
Screening 
Baseline 
Weekly visits at MGH (Week 1 to Week 23 or up to Week 47) 
Week 28 or 52 
(phone call)  

 
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1 
ETHICS/PROTECTION OF HUMAN SUBJECTS 
1.1 
Institutional Review Board (IRB) 
This study will be conducted in compliance with current Good Clinical Practices (GCP) and 
Title 21 Part 56 of the United States of America Code of Federal Regulations (CFR) relating to 
IRBs.  
1.2 
Ethical Conduct of Study 
The study will be conducted in accordance with GCP defined by the International Conference on 
Harmonization (ICH) and the ethical principles of the Declaration of Helsinki. 
1.3 
Subject Information and Consent 
This study will be conducted in compliance with Title 21 Part 50 of the United States of America 
Code of Federal Regulations (CFR), Federal Regulations and ICH Guidance Documents 
pertaining to informed consent.  At the first visit, prior to initiation of any study-related 
procedures, subjects will be informed about the nature and purpose of the study, 
participation/termination conditions, and risks and benefits. Subjects will be given adequate time 
to ask questions and become familiar with the study prior to providing consent to participate. 
Subjects will give their written consent to participate in the study and will be provided with a 
copy of the fully executed consent form for their records. 

 
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3 
OBJECTIVES 
3.1 
Study Objectives 
The primary objectives of the study are to determine the safety and tolerability of RNS60 in 18 
patients with ALS. The following clinical outcomes will be collected: ALS functional rating 
scale (ALSFRS-R), slow vital capacity (SVC), strength (measured by ATLIS- Accurate Test of 
Limb Isometric Strength). An additional primary objective is to measure the impact of RNS60 on 
several markers of neuro-inflammation measured by blood biomarkers in all subjects and by 
[11C]-PBR28 positron emission tomography (PET) imaging in a subgroup of 13 subjects. 
3.2 
Study Outcome Measures 
For all subjects enrolled in the study, the following will be primary outcome measures: 
1- Safety, as measured by AEs and clinically meaningful changes in vital signs, physical 
examination, and standard clinical laboratory tests; 
2- Tolerability, defined as the ability of subjects to complete the entire 24-week treatment 
portion of study; 
3- Clinical outcomes: Measured by ALSFRS-R, SVC, and strength (measured by ATLIS).  
4- Blood biomarkers of inflammation. 
 
For subjects in the “Imaging group”, the following additional outcome measures will be 
obtained: 
1- Neuroimaging biomarkers ([11C]-PBR28-PET) including both regions of interest (ROI) 
and voxel-based analyses 
 
 

 
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4 
STUDY DESIGN 
4.1 
Overall Study Design and Plan 
During the enrollment period, approximately 25 subjects will be screened at the Massachusetts 
General Hospital (MGH).  Approximately 18 of these subjects are expected to be eligible to 
receive RNS60 per study protocol.  RNS60 will be administered in two ways: by IV infusion one 
day a week (infusions to occur at MGH) and by inhalation (once a day for the remaining 6 days a 
week). All visit windows (± 3 days) are consecutive calendar days and are calculated from the 
day the participant starts study treatment (the day of the Baseline Visit). 
4.2 
Study Centers 
This study will be conducted as a single center study at the MGH. 
4.3 
Study Duration 
Subjects in the core study will remain on treatment for 24 weeks. Subjects may elect to continue 
with the 24-week extension phase sometime between Week 18 and Week 23. Each subject will 
also have a Follow-up Telephone Interview 28 days ±5 to assess for AEs, changes in 
concomitant medications and to administer the ALSFRS-R. 
4.4 
Protocol Adherence 
The Principal Investigators (PIs) agree to adhere to the protocol detailed in this document and 
agrees that any changes to the protocol must be approved by the site Institutional Review Board 
(IRB).   The PIs will be responsible for enrolling only those study subjects who have met 
protocol eligibility criteria. 
 

 
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5 
SELECTION AND WITHDRAWAL OF STUDY POPULATION 
5.1 
Number of Study Subjects 
Approximately 25 subjects will be consented for the study. Any subject who signs consent will 
be considered enrolled in the study. Screening study procedures will begin after informed 
consent. 
 
If a subject fails screening, at a minimum, the following information will be captured and entered 
in the data capture system: inclusion/exclusion criteria, demographics, screening lab results, 
reason for screen failure. 
 
Fifteen (15) subjects will receive RNS60 for up to 48 weeks per study protocol and will be 
followed up to 52 weeks.  
5.2 
Inclusion and Exclusion Criteria 
5.2.1 Inclusion Criteria 
 
Study subjects meeting all of the following criteria will be allowed to enroll in the study:  
1- ALS volunteers must be diagnosed as having possible, probable, probable-laboratory 
supported, or definite ALS, either sporadic or familial according to modified El Escorial 
criteria.  
2- Age 18-80, able to provide informed consent, and comply with study procedures.  
3- Participants must not have taken riluzole for at least 30 days, or be on a stable dose of 
riluzole for at least 30 days, prior to screening (riluzole-naïve participants are permitted 
in the study).  
4- Women must not be lactating or able to become pregnant (e.g. post menopausal, 
surgically sterile, or using adequate birth control) for the duration of the study and 3 
months after study completion.  
5- Males should practice contraception for the duration of the study and 3 months after 
completion. 
 
Study subjects in the “Imaging group” will also need to meet the following additional inclusion 
criteria: 
1- Ability to safely lie flat for 90 min for PET procedures in the opinion of the study 
physician. 
2- High or mixed affinity to bind TSPO protein (Ala/Ala or Ala/Thr) (Details below). 
3- Score of 25 or greater (out of 45) on the Upper Motor Neuron Burden (Details below).  
 

 
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TSPO affinity test: venous blood will be drawn from all participants at Screening in order to 
have them genotyped for the Ala147Thr TSPO polymorphism in the TSPO gene (rs6971). About 
10% of humans show low binding affinity to PBR2824. A recent study has demonstrated that the 
rs6971 polymorphism predicts PBR28 binding affinity in human platelets25. Since the low-
affinity binder phenotype is consistent across all tissues within the same person, testing for the 
Ala147Thr polymorphism can be performed to predict low affinity for PBR28 in all organs, 
including the brain25. High or Mixed affinity binders (Ala/Ala or Ala/Thr) will be considered 
eligible, whereas the low affinity binders (Thr/Thr) will be considered ineligible for the study. 
 
Upper Motor Neuron Burden (UMN-B): The UMN-B at screening will be calculated by 
assessing five bilateral deep tendon reflexes on a scale of 0-4, as well as three pathological 
reflexes (bilateral Hoffman and Babinski signs, and jaw jerk) 0 or 1, for a total possible score of 
45. Subjects screening for the imaging group with scores of 25 or more may be considered 
eligible.  
5.2.2 Subject Exclusion Criteria  
 
Study subjects meeting any of the following criteria during screening evaluations will be 
excluded from entry into the study: 
1- Abnormal liver function defined as AST and/or ALT > 3 times the upper limit of the 
normal. 
2- Renal insufficiency as defined by a serum creatinine > 1.5 times the upper limit of 
normal. 
3- The presence of unstable psychiatric disease, cognitive impairment, or dementia that 
would impair ability of the participant to provide informed consent, according to PI 
judgment. 
4- Clinically significant unstable medical condition (other than ALS) that would pose a risk 
to the participant if they were to participate in the study.   
5- History of HIV, clinically significant chronic hepatitis, or other active infection. 
6- Active participation in another ALS clinical trial within 30 days of the Screening Visit 
 
Study subjects in the Imaging group meeting any of the additional following criteria during 
screening evaluations will be excluded from entry into the study: 
1- Exposure to immunomodulatory medications within 30 days of the Screening Visit.  
2- Any contraindication to undergo MRI studies such as  
a. History of a cardiac pacemaker or pacemaker wires 
b. Metallic particles in the body 
c. Vascular clips in the head 
d. Prosthetic heart valves 
e. Claustrophobia 
3- Radiation exposure that exceeds the site’s current guidelines 

 
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4- Current use of tobacco products including cigarettes, cigars, snuff and chewing tobacco, 
or nicotine replacement products such as gum or patch. 
5- Current use of medications / treatments under investigation in ALS clinical trials or use 
of “off-label” medications for ALS as determined by the clinical judgment of the 
principal investigator.  
5.3 
Withdrawal 
A study subject will be discontinued from participation in the study if: 
• Any clinical AE, laboratory abnormality, concurrent illness, or other medical condition or 
situation occurs such that continued participation in the study would not be in the best 
interest of the subject. 
• The participant meets any exclusion criteria (either newly developed or not previously 
recognized). 
 
Subjects are free to withdraw from participation in the study at any time upon request. 
5.3.1 Handling of Withdrawals 
A subject may choose to discontinue participation in the study at any time.  Subjects who 
permanently discontinue study drug should complete early study drug termination procedures per 
protocol.  The subject should then return any unused study drug and will be asked to return to the 
study site for a final safety visit. At that visit, the subject will be asked to have a final telephone 
call 28 days (+ 5 days) after taking their last dose of study drug.  
5.3.2 Termination of Study  
This study may be prematurely terminated if, in the opinion of the PIs, there is sufficient 
reasonable cause.   
 
Circumstances that may warrant termination include, but are not limited to: 
• Determination of unexpected, significant, or unacceptable risk to subjects. 
• Enrollment is unsatisfactory. 
• Insufficient adherence to protocol requirements. 
• Data are not sufficiently complete and/or evaluable.  

 
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6 
TREATMENTS ADMINISTERED 
6.1 
Treatments  
6.1.1 Study Product Description 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
   
 
 
 
6.1.2 Treatments administered 
 
RNS60 will be administered in two ways: by IV infusion one day a week (infusion dose: 375 ml, 
infused over a 40-minute period) and by inhalation (the remaining 6 days a week, 4 ml/day). The 
nebulizer system supplied is comprised of the PARI Trek S nebulizer compressor and the LC 
Sprint reusable nebulizer. 
 
 
 
 
 
 

 
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RNS60 will be administered intravenously at weekly study visits (starting on the Baseline visit) 
at the clinic site by properly trained staff designated by the investigator.  Subjects will receive 
375 ml RNS60 infused over 40 minutes. Infusion documentation should include recording 
infusion start and stop times, volume infused, and any interruptions to the infusion.   
  
During the remaining days of the week, treatment with RNS60 will be nebulized at home in the 
morning.  
 
 
 
 
 
 
 
 
 
 
 
 
 
6.2 
Receiving, Storage, Dispensing 
6.2.1 Receipt of Drug Supply 
 
RNS60 will be provided by Revalesio Corporation (Tacoma, WA). The company will supply 
both the IV and inhalation preparations. RNS60 will be shipped directly to the MGH Research 
Pharmacy. The Research Pharmacist will be responsible for keeping records of study drug 
receipt and inventory. 
6.2.2 Storage 
 
The drug supply will be kept refrigerated in the MGH Research Pharmacy with access limited to 
those directly involved in the study.  
 
6.2.3 Dispensing of Study Drug 
 

 
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6.3 
Modification of Study Intervention/Investigational Product for a Subject 
Any dosage adjustment, including the reason for and dates of adjustment, will be documented in 
the CRF for each subject requiring this manipulation. The PIs or licensed physician Sub-
Investigator  may reduce the dosage of study drug or discontinue the study drug in its entirety for 
AEs thought to be related to the study drug or for other reason during the trial (the reason for, 
and dates of suspension or dose reduction must be documented).  If the AE is mild or moderate, 
the dosage may be reduced until the event improves.  The PIs may then choose to resume the 
higher dosage or maintain the subject at a reduced dosage. The option to continue with 
administration by IV only or inhalation only is allowable. 
 
If the event is serious or life threatening, and deemed to be definitely drug related, the study drug 
will be discontinued immediately. Study subjects must remain off the study drug permanently. 
Subjects may not resume study drug.  All AEs will be followed to resolution.  

 
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6.3.1. Dosage Discontinuation 
Reasons for discontinuation of study medication may include an AE, PI recommendation, 
protocol deviation, loss-to-follow-up, patient request, or patient death.   
 
Study subjects who discontinue study drug prematurely (early termination from study) will be 
encouraged to return for a Final Safety Visit and participate in a Follow-Up Telephone Call 28 
days (+ 5 days) after the last dose of study drug.  
6.4 
Accountability Procedures  
Subjects will be provided with a drug diary at each time point when drug for inhalation is 
dispensed (baseline, week 7, and week 15 for the core study, and week 23, week 30, and week 38 
for the extension phase). Subjects will be instructed to return all drug for inhalation consumed 
and remaining, as well as a completed diary, at weeks 7, 15, 23, 30, 37, and 47. Reconciliation of 
drug consumed and drug remaining will be logged on the drug dispensing and return log, signed 
and dated.  Any discrepancies noted will be investigated, resolved, and documented prior to 
return or destruction of unused study drug.  Drug destroyed on site will be documented in the 
study files. 
6.5 
Assessment of Subject Compliance  
Subjects will be instructed to return empty study medication containers at weeks 7, 15, 23, 30, 
37, and 47.  Site personnel will review returned study medication to determine compliance.  
6.6 
Prior and Concomitant Therapy 
Throughout the study, the subject may be prescribed concomitant medications or treatments 
deemed necessary to provide adequate supportive care provided that the medications are licensed 
in the United States. All concomitant medications and/or treatments received by a subject should 
be recorded on the appropriate source document and eCRF. 
6.6.1 Prohibited Medications and Contraindications 
Prohibited Medications 
Prohibited medications for subjects in the Imaging group are as follows: 
1- immunomodulatory medications  
2- nicotine replacement products such as gum or patch 
 
Additionally, subjects in the Biomarker group should wash from benzodiazepines and non-
steroidal anti-inflammatory medications one week prior to PET scan as these compounds would 
affect the results of the scan. 

 
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Pregnancy & Nursing Mothers 
There are no adequate and well-controlled studies in pregnant women.   Subjects or partners of 
male subjects should not become pregnant during the study or 3 months after stopping study 
drug.  If a female subject becomes pregnant, study treatment must be discontinued immediately. 
 
 
 
6.7 
Statistical considerations 
Sample size calculation was based on the primary outcomes of safety and tolerability. With a 
sample size of 15 participants, we will have over a 90% chance of seeing at least one occurrence 
of any adverse event whose probability of occurrence is 15% or greater. Tolerability will be 
defined as the ability of subjects to complete the entire 24-week treatment portion of study. With 
15 participants on active drug in this study, if 10 or more participants tolerate the drug, there is 
an 85% chance that the true tolerability among people with ALS is at least 75%.  Furthermore, if 
10 or more people tolerate the drug, there is only a 3% chance that the true tolerability will be as 
low as 40% in people with ALS. For people in the Biomarker group, primary outcomes will 
include changes in the ROI in the motor cortex as assessed by [11C]-PBR29-PET. Our previous 
studies comparing mean PBR28 binding in the motor cortices in limb-onset ALS subjects (1.18 
units) with matching healthy volunteers (1.064 units) revealed 0.116 mean difference between 
the two groups, with 0.08 standard deviation in the ALS group. With 10 people in the Biomarker 
group, the probability is 90 percent that the study will detect a treatment difference at a one-sided 
0.1 significance level if the true difference is 0.096 units.  
 
 
 
 

 
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7 
STUDY SCHEDULE 
No study procedures should be performed prior to the signing of the informed consent form 
(ICF). All subjects will sign an ICF prior to undergoing any study tests or procedures. Visit 
windows (±3 days) are consecutive calendar days and the target visit dates are calculated from 
the Baseline Visit.   
7.1 
Screening Visit 
The following procedures will be performed at an office visit to determine the subject’s 
eligibility for the study: 
o Obtain written informed consent from subject 
o Assess inclusion and exclusion criteria 
o Obtain medical history and demographics 
o Obtain ALS diagnosis history 
o Perform physical examination 
o Perform neurological examination (including UMN-B for the Imaging group) 
o Measure vital signs including height and weight 
o Collect blood and urine for safety labs 
o Collect blood for TSPO testing (Imaging group ONLY) 
o Perform ECG 
o Review and document concomitant medications and therapies 
o Assess and document AEs  
 
If time permits, ATLIS (strength testing) will be performed for all participants at the screening 
visit. This may facilitate a more accurate baseline assessment as some individuals may benefit 
from a learning effect. 
 
7.1.1 Screen Failures 
Any subject who signs consent will be considered enrolled in the study.  If a subject fails 
screening, at a minimum, the following information should be captured and entered in the 
Electronic Data Capture (EDC) System: 
o Demographics 
o Inclusion and Exclusion criteria 
o Reason for screen failure 
o Screening labs results 

 
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7.2 
Baseline Visit 
This visit will take place within 6 weeks of the Screening Visit.  The following procedures will 
be performed: 
o Review inclusion and exclusion criteria  
o Measure vital signs including weight 
o Collect blood and urine for safety labs  
o Perform ECG 
o Collect blood samples for biomarkers  
o Administer ALSFRS-R questionnaire  
o Perform U. Penn upper motor Neuron Burden (UMNB) 
o Perform Pulmonary Function Tests  
o Measure baseline strength (ATLIS) 
o Columbia Suicide Severity Rating Scale (C-SSRS) – Baseline 
o Administer 1st dose of study drug.  
o Dispense study medication (for inhalation use) for the following 8 weeks 
o Review and document concomitant medications and therapies 
o Assess and document AEs 
 
Pre- treatment neuroimaging study (MRI/PET) (Imaging group only) will take place after TSPO 
affinity test results are available. This may occur on any day between release of TSPO test 
results and Baseline, or on the same day as the Baseline Visit. This first neuroimaging study will 
be performed before any treatment is administered. ALSFRS-R and SVC will be repeated on the 
same day as the scan. STAT quantitative serum human chorionic gonadotropin (hCG) testing 
will also be performed prior to the MRI/PET scan for all women of childbearing potential 
(WOCBP).  
7.3 
Weekly study visits (Week 1 through Week 10, Week 12 through Week 22, Week 24 
through 34, and Week 36 through 46) 
Subjects will return to MGH on a weekly basis until Week 22. The following procedures will be 
performed at the Week 1 through Week 10, Week 12 through Week 22, Week 24 through 34, 
and Week 36 though 46 visits: 
o Vital signs including weight 
o Administer study drug via IV infusion  
o Review and document concomitant medications and therapies 
o Assess and document AEs 
o Check study drug compliance and accountability 
o Dispense study medication (for inhalation use) (at Week 7, Week 15, Week 23, Week 30 
and Week 38 only) 
 
Post-treatment neuroimaging study (MRI/PET) (Imaging group only) will be performed at one 
time only between the Week 18 and Week 23 visits. ALSFRS-R and SVC will be repeated on the 

 
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same day as the scan. STAT quantitative serum hCG testing will also be performed prior to the 
MRI/PET scan for all WOCBP. 
 
Subjects who wish to continue to take study drug as part of the optional extension phase will sign 
consent between Weeks 18 and 23. 
7.4 
Week 11 Visit  
The following procedures will be performed at the Week 11 visit: 
o Measure vital signs including weight 
o Collect blood and urine for safety labs  
o Collect blood for biomarkers 
o Administer ALSFRS-R questionnaire  
o Perform U. Penn upper motor Neuron Burden (UMNB) 
o Perform Pulmonary Function Tests  
o Measure strength (ATLIS) 
o Columbia Suicide Severity Rating Scale (C-SSRS) – Since last visit 
o Administer study drug via IV infusion  
o Check study drug compliance and accountability  
o Review and document concomitant medications and therapies 
o Assess and document AEs 
 
7.5 
Week 23 Visit 
The following procedures will be performed at the Week 23 visit: 
o Measure vital signs including weight 
o Perform ECG 
o Perform neurological exam 
o Perform physical exam 
o Collect blood and urine for safety labs  
o Collect blood for biomarkers  
o Administer ALSFRS-R questionnaire  
o Perform U. Penn upper motor Neuron Burden (UMNB) 
o Perform Pulmonary Function Tests  
o Measure strength (ATLIS) 
o Columbia Suicide Severity Rating Scale (C-SSRS) – Since last visit 
o Administer  study drug via IV infusion 
o Review and document concomitant medications and therapies 
o Assess and document AEs 
o Check study drug compliance 
o For those subjects that do not wish to continue, perform study drug accountability and 
collect all unused study drug, empty containers and nebulizers 
o For those subjects that wish to participate in the 24-week extension phase, medication for 
inhalation will be dispensed at this visit 

 
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7.6 
Week 35 Visit 
The following procedures will be performed at the Week 35 visit: 
o Measure vital signs including weight 
o Perform ECG 
o Collect blood and urine for safety labs  
o Administer ALSFRS-R questionnaire  
o Perform Pulmonary Function Tests  
o Columbia Suicide Severity Rating Scale (C-SSRS) – Since last visit 
o Review and document concomitant medications and therapies 
o Assess and document AEs 
o Check study drug compliance and accountability 
7.7 
Week 47 Visit 
The following procedures will be performed at the Week 23 visit: 
o Measure vital signs including weight 
o Perform ECG 
o Perform neurological exam 
o Perform physical exam 
o Collect blood and urine for safety labs  
o Administer ALSFRS-R questionnaire  
o Perform Pulmonary Function Tests  
o Columbia Suicide Severity Rating Scale (C-SSRS) – Since last visit 
o Review and document concomitant medications and therapies 
o Assess and document AEs 
o Check study drug compliance 
o Perform study drug accountability and collect all unused study drug, empty containers 
and nebulizers 
7.8 
Week 28 or 52 Phone Interview 
The following procedures will be performed at the Week 28 Phone Call: 
o Administer ALSFRS-R questionnaire  
o Review and document concomitant medications and therapies 
o Assess and document AEs 
7.9 
Final Safety Visit 
Subjects who withdraw consent will be asked to come in for a Final Safety Visit as soon as 
possible, and will be asked to have a final Follow-Up Telephone Call (+ 5 days, but no earlier 
than 28 days, after subject’s last dose of study drug) to assess for adverse events.  
 
The following will be performed at the Final Safety Visit: 

 
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o Measure vital signs  
o Perform ECG 
o Perform neurological exam 
o Perform physical exam 
o Collect blood samples for safety labs  
o Collect blood for biomarkers  
o Administer ALSFRS-R questionnaire  
o Perform U. Penn upper motor Neuron Burden (UMNB) 
o Perform Pulmonary Function Tests  
o Measure strength (ATLIS) 
o Columbia Suicide Severity Rating Scale (C-SSRS) – Since last visit 
o Review and document concomitant medications and therapies 
o Assess and document AEs 
o Check study drug compliance  
o Perform study drug accountability and collect all unused study drug and empty containers 
and nebulizers 
7.10 
Follow-up 
After the Week 28 Follow-up Telephone Interview, subjects may be contacted every three 
months for up to two years, or until consent is withdrawn, in order to obtain vital status and 
clinical information including the ALSFRS-R.  Additionally, two years of post-study access to 
subjects’ medical records will be requested to allow for review in combination with study data in 
order to investigate any correlation between imaging data collected during this study and 
subjects’ clinical outcomes. 

 
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8 
CLINICAL ASSESSMENTS AND OUTCOME MEASURES 
8.1 
Clinical Variables 
Assessments will be performed at designated time-points throughout the study for clinical 
evaluation.  In addition to the assessments evaluated below, subjects will provide information on 
their demographics, past medical history, including ALS, as well as concomitant medication 
usage. 
8.1.1 Vital Signs, Height & Weight 
Vital signs, including systolic and diastolic blood pressure, pulse rate (radial artery)/minute, 
respiratory rate/minute, temperature and weight will be assessed at specified visits.  Height will 
be measured and recorded at the Screening Visit only.   
8.1.2 Clinical Laboratory Assessments 
 
The following safety laboratory tests will be performed during the study: 
 
o Hematology with differential panel and urinalysis: complete blood count with differential 
(hematocrit, hemoglobin, platelet count, RBC indices, Total RBC, Total WBC, and WBC 
& differential)  
o Blood chemistry panel/Liver function tests (LFTs): alanine aminotransferase (ALT 
(SGPT)), aspartate aminotransferase  (AST (SGOT)), albumin, alkaline phosphatase, 
bicarbonate, blood urea nitrogen, calcium, chloride, creatinine, glucose, magnesium, 
phosphate, potassium, sodium, total bilirubin and total protein  
o Urine human chorionic gonadotrophin (hCG) for women of childbearing potential 
(WOCBP) STAT quantitative serum hCG testing will also be performed prior to the 
MRI/PET scan for all WOCBP. 
 
Additional testing may be ordered if needed, to further assess an AE, or if there is any suspicion 
that a subject may be pregnant, throughout the course of the study. 
8.1.3 Physical Examination 
A physical examination will be performed and recorded.  The following systems will be 
examined: head/neck, eyes, ears, nose/throat, cardiovascular, lungs, abdomen, musculoskeletal, 
central nervous system, extremities, and skin.   

 
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8.1.4 Neurological Examination 
A neurological examination will be performed and recorded.   
8.1.5 Adverse Events 
AEs will be documented at each study visit, including the final telephone call 28 days after the 
last dose of study drug.  Information on adverse effects of study medication and on inter-current 
events will be determined at each visit by direct questioning of the subjects and review of 
concomitant medications.  
8.1.6 ALSFRS-R 
The ALSFRS-R is a quickly administered (5 minutes) ordinal rating scale (ratings 0 to 4) used to 
determine subjects' assessment of their capability and independence in 12 functional activities.  
All 12 activities are relevant in ALS. Initial validity was established by documenting that in ALS 
patients, change in ALSFRS-R scores correlated with change in strength over time, was closely 
associated with quality of life measures, and predicted survival. The test-retest reliability is 
greater than 0.88 for all test items. The advantages of the ALSFRS-R are that the categories are 
relevant to ALS, it is a sensitive and reliable tool for assessing activities of daily living function 
in those with ALS, and it is quickly administered.  With appropriate training the ALSFRS-R can 
be administered with high inter-rater reliability and test-retest reliability.  The ALSFRS-R can be 
administered by phone with good inter-rater and test-retest reliability.  The equivalency of phone 
versus in-person testing, and the equivalency of study subject versus caregiver responses have 
also recently been established.  Therefore, if necessary, the ALSFRS-R may be given to the 
study subject over the phone.   
8.1.7 Pulmonary Function Testing 
Pulmonary Function Testing includes Slow Vital Capacity (SVC). 
 
Slow Vital Capacity (SVC): The vital capacity (VC) (percent of predicted normal) will be 
determined, using the upright slow VC method. The VC can be measured using conventional 
spirometers that have had a calibration check prior to subject testing.  A printout from the 
spirometer of all VC trials will be retained.  Three VC trials are required for each testing session, 
however up to 5 trials may be performed if the variability between the highest and second 
highest VC is 10% or greater for the first 3 trials. Only the 3 best trials are recorded on the CRF.  
8.1.8  C-SSRS 
The US FDA recommends the use of a suicidality assessment instrument that maps to the 
Columbia Classification Algorithm for Suicide Assessment (C-CASA)62. The C-CASA was 
developed to assist the FDA in coding suicidality data accumulated during the conduct of clinical 

 
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trials of antidepressant drugs. One such assessment instrument is the Columbia Suicide Severity 
Rating Scale (C-SSRS)63. The C-SSRS involves a series of probing questions to inquire about 
possible suicidal thinking and behavior. 
Only investigators who have been fully trained in the administration of the C-SSRS will assess 
subject suicidality. As part of training, investigators are prepared to respond to and manage 
instances in which patients express suicidal ideation or exhibit suicidal behavior. 
At the Baseline Visit, the C-SSRS Baseline version will be administered. This version is used to 
assess suicidality over the subject’s lifetime and specifically for the previous 6 month time 
period. 
At the Week 11, Week 23, Week 35, Week 47, and the Final Safety visit, as applicable, the Since 
Last Visit version of the C-SSRS will be administered. This version of the scale assesses 
suicidality since the subject’s last visit. 
Information obtained from: http://www.cssrs.columbia.edu/ 
8.1.9  Upper Motor Neuron-Burden (UMN-B) 
 
The Penn Upper Motor Neuron-Burden (UMN-B) is the total number of pathological UMN signs 
on examination including pathologically brisk biceps, supinator, triceps, finger, knee and ankle 
reflexes, and extensor plantar responses assessed bilaterally and brisk facial and jaw jerks (9).  
The scale is a combination of Ashworth, Reflexes, and Pseudobulbar Affect scale (Range score: 
0 to 32). 
 
The UMN also includes scoring of the Center for Neurologic Study-Lability Scale (CNS-LS), a 
7-item self report scale that assesses pseudobulbar affect (PBA) by measuring the perceived 
frequency of PBA episodes (laughing or crying) and the Ashworth Spasticity Scale, a standard 
measure for spasticity that has been used in numerous ALS clinical trials to assess spasticity due 
to upper motor neuron dysfunction in ALS.  Data is generated from the clinical exam and scored 
from 1 to 5, the lowest score indicating normal tone and the highest extreme spasticity. 
8.1.10 
Blood Biomarkers  
Subjects will also be asked to provide blood samples for biomarker analysis per Schedule of 
Activities. These blood samples will be stored in a sample repository.  These samples will be 
used for biomarker research.  All samples will be labeled with a code.  The code will not include 
any identifiable information.  Any analysis performed on these samples is for research purposes 
only.   
 

 
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Unused samples will remain in the biorepository for future ALS-related research. There is no 
scheduled date on which the samples will be destroyed.  Samples may be stored for research 
until they are used, damaged, decayed or otherwise unfit for analysis. Subjects have the option of 
declining participation in this portion of the study at any time by withdrawing their consent to 
have their sample used.  However, it will not be possible to destroy samples that may have 
already been used.   
8.1.11 Strength measurement (ATLIS) 
Changes in strength will be measured using ATLIS (Accurate Test of Limb Isometric Strength), 
a non-invasive device that allows measurements of isometric strength in 12 muscle groups of the 
arms and legs using a standard protocol (elbow and knee flexion and extension, grip, and 
dorsiflexion). ATLIS consists of a frame with metal uprights. A wireless load cell is attached to 
adjustable testing stations positioned on the frame. The load cell transmits data (peak force) to a 
laptop computer using wireless technology. The General Hospital Corporation was granted a 
patent for this device by the US Patent Office (Patent # 7,493,812  issued 2/24/09). This device is 
not FDA approved. 
8.1.12 Neuroimaging  
Subjects in the Imaging group will undergo Magnetic Resonance Imaging (MRI) / Positron 
Emission Tomography (PET) twice during the course of the study. MR-PET scanning will be 
performed simultaneously using the Siemens 3 Tesla TIM Trio whole-body MRI system with a 
head PET camera insert. The goal of these scans is to measure activated microglia in study 
participants before treatment and after several weeks of treatment. The first scan will occur 
between the Screening and the Baseline visits (off treatment), after subject eligibility has been 
confirmed by TSPO affinity binding assay. The second scan will occur between the Week 18 and 
Week 23 visits (on treatment). Neuroimaging will be performed at the MGH Martinos Center for 
Biomedical Imaging.  Subjects will be asked to lie still in a supine position for the duration of the 
study, which will take approximately 90 min.  
 
 

 
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9 
SAFETY AND ADVERSE EVENTS 
The AE definitions and reporting procedures provided in this protocol comply with all applicable 
regulations and ICH guidelines.  The PIs will carefully monitor each subject throughout the 
study for possible AEs.  All AEs will be documented on CRFs designed specifically for this 
purpose.  It is also important to report all AEs, especially those that result in permanent 
discontinuation of the investigational product being studied, whether serious or non-serious. 
9.1 
Definitions of AEs, Suspected Adverse Drug Reactions & SAEs 
9.1.1 Adverse Event and Suspected Adverse Drug Reactions 
An adverse event (AE) is any unfavorable and unintended sign (including a clinically significant 
abnormal laboratory finding, for example), symptom, or disease temporally associated with the 
study, use of a drug product or device whether or not considered related to the drug product or 
device.  
 
Adverse drug reactions (ADR) are all noxious and unintended responses to a medicinal product 
related to any dose.  The phrase “responses to a medicinal product” means that a causal 
relationship between a medicinal product and an adverse event is at least a reasonable possibility, 
i.e., the relationship cannot be ruled out.  Therefore, a subset of AEs can be classified as 
suspected ADRs, if there is a causal relationship to the medicinal product. 
 
Examples of AEs include: new conditions, worsening of pre-existing conditions, clinically 
significant abnormal physical examination signs (i.e. skin rash, peripheral edema, etc), or 
clinically significant abnormal test results (i.e. lab values or vital signs), with the exception of 
outcome measure results, which are not being recorded as AEs in this trial (they are being 
collected, but analyzed separately). Stable chronic conditions (i.e., diabetes, arthritis) that are 
present prior to the start of the study and do not worsen during the trial are NOT considered AEs.  
Chronic conditions that occur more frequently (for intermittent conditions) or with greater 
severity, would be considered as worsened and therefore would be recorded as AEs. 
 
AEs are generally detected in two ways: 
 
 
Clinical  symptoms reported by the subject or signs detected on examination. 
 
Ancillary Tests  abnormalities of vital signs, laboratory tests, and other diagnostic 
procedures (other than the outcome measures, the results of which are not being captured 
as AEs). 

 
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For the purposes of this study, symptoms of progression/worsening of ALS, including ‘normal’ 
progression, will be recorded as AEs.     
 
The following measures of disease progression will not be recorded as AEs even if they worsen 
(they are being recorded and analyzed separately): vital capacity results and ALSFRS-R results.  
 
If discernible at the time of completing the AE log, a specific disease or syndrome rather than 
individual associated signs and symptoms should be identified by the PI and recorded on the AE 
log.  However, if an observed or reported sign, symptom, or clinically significant laboratory 
anomaly is not considered by the Site Investigator to be a component of a specific disease or 
syndrome, then it should be recorded as a separate AE on the AE log.  Clinically significant 
laboratory abnormalities, such as those that require intervention, are those that are identified as 
such by the PI. 
 
Subjects will be monitored for AEs from the time they sign consent until completion of their 
participation in the study (defined as death, consent withdrawal, loss to follow up, early study 
termination for other reasons or following completion of the entire study).   
9.1.2 Serious Adverse Events 
A serious adverse event (SAE) is defined as an adverse event that meets any of the following 
criteria: 
1. Results in death. 
2. Is life threatening: that is, poses an immediate risk of death as the event occurred. 
a. This serious criterion applies if the study subject, in the view of the PI or Sponsor, 
is at immediate risk of death from the AE as it occurs.  It does not apply if an AE 
hypothetically might have caused death if it were more severe. 
3. Requires inpatient hospitalization or prolongation of existing hospitalization. 
a. Hospitalization for an elective procedure (including elective PEG tube/g-
tube/feeding tube placement) or a routinely scheduled treatment is not an SAE by 
this criterion because an elective or scheduled “procedure” or a “treatment” is not 
an untoward medical occurrence. 
4. Results in persistent or significant disability or incapacity. 
a. This serious criterion applies if the “disability” caused by the reported AE results 
in a substantial disruption of the subject’s ability to carry out normal life 
functions. 
5. Results in congenital anomaly or birth defect in the offspring of the subject (whether the 
subject is male or female).   

 
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6. Necessitates medical or surgical intervention to preclude permanent impairment of a 
body function or permanent damage to a body structure. 
7. Important medical events that may not result in death, are not life-threatening, or do not 
require hospitalization may also be considered SAEs when, based upon appropriate 
medical judgment, they may jeopardize the subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition.  Examples of such 
medical events include blood dyscrasias or convulsions that do not result in inpatient 
hospitalization, or the development of drug dependency or drug abuse. 
 
An inpatient hospital admission in the absence of a precipitating, treatment-emergent, clinical 
AE may meet criteria for "seriousness" but is not an adverse experience, and will therefore, not 
be considered an SAE.  An example of this would include a social admission (subject admitted 
for other reasons than medical, e.g., lives far from the hospital, has no place to sleep). 
 
The PI is responsible for classifying AEs as serious or non-serious. 
9.2 
Assessment and Recording of Adverse Events 
The PIs will carefully monitor each subject throughout the study for possible AEs.  All AEs will 
be documented on CRFs designed specifically for this purpose.  All AEs will be collected and 
reported in the electronic data capture (EDC) system. The PIs shall promptly review all 
information relevant to the safety of the investigational product, including all SAEs.  Special 
attention will be paid to those that result in permanent discontinuation of the investigational 
product being studied, whether serious or non-serious. 
9.2.1 Assessment of Adverse Events 
At each visit (including telephone interviews), the subject will be asked if they have had any 
problems or symptoms since their last visit in order to determine the occurrence of AEs.   If the 
subject reports an AE, the Investigator will probe further to determine: 
1. Type of event 
2. Date of onset and resolution (duration) 
3. Severity (mild, moderate, severe) 
4. Seriousness (does the event meet the above definition for an SAE) 
5. Causality, relation to investigational product and disease 
6. Action taken regarding investigational product 
7. Outcome 
9.2.2 Relatedness of Adverse Event to Investigational Product 
The relationship of the AE to the investigational product should be specified by the PIs, using the 
following definitions: 

 
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1.  Not Related:          
Concomitant illness, accident or event with no reasonable 
association with treatment. 
 
2.  Unlikely: 
The reaction has little or no temporal sequence from administration 
of the investigational product, and/or a more likely alternative 
etiology exists. 
 
3.  Possibly Related: 
The reaction follows a reasonably temporal sequence from 
administration of the investigational product and follows a known 
response pattern to the suspected investigational product; the 
reaction could have been produced by the investigational product 
or could have been produced by the subject’s clinical state or by 
other modes of therapy administered to the subject. (Suspected 
ADR) 
 
4.  Probably Related: 
The reaction follows a reasonably temporal sequence from 
administration of investigational product; is confirmed by 
discontinuation of the investigational product or by re-challenge; 
and cannot be reasonably explained by the known characteristics 
of the subject’s clinical state. (Suspected ADR) 
 
5.  Definitely Related: 
The reaction follows a reasonable temporal sequence from 
administration of investigational product; that follows a known or 
expected response pattern to the investigational product; and that is 
confirmed by improvement on stopping or reducing the dosage of 
the investigational product, and reappearance of the reaction on 
repeated exposure. (Suspected ADR) 
9.2.3 Recording of Adverse Events 
All clinical adverse events are recorded in the Adverse Event (AE) Log in the subject’s study 
binder. Study staff should fill out the AE Log and enter the AE information into the EDC system 
within 48 hours of the site learning of a new AE or receiving an update on an existing AE.   
 
Entries on the AE Log (and into the EDC) will include the following: name and severity of the 
event, the date of onset, the date of resolution, relationship to investigational product, action 
taken, and primary outcome of event.   
 

 
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10 
SAFETY MONITORING  
10.1 
Safety Monitoring  
The study PIs will review safety data throughout the trial and may stop the trial for safety if they 
determine that there is a significant difference in the rate of a particular adverse event that would 
indicate a risk that is greater than the possible benefit of the study drug.   
 
Unanticipated problems involving risks to subjects or others including adverse events will be 
reported to the Partners Human Research Committee (PHRC) in accordance with PHRC 
unanticipated problems including AEs reporting guidelines. 
 

 
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11 
DATA COLLECTION 
All data collected as part of this study will be entered into an EDC maintained by the 
Massachusetts General Hospital (MGH) Neurological Clinical Research Institute (NCRI).  This 
platform facilitates: 
1. Capture of clinical and research data from neurologic patients for individual projects in a 
structured and secure system; 
2. Aggregating and sharing uniform, deidentified and/or anonymized datasets for secondary 
analyses. 
11.1 
ROLE OF DATA MANAGEMENT 
Data Management (DM) is responsible for the development, execution and supervision of plans, 
policies, programs, and practices that control, protect, deliver, and enhance the value of data and 
information assets. 
 
All data will be managed in compliance with applicable Sponsor and regulatory requirements. 
Site personnel will collect, transcribe, correct, and transmit the data onto source documents, Case 
Report Forms (CRFs), and/or other forms used to report, track and record clinical research data.  
DM is responsible for developing, testing, and managing clinical data management activities. 
11.1.1 Data Entry and Checks 
The site personnel are instructed to enter information into the EDC. Data capture is the 
responsibility of the staff at the site under the supervision of the PIs.  During the study, the PIs 
must maintain complete and accurate documentation for the study. The EDC provide password 
protection.  An edit checking and data clarification process will be put in place to ensure 
accuracy of the data.  Logic and range checks as well as more sophisticated rules may be built 
into the eCRFs to provide immediate error checking of the data entered.  The system has the 
capability to automatically create electronic queries for forms that contain data that are out of 
range, out of window, missing or not calculated correctly.   
11.1.2 Data Lock Process 
The platform will have the ability to lock the project-specific visits to prevent any modification 
of data once the project is closed.  Once this option is activated, every user will have Read-Only 
access to the data. 

 
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11.1.3 Data handling and record keeping 
The PIs are responsible to ensure the accuracy, completeness, legibility, and timeliness of the 
data reported.  Data reported in the eCRF derived from source documents should be consistent 
with the source documents and discrepancies should be explained. 
11.2 
CONFIDENTIALITY 
 
The EDC software and patient data reside on servers located in the Partners Healthcare Systems 
(Partners) server farm.  Physical and software access to the servers and security is provided by 
the Partners IT department.   
11.3 
RETENTION OF RECORDS 
Research records will be retained in accordance with site IRB policies.  
11.4 
PUBLICATIONS 
The PIs will be responsible for publications of results from this trial. Responsibilities will 
include the following: 
• Analyze and interpret data gathered in this study, and write publications from these data. 
• Submit manuscripts to selected journals and address peer reviewers’ comments. 
• Submit abstracts to selected meetings and present data at the meetings. 
• Determine authorship on the basis of the Uniform Requirements for Manuscripts. 
 
 

 
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12 
LITERATURE REFERENCES 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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24. 
Owen DR, Yeo AJ, Gunn RN, et al. An 18-kDa translocator protein (TSPO) 
polymorphism explains differences in binding affinity of the PET radioligand PBR28. J Cereb 
Blood Flow Metab 2012;32:1-5. 
25. 
Kreisl WC, Jenko KJ, Hines CS, et al. A genetic polymorphism for translocator protein 
18 kDa affects both in vitro and in vivo radioligand binding in human brain to this putative 
biomarker of neuroinflammation. J Cereb Blood Flow Metab 2013;33:53-58. 
 
 
 

 
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13 
APPENDICES 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 

 
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