Open Label Extension Study to Evaluate the Long-Term Safety and Efficacy of Pegunigalsidase Alfa (PRX-102) in Patients With Fabry Disease
Phase: PHASE3
Conditions: Fabry Disease
Sponsor: Chiesi Farmaceutici S.p.A.

Study Title 
Open-Label Extension Study to Evaluate the Long-Term Safety and Efficacy of 
Pegunigalsidase Alfa (PRX-102) in Patients with Fabry Disease 
 
NCT Number 
NCT03566017 
 
Date of the document 
25 April 2022 

SIGNATURE PAGE
Document Code: 
Title: PB-102-F60 Protocol 
Version: 
Status:Approved, since: 
Electronic Signature:
Signed by: 
Date: 
Meaning of Signature: Statistician Approval
Signed by: 
Date: 
Meaning of Signature: Sponsor Medical Expert
Note:  Each electronic signature above is equivalent to a handwritten signature since the
computer system managing the electronic document fully complies with the international rules
(i.e. FDACFR21part11, EU Annex11) concerning Electronic Records and Electronic Signatures
Management.
Confidential Declaration
This document contains confidential data which is the property of Chiesi. The use of this data or any
part of it must be authorized by the Department Head/Study Responsible. A secrecy agreement must
be set up and signed prior to disclosing any content of the document to a Third Party.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 1 of 66
 
CLINICAL STUDY PROTOCOL
Protocol Title: Open-Label Extension Study to Evaluate the Long-
Term Safety and Efficacy of Pegunigalsidase Alfa (PRX-102)
in Patients with Fabry Disease
Protocol Number:
CLI-06657AA1-04 (Previously PB-102-F60)
Investigational Product:
Pegunigalsidase alfa (PRX-102) PEGylated, chemically modified, 
recombinant human α-galactosidase A
Indication:
Pegunigalsidase alfa (PRX-102) is indicated for long-term 
enzyme replacement therapy in patients with a confirmed 
diagnosis of Fabry Disease (α-galactosidase A deficiency)
Phase:
3
Protocol Version
Name and Address of Sponsor:
Chiesi Farmaceutici S.p.A.*
Via Palermo 26/A
43122 Parma -– Italy
*also reported as Chiesi throughout the text
Sponsor Medical Expert:
(Clinical Research Physician)
*Readily available in case of medical questions

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 2 of 66
 
GCP Statement:
This study will be performed in compliance with GCP, including 
the archiving of essential documents
The information in this document is confidential and is proprietary to Chiesi Farmaceutici S.p.A. It is 
understood that information in this document shall not be disclosed to any third party, in any form, 
without the prior written consent of Chiesi.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 3 of 66
 
1.
SYNOPSIS
TITLE: Open-label extension study to evaluate the long-term safety and efficacy of 
pegunigalsidase alfa (PRX-102) in patients with Fabry disease.
INVESTIGATIONAL PRODUCT: Pegunigalsidase alfa (PRX-102), a chemically modified, 
recombinant human α-galactosidase A.
INDICATION: Pegunigalsidase alfa (PRX-102) is indicated for long-term enzyme 
replacement therapy in patients with a confirmed diagnosis of Fabry disease (α-galactosidase 
A deficiency).
PHASE OF DEVELOPMENT: 3
INVESTIGATIONAL SITES/LOCATIONS: Multicenter.
OBJECTIVES: To evaluate the ongoing safety, tolerability, and efficacy parameters of 
1 mg/kg pegunigalsidase alfa (PRX-102) every other week in adult Fabry patients who have 
completed studies PB-102-F20, PB-102-F30 or completed at least 48 months in PB-102-F03 
study.
STUDY DESIGN: Patients will be enrolled to receive 1 mg/kg pegunigalsidase alfa 
(PRX-102) as intravenous infusions every two weeks (±3 days). The duration of treatment is 
until pegunigalsidase alfa is commercially available to the patient or at the Sponsor's discretion. 
The end of study will be the last patient’s last visit. The last visit is defined based on the 
assumptions indicated above.
Interim analyses may be performed for administrative purposes during the study. For the 
analysis, available efficacy and safety parameters will be summarized using descriptive 
statistics.
NUMBER OF PATIENTS (PLANNED): Up to 110 adult (male and female) Fabry patients 
(≥18 yrs) who completed PB-102-F20 Study, PB-102-F30 Study, or completed at least 
48 months in PB-102-F03 Study.
MAIN CRITERIA FOR INCLUSION AND EXCLUSION:
Key Inclusion Criteria:
Eligible patients must fulfill the following inclusion criteria:
1. Completion of study PB-102-F20 or PB-102-F30 or at least 48 months in study PB-102-
F03
2. The patient signs informed consent.
3. Female patients and male patients whose co-partners are of child-bearing potential agree to 
use a medically acceptable method of contraception. These include combined (estrogen- and 
progestogen-containing) hormonal contraception associated with inhibition of ovulation (oral, 
intravaginal, or transdermal) supplemented with a barrier method (preferably male condom), 
progestogen-only hormonal contraception associated with inhibition of ovulation (oral, 
injectable, or implantable) supplemented with a barrier method (preferably male condom), 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 4 of 66
 
intrauterine device (IUD), intrauterine hormone-releasing system (IUS), bilateral tubal 
occlusion, vasectomised partner, or sexual abstinence.Contraception should be used for 2 
weeks after treatment termination.
Key Exclusion Criteria:
The following excludes a patient from study enrollment:
Presence of any medical, emotional, behavioral, or psychological condition that, in the 
judgment of the Investigator, would interfere with patient compliance with the requirements of 
the study.
TEST PRODUCT, DOSE AND MODE OF ADMINISTRATION: Pegunigalsidase alfa 
(PRX-102) 1 mg/kg, intravenously every 2 two weeks (±3 days).
Infusion and clinical observation time:
All patients who completed PB-102-F20 study will be treated in PB-102-F60 study with 
pegunigalsidase alfa 1 mg/kg every other week. PB-102-F20 study is an ongoing double-blind 
study in which up to 26 patients are treated with agalsidase beta. To maintain the blinding of 
PB-102-F20 study, the first infusion in PB-102-F60 study of these patients will be administered 
intravenously over 3 hours with 2 hours of post-dosing clinical observation. Subsequent 
infusions will be managed according to Appendix 6, the principal investigator’s (PI) evaluation.
If used in PB-102-F20 infusions, premedication will be continued with the first infusion of 
PB-102-F60 study and then tapered down at the PI's discretion, pending the patient tolerability 
and according to Appendix 6.
The patient will be able to return to the previously established treatment format, whether home 
infusion or through a predefined infusion center, once the PI agrees that it is safe to do so.
Patients who completed PB-102-F30 study can continue PB-102-F60 study infusions at the 
same duration and setting as in PB-102-F30 study, but not less than 60 minutes, with a post-
dosing clinical observation time an additional 60 minutes and the same premedication if used at 
PB-102-F30 study.
Patients who completed at least 48 months in PB-102-F03 study can continue the PB-102-F60 
study infusions at the same duration and setting as in PB-102-F03 study, but not less than 60 
minutes with a post-dosing clinical observation time of an additional 60 minutes and the same 
premedication if used at PB-102-F03 study.
Reducing the infusion time from 90 minutes to 60 minutes will be done step-wise, pending the 
patient’s tolerability.
DURATION OF TREATMENT: Until pegunigalsidase alfa is commercially available to the 
patient or at the Sponsor's discretion. The end of study will be the last patient’s last visit. The 
last visit is defined based on the assumptions indicated above.
DISCONTINUATION FROM TREATMENT:

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 5 of 66
 
Reasons for permanent discontinuation include the following:
The patient experiences two or more Grade 3 toxicities or one or more Grade 4 
toxicities considered by the Investigator associated with pegunigalsidase alfa’s 
treatment.
The patient experiences a progressive hypersensitivity or a severe hypersensitivity that 
is not allayed with a pre-treatment.
The patient requests to discontinue the treatment.
The Investigator feels that it is not in the patient's best interest to continue treatment and 
if the Investigator believes that the patient can no longer be compliant with the 
requirements of the study.
Marketing approval is obtained, and the drug is available at the patient country.
At the Sponsor's discretion (e.g. safety concerns, potential major protocol violation and/or 
fraud).
EFFICACY ENDPOINTS:

Estimated glomerular filtration rate (eGFRCKD-EPI).


Left Ventricular Mass Index (g/m2) by magnetic resonance imaging (MRI).

Plasma Lyso-Gb3 concentration.

Plasma Gb3 concentration.

Protein/Creatinine ratio, spot urine test (UPCR).

Frequency of pain medication use.

Exercise tolerance (Stress Test).

Short Form Brief Pain Inventory (BPI).

Mainz Severity Score Index (MSSI).

Quality of life (EQ-5D-5L).

Fabry disease Clinical events.
SAFETY ENDPOINTS:
Changes from baseline in:

Clinical laboratory tests.

Physical examination.

Assessment of the injection site.

Electrocardiography (ECG).

Brain MRI.

Treatment-emergent adverse events (TEAE).

The ability to taper off infusion’s pre-medication at the start of the study.

Requirement for the use of pre-medication overall to manage infusion reactions.

Treatment-emergent anti-pegunigalsidase alfa antibodies.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 6 of 66
 
STATISTICAL ANALYSIS:
This extension study's sample size depends on the number of patients who completed 
PB-102-F20 study PB-102-F30 study or PB-102-F03 and enrolled into this study; up to 
110 male and/or female patients.
Safety analysis will be assessed for the safety population by evaluating AEs, injection site 
reactions, ECG, clinical laboratory results, brain MRI, anti-pegunigalsidase alfa antibodies 
ability to taper off infusion pre-medication, and requirement for using premedication to 
manage infusions reactions.
Efficacy will be assessed for the per protocol population and summarized using descriptive 
statistics.
A detailed statistical analysis plan (SAP) containing the analysis information in detail 
including the definition of the analysis populations, derivation of variables, convention of 
analysis scope, and statistical methodology for the analyses of safety and efficacy 
parameters of pegunigalsidase alfa based on the data collected per the study protocol will 
be issued prior to the data base lock. In case of disagreement between the SAP and the 
Clinical Study Protocol, the SAP prevails

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 7 of 66
 
DOCUMENT APPROVAL
This study will be conducted in compliance with the protocol, Good Clinical Practice (GCP), and 
applicable regulatory requirements.
PRINCIPAL INVESTIGATOR
Signature
Date
Print Name: 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 8 of 66
 
TABLE OF CONTENTS
1.
SYNOPSIS ..............................................................................................................................3
2.
LIST OF ABBREVIATIONS ...............................................................................................12
3.
ETHICAL CONDUCT OF THE STUDY AND REGULATORY 
REQUIREMENTS ................................................................................................................14
3.1
Institutional Review Board ............................................................................................14
3.2
Ethical Conduct of the Study .........................................................................................14
3.3
Patient Information and Consent....................................................................................14
4.
INTRODUCTION.................................................................................................................15
Risk/benefit assessment...........................................................................................................18
5.
STUDY OBJECTIVES .........................................................................................................19
6.
INVESTIGATIONAL PLAN................................................................................................19
6.1
Overall Study Design and Plan – Description................................................................19
6.2
Discussion of Study Design ...........................................................................................19
6.3
Selection of Study Population........................................................................................19
6.3.1
Inclusion Criteria ...................................................................................................19
6.3.2
Exclusion Criteria ..................................................................................................20
6.3.3
Removal of Patients from Therapy or Assessment................................................20
7.
STUDY PRODUCT ..............................................................................................................20
7.1
Study Medication Supply...............................................................................................20
7.2
Description and Formulation of Study Product .............................................................21
7.3
Study Drug Dosage and Preparation..............................................................................21
7.4
Description of Comparator Product ...............................................................................21
7.5
Study Drug Administration............................................................................................21
7.6
Packaging and Labeling .................................................................................................22
7.7
Conditions for Storage and Use .....................................................................................22
7.8
Method of Assigning Patients to Treatment Groups......................................................22
7.9
Dispensing, Compliance, and Accountability................................................................22
7.10 Prior and Concomitant Therapy.....................................................................................23
8.
EFFICACY AND SAFETY ASSESSMENTS .....................................................................23
8.1
Efficacy Variables..........................................................................................................23

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 9 of 66
 
8.2
Safety Variables .............................................................................................................24
8.2.1
Clinical Laboratory................................................................................................25
8.2.2
Anti-Pegunigalsidase alfa Antibodies....................................................................25
8.2.3
Adverse Events ......................................................................................................25
9.
STUDY PROCEDURES AND FLOW CHART ..................................................................30
9.1
Study Flow Chart ...........................................................................................................30
9.2
Study Visits....................................................................................................................33
9.2.1
Screening Visit (Visit 53 of PB-102-F20 Study / Visit 27 of PB-102-F30 
Study / Last Visit of PB-102-F03 Study) ..............................................................33
9.2.2
Visits 1-209 (Infusions, ± 3 Days).........................................................................33
9.2.3
Visits 3 and 10 (±3 d), Applicable for Patients Enrolling from PB-102-
F20 Study...............................................................................................................34
9.2.4
Visits: 20, 33, 46, 60, 72, 86, 99, 112,124, 137, 150, 163, 176, 189, and 
202 (±6 d)...............................................................................................................35
9.2.5
Visit 7 (Only Applicable for Patients who Completed PB-102-F20 
Study) (± 6 Days)...................................................................................................35
9.2.6
Visits 14, 40, 66, 92,118, 144, 170 and 196 (±3 d) ...............................................35
9.2.7
Visits 20 (±3 d) Applicable for Patients Enrolling from PB-102-F20...................36
9.2.8
Visits 27,79, 131 and 183 (± 6 Days) ....................................................................36
9.2.9
Visits 53, 105, 157 and 209 (± 6 Days) .................................................................37
9.2.10 Premature Withdrawal Visit ..................................................................................38
9.2.11 Unscheduled Visit..................................................................................................38
10. STATISTICAL METHODS PLANNED AND SAMPLE SIZE..........................................38
10.1 Determination of Sample Size .......................................................................................38
10.2 Patient Populations.........................................................................................................38
10.2.1 Intent-to-Treat Population .....................................................................................38
10.2.2 Per Protocol Population .........................................................................................39
10.2.3 Safety Population...................................................................................................39
10.3 Analysis..........................................................................................................................39
10.3.1 Vital Signs and Physical Examination...................................................................39
10.3.2 Medications............................................................................................................39
10.3.3 Efficacy Variables .................................................................................................39
10.4 Safety Analysis...............................................................................................................39

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 10 of 66
 
10.4.1 Adverse Events ......................................................................................................39
10.4.2 Clinical Laboratory................................................................................................40
10.5 Interim Analysis.............................................................................................................40
11. QUALITY CONTROL AND QUALITY ASSURANCE ....................................................40
11.1 Source Data and Records ...............................................................................................40
11.2 Reporting of Results.......................................................................................................41
11.3 Confidentiality of Patient Data.......................................................................................41
12. REPORTING AND PUBLICATION ...................................................................................42
12.1 Confidentiality of Study Data ........................................................................................42
13. REFERENCES......................................................................................................................43
14. APPENDICES.......................................................................................................................47
14.1 Appendix 1. Tolerability and Infusion Rate Algorithm.................................................47
14.2 Appendix 2. Pegunigalsidase alfa Hypersensitivity Evaluation and Treatment 
Algorithm.......................................................................................................................49
14.2.1 Clinical Signs.........................................................................................................49
14.2.2 Treatment Algorithm .............................................................................................49
14.2.3 Treat as Follows.....................................................................................................50
14.2.4 Premedication ........................................................................................................51
14.3 Appendix 3. Cardiac MRI..............................................................................................52
14.3.1 Patients and Sites ...................................................................................................52
14.3.2 Magnetic Resonance Imaging Data.......................................................................52
14.3.3 MRI Evaluation Parameters...................................................................................53
14.3.4 Sites and Image Data Management .......................................................................53
14.3.5 Image Processing and Centralized Analysis..........................................................53
14.3.6 Data and Report Transfers to Sponsor...................................................................54
14.3.7 Direct Access to Study Data..................................................................................54
14.3.8 Unevaluable MRI...................................................................................................55
14.4 Appendix 4. The Mainz Severity Score Index (MSSI)..................................................56
14.4.1 The Mainz Severity Score Index (MSSI) ..............................................................56
14.5 Appendix 5. Brief Pain Inventory- BPI (Short Form) ...................................................58
14.6 Appendix 6. Guide for the Transition of Infusion Time................................................61
14.6.1 Introduction............................................................................................................61

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
                                                                                                                
 11 of 66
 
14.7 Appendix 7. EQ-5D-5L..................................................................................................64
14.8 Appendix 8 National Kidney Foundation Guidelines for Chronic Kidney 
Disease ...........................................................................................................................66

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 12 of 66
 
2.
LIST OF ABBREVIATIONS
AE
Adverse Event
α-GAL
α-galactosidase A
ADL
Activities of Daily Living
AKI
Acute Kidney Injury
AUC
Area under the concentration-time curve
BPI
Brief pain inventory
BLISS
Barisoni Lipid Inclusion Scoring System
CHO
Chinese hamster ovary
CRF
Case report form
CT
Computed tomography
CTCAE
Common Terminology Criteria for Adverse Events
ECG
Electrocardiography
EF
Ejection fraction
eGFR
Estimated glomerular filtration rate
eGFRCKD-EPI
Estimated glomerular filtration rate Chronic Kidney Disease Epidemiology 
Collaboration
ERT
Enzyme replacement therapy
ESRD
End-stage renal disease
FOS
Fabry Outcome Survey
Gb3
Globotriaosylceramide
GCP
Good Clinical Practice
GSA
Gastrointestinal Symptoms Assessment
IC
Informed consent
IDP
Investigational Drug Product
IEC
Institutional ethics committee
IgE
Immunoglobulin E
IgG
Immunoglobulin G
IR
Infusion rate
IRB
Institutional Review Board
IRR
Infusion-related reaction
ITT
Intent-to-Treat

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 13 of 66
 
AE
Adverse Event
LOCF
Last observation carried forward
LVH
Left ventricular hypertrophy
LVM
Left ventricular mass
LVMI
Left ventricular mass index
Lyso-Gb3
Globotriaosylsphingosine
MedDRA
Medical Dictionary for Regulatory Activities
MRI
Magnetic resonance imaging
MSSI
Mainz Severity Score Index
PEG
Polyethylene glycol
PI
Primary investigator
PP
Per Protocol
PT
Prothrombin time
PTT
Partial thromboplastin time
SAE
Serious adverse event
TIA
Transient ischemic attack
t 1/2
Half life

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 14 of 66
 
3.
ETHICAL CONDUCT OF THE STUDY AND REGULATORY 
REQUIREMENTS
3.1
Institutional Review Board
An Institutional Review Board (IRB) or Institutional Ethics Committee (IEC) will review the study 
protocol and any amendments. The IRB or IEC will also review the informed consent forms, their 
updates (if any), and any written materials given to the patients. A list of all IRBs and IECs and 
contact information will be included in the study report.
3.2
Ethical Conduct of the Study
This study will be conducted in accordance with the ethical principles that have their origins in the 
Declaration of Helsinki, in compliance with the approved protocol, GCP, and applicable regulatory 
requirements.
3.3
Patient Information and Consent
The investigator will obtain a freely given written consent from each patient after an appropriate 
explanation of the aims, methods, anticipated benefits, potential hazards, and any other study 
aspects relevant to the patient's decision to participate. The consent forms must be signed and dated 
by the patient before he/she is exposed to any protocol-specific procedure.
The investigator will explain that the patients are entirely free to refuse to enter the study or to 
withdraw from it at any time, without any consequences for their further care, and without the need 
to justify their decision.
The patient will receive a copy of the patient's information and the signed informed consent forms.
The patient will be informed if information becomes available that may be relevant to his/her 
willingness to continue participation in the study.
Each patient will be informed that a monitor or a health authority inspector may review the portions 
of their source records and source data related to the study in accordance with applicable regulatory 
requirements. Data protection and confidentiality will be handled in compliance with local laws.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 15 of 66
 
4.
INTRODUCTION
Fabry disease is a progressive lysosomal storage disease that is seriously debilitating and 
ultimately life-threatening. It is caused by an X-linked deficiency of the enzyme α-galactosidase 
A (α-GAL) and affects both males and females. The disease is characterized by the subnormal or 
absent activity of α-GAL. Clinical onset of the disease typically occurs during childhood or 
adolescence (Schaefer et al., 2009 [27]) and will progress to end-stage renal disease (ESRD), 
cardiac complications, and cerebrovascular problems in the fourth or fifth decade of life (Wilcox 
et al., 2008 [40]). Although Fabry disease is an X-linked disorder, females are also affected and 
develop manifestations of the disease due to lack of cross-correction between cells with normal α-
GAL activity (mutated X chromosome is inactivated) and cells with enzyme deficiency (non-
mutated X chromosome is inactivated). The clinical abnormalities in females are more variable, 
and of later onset compared to males (Schiffmann, 2009 [31])
Fabry disease is regarded as a rare disease, and it is estimated that 1 in 40,000 males has the disease, 
whereas the estimated prevalence in the general population is 1 in 117,000 (Meikle et al., 1999 
[22]). Random screening of 37,104 newborns for Fabry disease in Italy indicated the prevalence 
in males to be 1 in 3,100 (Spada et al., 2006 [33]). The large difference in statistics was explained 
as being due to the inclusion of often undiagnosed patients with the non-classic form of Fabry 
disease (late-onset), with the ratio of late-onset to classical being 11 to 1 (Spada et al., 2006). 
Random screening of 110,027 newborns in Taiwan discovered the incidence in males to be about 
1 in 1,500 (Lin et al., 2009 [20]). This study determined there were still significantly fewer females 
affected than males, with approximately 1 in 17,000 affected; this prevalence is still a much greater 
incidence than was previously thought for males (Lin et al., 2009). While lysosomal storage 
diseases are individually rare, the cumulative incidence of known patients and the undetected 
reservoir of undiagnosed patients with these diseases constitute a significant total incidence of 
disease with a large societal impact.
α-GAL is a lysosomal enzyme that primarily catalyzes the hydrolysis of the glycolipid 
globotriaosylceramide (Gb3) to galactose and lactosylceramide. Fabry disease is characterized by 
massive storage of Gb3, predominantly in the endothelial cells of the vascular system, 
cardiomyocytes, neuronal cells, and kidney podocytes. Progressive accumulation of Gb3, and 
related lipids, leads to impaired tissue and organ function. The ultimate consequence of glycolipid 
deposition in the vasculature and other tissues is an end-organ failure, particularly in the kidney, 
but also the heart and cerebrovascular system (Schiffmann, 2009 [31]). This organ failure is brought 
on by Gb3 and globotriaosylsphingosine (Lyso-Gb3) activation of the innate immune system via 
the toll-like receptors on the dendritic cells. In the kidney, Gb3 accumulation is associated with an 
increase of transforming growth factor-beta and the dedifferentiation of the endothelial cells, 
leading to renal fibrosis. Fibrosis is also a typical feature of heart involvement in Fabry disease. 
Endomyocardial biopsies show infiltration of lymphocytes and macrophages, suggesting a role for 
inflammation in causing tissue damage (Rozenfeld and Feriozzi, 2017 [26]). In addition, 
involvement of the central, peripheral, and autonomic nervous systems results in episodes of pain 
and impaired peripheral sensation. Vascular changes in the skin also result in angiokeratomas 
(Hoffmann et al., [14] 2009). The mechanism by which α-GAL deficiency and glycolipid 
accumulation cause such a wide variety of complications are not well understood. Based on the 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 16 of 66
 
pathology of Fabry disease, the ongoing accumulation of alpha-D-galactosyl moieties, particularly 
of Gb3, appears to be a chronic toxicity state (Schiffmann, 2009 [31]). Aerts et al., 2008 [01], 
reported that globotriaosylsphingosine (Lyso-Gb3), a Gb3 metabolite, is dramatically increased in 
the plasma of male Fabry patients and plasma and tissues of Fabry mice and may have an important 
role in the pathogenesis of Fabry disease. Increased levels of Lyso-Gb3 also occur in symptomatic 
Fabry females (Van Breemen et al., 2011 [35]).
As Fabry disease is an X-linked disorder, the prevalence of the mutation is predicted to be two 
times higher in women than in men. There is considerable variation in phenotype in heterozygous 
females. However, despite the X-linked nature of the disease, heterozygous and therefore tissue-
mosaic females can be as severely affected by Fabry disease as hemizygous males, experiencing 
progressive, multi-organ involvement, reduced quality of life, and reduced life expectancy. Case-
finding studies have reported mutations that are known to be associated with Fabry disease in 0.3- 
2.4% of women who had an unexplained stroke, hypertrophic cardiomyopathy, or renal failure 
requiring hemodialysis. A study comparing men and women with Fabry disease, using data from 
the Fabry Outcome Survey (FOS), showed no significant differences between men and women for 
most clinical features evaluated after four years of treatment. Overall, both sexes responded to 
enzyme replacement treatment in a similar way (Hughes et al., 2011 [17]).
Enzyme replacement therapy (ERT), by exogenous administration of purified recombinant 
enzyme, is nowadays among the most successfully employed drug treatments for lysosomal 
storage disorders. The first disorder for which this treatment modality has proven effective is type 
1 Gaucher disease (Barton et al., 1991 [02]; Hollak et al., 1995 [15]). This success has paved the 
way for ERT development for other lysosomal storage disorders, including Fabry disease.
Recombinant human α-GAL metabolizes the accumulated Gb3 in patients. Currently, two ERTs 
using this enzyme are commercially available; agalsidase-alpha (Replagal®), approved in Europe, 
and agalsidase-beta (Fabrazyme®), which was approved in Europe and the United States. Both 
recombinant enzymes are comparable in their properties and differ only slightly in glycan 
composition (Blom et al., 2003 [05]). They are produced using different protein expression 
systems and are administered at different doses. Fabrazyme® is produced in Chinese Hamster 
Ovary (CHO) cells and is administered by IV infusion every two weeks at a dose of 1 mg/kg. 
Replagal® is produced in a human cell line (stably expressed in human foreskin fibroblast) 
(Schiffmann et al., 2000 [28]) and is administrated by IV infusion every two weeks at a dose of 0.2 
mg/kg. Both products have shown their efficacy in clinical studies with regard to clearance of Gb3 
from plasma, kidney cells (such as capillary endothelial cells, glomerular endothelial cells, 
noncapillary endothelial cells, and noncapillary smooth muscle cells), and capillary endothelial 
cells of the cardiac and skin (Eng and Guffon et al., 2001 [10]; Germain et al., 2007 [13]; Schaefer 
et al., 2009 [27]; Deegan, 2012 [07]). In addition, ERT with both products leads to improvement 
in quality of life evaluated by SF-36 questionnaire, reduction or stabilization of cardiac mass, 
preservation of renal function, and slowing down the decline of glomerular function (Wilcox et al., 
2004 [39]; Schiffmann et al., 2006 [29]; Germain et al., 2007; Schiffmann 2009 [31]). The 
improvements observed in the quality of life were scored and found to be significant in physical 
functioning, role emotional, body pain, and standardized physical component scale (Germain et 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 17 of 66
 
al., 2007). Although these findings are encouraging, the clinical effects of the current treatment of 
Fabry patients are not as robust as anticipated and show only limited clinical improvement 
(Schaefer et al., 2009; Lidove et al., 2010 [19]; El Dib et al., 2011 [08]).
One of the major factors responsible for the limited efficacy of current treatment is the presence 
of irreversible organ damage. Another factor that may contribute to this is the characteristics of the 
current ERTs (such as short pharmacokinetic half-life and dose regimens), which seem to be 
insufficient in preventing the chronic toxic effect of Gb3. One way to improve enzyme 
bioavailability may be to extend circulation residence and tissue half-life. A third factor, which 
may influence treatment outcome, is the induction of antibodies towards the recombinant proteins 
(Hollak et al., 2009 [16]). The emergence of antibodies with in vivo neutralizing capacity is 
frequently encountered in treated Fabry disease patients, resulting in inhibition of enzyme activity 
and adversely affecting Gb3 clearance (Hollak et al., 2009 [16]). In early clinical studies, 53 to 
88% (Schiffmann et al., 2006 [31]; Eng and Banikazemi et al., 2001 [09]; Eng and Guffon et al., 
2001 [10]) of male patients developed these immunoglobulin G (IgG) antibodies within the first 
six months of treatment. Regarding treatment outcome, it was shown that antibodies against α-
GAL interfere with the clearance of Gb3 from plasma, urine (Linthorst et al., 2004 [21]; Vedder et 
al., 2008 [36]), and from the tissue (Benichou et al., 2009 [03]). The cross-reactivity of α-GAL 
antibodies suggests that it is unlikely that switching from one recombinant protein to the other may 
prevent the immune response and related effects (Linthorst et al., 2004; Hollak et al., 2009). 
Currently, administering a higher dose of the recombinant enzyme is an effective way to overcome 
the increase in Gb3 observed in patients' urine associated with neutralizing antibodies. However, 
this approach is not considered a long-term solution (Vedder et al., 2008 [36]; Hollak et al., 2009 
[16]). A later study has shown that IgG levels are dose-dependent (Smid et al., 2013 [32]).
Protalix has developed pegunigalsidase alfa (PRX-102), a chemically modified (polyethylene 
glycol [PEG] addition) recombinant human α-GAL, with amino acid additions on both the N and 
C-terminus, expressed in a tobacco cell culture which results in oligomannose glycosylation. As a 
result of these modifications, pegunigalsidase alfa exhibits more stabilized enzymatic activity, 
extended circulation residence time, and enhanced bioavailability of the enzyme relative to the 
commercial drug. Therefore, pegunigalsidase alfa provides the continuous presence of enzyme 
over the 2-week dosing interval (Kizhner et al., 2015 [18]).
Studies have shown that human α-GAL is a non-covalently bound homodimeric glycoprotein 
(Garman et al., 2004 [11]) and that dimerization is important for the enzymatic activity and stability 
of the enzyme (Bishop et al., 1988 [04]). The chemical modification of pegunigalsidase utilizes 
the reagent bis-NHS-PEG and renders PEGylated protein subunits, the majority of which are 
crosslinked into homodimers. In addition, the PEGylation modification may have an additive value 
through increasing drug retention time in blood and bioavailability (Veronese et al., 2005 [37]; 
Veronese et al., 2008 [38]). Preliminary non-clinical data show that this modification improves 
pegunigalsidase alfa stability in vitro under lysosomal and plasma conditions and extends 
circulation residence and bioavailability in vivo, probably due to stabilization of its quaternary 
structure. Therefore, the modifications in pegunigalsidase alfa have the potential to improve the 
efficacy of ERT.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 18 of 66
 
Pegunigalsidase alfa enhanced pharmacokinetic properties including a half-life (t½) of 
approximately 80 hours and AUC (Area under the concentration-time curve) of approximately 
400,000 ng*hour/mL for the 1 mg/kg dose after one day of treatment (Day 1), which are believed 
to be the result of the covalent cross-linking to make pegunigalsidase alfa a more stable 
homodimer. This extended exposure of the target organs to enzyme may be important for 
improving efficacy similar to what Schiffmann and colleagues (Schiffman, R 2007 [30]) showed 
with weekly compared to every other week agalsidase alfa (Replagal®), which reports, in 
comparison, elimination t½ of 108±17 minutes and 89±28 minutes for males and females, 
respectively (Replagal® EMA, 2006 [24]). Agalsidase beta (Fabrazyme®) reports a comparable 
terminal t½ within the range of 45-102 minutes, independent of concentration (Genzyme FDA, 
2003 [12]).
In view of the data to date, it is concluded that dosing of pegunigalsidase alfa at 1 mg/kg every 
two weeks offers an appropriate treatment regimen for attenuating disease progression.
Risk/benefit assessment
As of 12 October 2020, there were 224 patient-years of exposure for the regimen of 1.0 mg/kg 
PRX-102 administered biweekly and 67 patient-years for the regimen of 2 mg/kg administered 
every 4 weeks, which is considered sufficient for the assessment of safety and tolerability in a rare 
disease. Both treatment-naive and ERT-experienced patients have been included in clinical studies. 
Benefits have been seen in reduction in the tissue Gb3 accumulation (evaluated on kidney biopsies 
using the Barisoni Lipid Inclusion Scoring System – BLISS), in the biomarker of plasma lyso-
Gb3, stability or improvement in kidney and cardiac function, and stabilization on other indicators 
of clinical progression such as scores on the Mainz Severity Score Index, the Brief Pain Inventory, 
and quality of life questionnaires, thereby demonstrating achievement of the therapeutic goals of 
Fabry disease treatment. Given the progressive nature of the disease, stabilization of overall 
clinical progression can be considered a therapeutic success. 
Currently available safety data indicate that the drug has a favorable safety profile and is well 
tolerated. There have been no deaths related to treatment; few serious adverse events related to 
study product, infusion-related reactions (IRRs) in particular.  In general, IRRs are well-controlled 
through pausing and re-starting the infusion and/or through the use of premedication (both before 
and during the infusion) and/or through slowing down the infusion rate. IRRs recorded in the trials 
were for the majority of the cases mild to moderate, however the very few events that led to study 
discontinuation were severe IRRs and occurred at the beginning of the treatment. All patients were 
appropriately treated and quickly fully recovered. Discontinuations from the study have been 
related to hypersensitivity reactions (1 event of bronchospasm in F01, 2 events of type I 
hypersensitivity in F30, 1 event of hypersensitivity in F20, 1 event of type I hypersensitivity in the 
Early Access Program) and consent withdrawal by the study participants, for various reasons (not 
safety related). In addition, there is a low rate of treatment-induced antibody formation, which is 
important as the need for ERT treatment is lifelong. Treatment with the posology at 2mg/kg every 
4 weeks was equally safe, with very few SAEs reported in the F50, none related, and no serious or 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 19 of 66
 
severe IRRs. Overall, the risk/benefit profile is positive, and it can be concluded that a regimen of 
PRX-102 at 1.0 mg/kg every 2 weeks, and the alternative posology at 2 mg/kg every 4 weeks, 
offer an appropriate treatment for attenuating the progression of Fabry disease. Full details on the 
properties of pegunigalsidase alfa and data related to its nonclinical and clinical development are 
provided in the Investigator’s Brochure.
5.
STUDY OBJECTIVES
To evaluate the ongoing safety, tolerability, and efficacy parameters of pegunigalsidase alfa in 
adult Fabry patients who have completed studies PB-102-F20 and PB-102-F30 studies or at least 
completed 48 months on PB-102-F03 study.
6.
INVESTIGATIONAL PLAN
6.1
Overall Study Design and Plan – Description
This will be an open-label, multicenter study of 1 mg/kg of pegunigalsidase alfa intravenous 
infusion every two weeks (±3 days) to evaluate the safety, tolerability, and efficacy of 
pegunigalsidase alfa in adult Fabry patients (≥18 years of age).
The duration of treatment will be until pegunigalsidase alfa is commercially available to the patient 
or at the Sponsor's discretion. The end of study will be the last patient’s last visit. The last visit is 
defined based on the assumptions indicated above.
Disease parameters evaluated during PB-102-F20, PB-102-F30, and PB-102-F03 studies will 
continue to be assessed in this extension protocol (CLI-06657AA1-04, previously PB-102-F60 
study).
6.2
Discussion of Study Design
The extension study may provide additional, long-term information on tolerability, safety, and 
efficacy in patients treated with pegunigalsidase alfa.
6.3
Selection of Study Population
6.3.1
Inclusion Criteria
Eligible patients must fulfill the following inclusion criteria:
1. Completion of PB-102-F20 or PB-102-F30 studies, or at least 48 months in PB-102-F03 
study.
2. The patient signs informed consent.
3. Female patients and male patients whose co-partners are of child-bearing potential agree 
to use a medically acceptable method of contraception. These include combined (estrogen- 
and progestogen-containing) hormonal contraception associated with inhibition of 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 20 of 66
 
ovulation (oral, intravaginal, or transdermal) supplemented with a barrier method 
(preferably male condom), progestogen-only hormonal contraception associated with 
inhibition of ovulation (oral, injectable, or implantable) supplemented with a barrier 
method (preferably male condom), intrauterine device (IUD), intrauterine hormone-
releasing system (IUS), bilateral tubal occlusion, vasectomised partner, or sexual 
abstinence.. Contraception should be used for 2 weeks after treatment termination.
6.3.2
Exclusion Criteria
Presence of any medical, emotional, behavioral, or psychological condition that, in the judgment 
of the Investigator, would interfere with the patient's compliance with the requirements of the 
study.
6.3.3
Removal of Patients from Therapy or Assessment
Reasons for permanent discontinuation include the following:

The patient experiences two or more Grade 3 toxicities or one or more Grade 4 toxicity 
considered by the investigator to be associated with pegunigalsidase alfa treatment 
(CTCAE v4.03, 2010 [34]). 

The patient experiences a progressive hypersensitivity or a severe hypersensitivity that is 
not allayed with pre-treatment.

The patient requests to discontinue the treatment.

The Investigator feels that it is not in the patient's best interest to continue the treatment 
and/or if the Investigator believes that the patient can no longer be compliant with the 
requirements of the study.

Marketing approval is obtained, and the drug is available at the patient country.

At the Sponsor’s discretion (e.g. safety concerns, potential major protocol violation and/or 
fraud).
For any discontinuation, the Investigator will obtain all the required details and document the date 
and the main reason for the premature termination. If the reason for discontinuation is an AE, the 
specific event or the main laboratory abnormality will be recorded in the eCRF. The Investigator 
will make thorough efforts to document the outcome. The Investigator will attempt to continue to 
follow the patient for the full duration of the study or at least for 60 days following discontinuation. 
If circumstances prevent the patient from completing all visits, every attempt will be made to 
complete all procedures listed in Section 9 for the last visit.
7.
STUDY PRODUCT
7.1
Study Medication Supply

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 21 of 66
 
The study drug will be supplied to the clinical site under the responsibility of the Sponsor, who 
will also provide the Pharmacist/Investigator with appropriate certificates of analytical conformity, 
if required.
7.2
Description and Formulation of Study Product
Pegunigalsidase alfa is a purified recombinant, plant cell-expressed chemically modified human 
α-GAL, described in detail in the Investigator's Brochure.
Each vial contains 10 mL (2.0 mg/mL) of the following contents in liquid form:

20 mg pegunigalsidase alfa.

Sodium chloride (NaCl).

 mM Sodium citrate (
7.3
Study Drug Dosage and Preparation
Pegunigalsidase alfa 2.0 mg/mL vials are stored at 2-8°C (36-46°F).
The individual dose for each patient (1 mg/kg) will be prepared according to patient weight at the 
screening visit (the last visit of the previous study). The dosage will be adjusted to patient weight 
obtained at Visits Screening, 14, 27, 40, 53, 66, 79, 92, 105,118, 131, 144, 157, 170, 183, 196 and 
209 if the weight changes by 25% from the previous adjustment.
The total volume of the infusion will be adjusted with normal saline (0.9% NaCl) to a final volume of:

150 mL/infusion for patients weighing up to 70 kg.

250 mL/infusion for patients weighing between 70 kg-100 kg.

500 ml/infusion for patients weighing above 100 kg.
The infusion volume may be re-calculated only if dosage adjustment was performed.
7.4
Description of Comparator Product
Not applicable.
7.5
Study Drug Administration
All patients will receive 1 mg/kg pegunigalsidase alfa, administered intravenously every two 
weeks (±3 days).
All patients who completed PB-102-F20 study will be treated in PB-102-F60 study with 1 mg/kg 
pegunigalsidase alfa every other week. PB-102-F20 study is a double-blind study in which patients 
have been enrolled after treatment with agalsidase beta and then randomized (2:1) to 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 22 of 66
 
pegunigalsidase alfa or continue on agalsidase beta. In order not to compromise the blind of 
PB-102-F20 study, the first infusion of pegunigalsidase alfa in these patients in the PB-102-F60 
study will be administered intravenously over 3 hours with 2 hours of post dosing clinical 
observation. The infusion will be managed from the second infusion and onwards according to 
Appendix 6, Investigator’s evaluation; Sponsor’s Medical Expert will be notified and available for 
consultation if needed. With the first infusions, premedication, if used as part of PB-102-F20 
infusions, will be continued and then tapered down at the Investigator's discretion pending the 
patient's tolerability and according to Appendix 6. The patient will return to the previous treatment 
set up, either home infusion or predefined infusion center, once the Investigator agrees that it is 
safe to do so; Sponsor’s Medical Expert will be notified and available for consultation if needed.
Patients who completed the PB-102-F30 study or PB-102-F03 study can continue the infusions at 
the same duration achieved in the previous study but not less than 60 minutes, with a post-dosing 
observation time of an additional 60 minutes and the same premedication, if used.
 The reduction of the infusion time from 90 minutes to 60 minutes will be conducted in a step-wise 
manner pending the patient’s tolerability and per Investigator’s discretion; Sponsor’s Medical 
Expert will be notified and available for consultation if needed.
7.6
Packaging and Labeling
The drug product is packed in vials containing 20 mg pegunigalsidase alfa (2.0 mg/mL), 
 
NaCl, and 
mM sodium citrate 
The study drug is packed in 15 mL clear injection glass vials. Rubber stoppers used for closure  
and are sealed with aluminum seals.
The study drug will be supplied to the Site Pharmacies and Central Pharmacies of the Homecare 
Service Providers in the form of treatment kits. Each treatment kit is composed of a labeled box 
containing 15 labeled vials.
7.7
Conditions for Storage and Use
The study product is stored at 2-8°C (36-46°F).
7.8
Method of Assigning Patients to Treatment Groups
The dose of all patients will be 1 mg/kg, thus one treatment group.
The patient number will continue to be as the one assigned in PB-102-F20, PB-102-F30 or 
PB-102-F03 studies.
7.9
Dispensing, Compliance, and Accountability
The Investigator or the designated/authorized representative, is responsible for the management of 
all the study medications to be used for the study. Study drugs should be stored in a locked and 
secure storage facility with access limited to those individuals authorized to dispense the study 
medication. 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 23 of 66
 
An inventory will be maintained by the Investigator or pharmacist (or other designated individual) 
to include a signed account of all the study drugs received, dispensed and returned during the trial. 
The Clinical Service Provider, Clinical Trial Supply Vendor and/or Homecare Service Provider(s) 
will provide drug accountability forms to assist the pharmacist in maintaining current and accurate 
inventory records covering receipt, dispensing, and the return of investigational drug supplies. 
When a shipment is received, the pharmacist and/or Investigator will verify the quantities received 
and return the acknowledgment to the Clinical Trial Supply Vendor. If a temperature excuriosn 
outside of the permitted ranges occurs, the drug will not be used without Sponsor's approval in 
writing. The pharmacist investigational drug accountability record includes the patient number to 
whom the drug is dispensed, the quantity and the date of dispensing, and any returned or unused 
drug, as well as a complete record of IDP storage temperature. This record is used in addition to 
any drug accountability information recorded on the Case Report Form (CRF). These records will 
be readily available for inspection by a monitor and/or Chiesi audits and are open to regulatory 
authority inspection at any time.
At the conclusion or termination of the study, the Investigator or the pharmacist must conduct and 
document a final inventory of all used and unused study drug. An explanation will be given for 
any discrepancies.
All study drugs supplied, used or unused, will be returned to Chiesi or to the designated Clinical 
Service Provider/Clinical Trial Supply Vendor under the Sponsor's responsibility or destroyed 
directly at the Site. In this case, a destruction certificate must be provided by the Site and filed 
both by the Site and by the Sponsor. Destruction may not occur unless previously authorized in 
writing by Chiesi Farmaceutici S.p.A.
7.10 Prior and Concomitant Therapy
Medications having the potential to interfere with the evaluation of efficacy are excluded 
throughout the trial. The following medications are strictly prohibited during the study:

Fabrazyme® (agalsidase beta).

Replagal® (agalsidase alfa).

Galafold™ (migalastat).

Any other investigational drug for treating Fabry disease.
8.
EFFICACY AND SAFETY ASSESSMENTS
8.1
Efficacy Variables
The following efficacy endpoints evaluated in PB-102-F03, PB-102-F20 and PB-102-F30 studies 
will continue to be measured in this extension study. Baseline values for this extension study will 
be the values from the last infusion of PB-102-F03, PB-102-F20, or PB-102-F30 studies. As one 
out of every three patients in the PB-102-F20 Study will be transitioning from agalsidase beta to 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 24 of 66
 
pegunigalsidase alfa, patients will undergo more frequent monitoring during the first year in CLI-
06657AA1-04 (previously PB-102-F60).

The mean change of the estimated glomerular filtration rate (eGFRCKD-EPI) calculated from 
the serum creatinine values, will be evaluated every six months, up to the end of the study. 
For patients who completed the PB-102-F20 study, serum creatinine will be measured at 
more frequent times (Visits 3, 7, 10, and 20) in the first year of the Study (Study Flow 
Chart).

Plasma Lyso-Gb3 and Plasma Gb3 concentrations will be evaluated every six months up 
to the end of the study. For patients who completed PB-102-F20, plasma Lyso-Gb3 and 
Plasma Gb3 concentration will also be measured every three months for the first year of 
the study.

Urine protein/Creatinine ratio (UPCR), measured by a spot urine sample, every six months 
up to the end of the study. For patients who completed PB-102-F20, UPCR will also be 
measured at Visit 7.

Short Form Brief Pain Inventory (BPI) will be evaluated every six months up to the end of 
the study. (See Appendix 5. Brief Pain Inventory- BPI (Short Form)).

Left ventricular mass (LVM) myocardial fibrosis and ejection fraction (EF) assessed by 
cardiac magnetic resonance imaging (MRI) - every 12 months up to the end of the study. 
For patients for whom cardiac MRI cannot be performed, LVM and EF will be assessed by 
echocardiography every 12 months up to the end of the study.

Stress Test will be performed every 12 months up to the end of the study.

Mainz Severity Score Index (MSSI) will be calculated every 12 months up to the end of 
the study.

The frequency of pain medication and premedication use will be evaluated throughout the 
study (all Visits).

Quality of life (Appendix 7, EQ-5D-5L) evaluation will be performed every six months up 
to the end of the study.
8.2
Safety Variables
Safety will be assessed by the frequency, severity, and duration of treatment-emergent adverse 
events (TEAE). including clinically significant laboratory abnormalities, ECG changes from 
baseline test, brain MRI changes from baseline, physical examination findings, assessment of the 
injection site reactions, and the existence of anti-pegunigalsidase antibodies after administration 
of the study drug.
In addition, the following parameters will be measured:

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 25 of 66
 

Ability to taper off infusion premedication at the start of the study.

The requirement for the use of premedication to manage infusion reactions.
8.2.1
Clinical Laboratory

Hematology: total white blood cell count, hemoglobin, and platelets.

Biochemistry: sodium, potassium, glucose, blood urea nitrogen, calcium, phosphate 
(inorganic), uric acid, total protein, albumin, bilirubin (total), alkaline phosphatase, 
aspartate transaminase, alanine transaminase, gamma-glutamyl transferase, lactate 
dehydrogenase, creatine Phosphokinase (CPK).

Serum Enzymatic Creatinine and Cystatin C. In case a patient reaches an end-stage renal 
disease condition, the Principal Investigator and the Sponsor’s Medical Expert will discuss 
whether or not to continue collecting the Enzymatic Creatinine and Cystatin C.

Urinalysis: dipstick for the presence of blood, glucose, ketones, Nitrite, Leukocyte, and 
protein.
8.2.2
Anti-Pegunigalsidase alfa Antibodies
Anti-pegunigalsidase antibodies, including neutralizing antibodies (in patients having a positive 
IgG antibody response), will be assessed using validated bioanalytical methods.

Anti-pegunigalsidase antibodies will be assessed every six months up to the end of the 
study. For patients who completed the PB-102-F20 study, anti-pegunigalsidase antibodies 
will be measured at more frequent times (Visits 3, 7, 10, and 20) in the first year of the 
study (see Study Flow Chart).
Anti-Drug Immunoglobulin E (IgE) antibodies will be assessed in any event of a hypersensitivity 
reaction, following the Sponsor’s request.
8.2.3
Adverse Events
8.2.3.1
Adverse Events and Serious Adverse Events
An Adverse Event (AE) is any untoward medical occurrence in a patient participating in a clinical 
trial. An AE can be any unfavorable and unintended sign, symptom, or disease temporally 
associated with the use of the study medication, whether or not considered related to the study 
medication. AEs will be collected from the start of treatment until 90 days following the final visit 
dose.
This definition also includes accidental injuries, reasons for any change in medication (drug and 
dose) other than planned titration, reasons for admission to a hospital, or reasons for surgical 
procedures (unless for minor elective surgery for a pre-existing condition). It also includes AEs 
commonly observed, and AEs anticipated based on the pharmacological effect of the study 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 26 of 66
 
medication. Any laboratory abnormality assessed as clinically significant by the Investigator must 
be recorded as an AE.
A Treatment-Emergent Adverse Event (TEAE) is any AE occurring after the start of study 
medication and within the time of residual drug effect (20 days after the last administration of the 
study medication), or a pre-treatment AE or pre-existing medical condition that worsens in 
intensity after the start of study medication and within the time of residual drug effect.
AEs should be recorded as diagnoses, if available. If not, separate sign(s) and symptom(s) are 
recorded. One diagnosis/symptom should be entered per record. Treatment-related 
hypersensitivity/infusion reactions are defined in Appendix 2 and can be defined as a single AE at 
the Investigator's discretion.
Note that death is not an event, but the cause of death is. An exception is the event of sudden death 
of an unknown cause. Note that hospitalization is not an event; however, the reason for 
hospitalization is. Procedures are not events; the reasons for conducting the procedures are. In 
general, only the reason for conducting the procedure will be captured as an AE. However, if 
deemed necessary by the Investigator, a procedure can be captured along with the reason for 
conducting the procedure.
An overdose or medication error is not an AE unless it is temporally associated with an unfavorable 
or unintended sign or symptom.
Each AE is to be classified by the investigator as serious or non-serious. A Serious Adverse Event 
(SAE) is any untoward medical occurrence or effect that occurs at any dose:

Results in death.

Is life-threatening (i.e., an immediate risk of death).

Requires in-patient hospitalization or prolongation of existing hospitalization.

Results in persistent or significant disability/incapacity.

Is associated with a congenital anomaly/birth defect.

Is an important medical event.
An AE caused by an overdose or medication error is considered serious if a criterion listed in the 
definition above is fulfilled.
Important AEs that may not result in death may not be life-threatening or do not require 
hospitalization may be considered serious when, based upon appropriate medical judgment, they 
may jeopardize the patient's safety or may require medical or surgical intervention to prevent one 
of the outcomes listed above.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 27 of 66
 
SAEs also include any other event that the investigator or sponsor judges to be serious or defined 
as serious by the regulatory agency.
The investigator will report all directly observed AEs and all AEs spontaneously reported by the 
trial patient using concise medical terminology. In addition, each trial patient will be questioned 
about AEs. The question asked will be, "Since you began taking the study medication, have you 
had any health problems?"
An Infusion Related Reaction is a reaction to the infusion of pharmacological or biological 
substances. Symptoms may appear within minutes to 2 hours following the end of the infusion and 
may include pruritus, flushing, swelling, dyspnea, bronchospasm, and hypotension. IRR’s may be 
evaluated up to 24 hours from occurrence.
8.2.3.2
Procedures for Assessing, Recording, and Reporting AEs and SAEs
Throughout the study, the Investigator will closely monitor each patient for evidence of drug 
intolerance and the development of clinical or laboratory evidence of AEs. All AEs (expected or 
unexpected) that occur during the study, whether observed by the Investigator or by the patient, and 
whether or not thought to be drug-related, will be reported and followed until resolution or until 
they become stable.
The description of the AE will include a description of the event, start date, stop date, intensity, 
whether it was serious or not, relationship to test drug, any change in the study drug dosage, if it 
was fatal, and if treatment was required.
Events will be coded to one of the following intensity categories below based on the Common 
Terminology Criteria for Adverse Events (CTCAE), Version 4.03; June 14, 2010:
Severity
Definition
Mild (Grade 1)
Asymptomatic or mild symptoms; clinical or diagnostic observations only; 
intervention not indicated
Moderate (Grade 2)
Minimal, local, or noninvasive intervention indicated, limiting age-appropriate 
instrumental ADL*
Severe (Grade 3)
Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; limiting 
self-care ADL**
Very Severe (Grade 4)
Life-threatening consequences: urgent intervention indicated.
*Activities of Daily Living (ADL) - Instrumental ADL refers to preparing meals, shopping for groceries or clothes, 
using the telephone, managing money, etc.
**Self-care ADL refers to bathing, dressing, and undressing, using the toilet, taking medications, and not 
bedridden.
Events will be coded into one of the following causality categories as defined below:
Category
Definition

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 28 of 66
 
Unrelated
Clearly and incontrovertibly due only to extraneous causes and does not meet 
criteria listed under possible or probable.
Unlikely
Does not follow a reasonable temporal sequence from the administration. It May 
have been produced by the patient's clinical state or by environmental factors or 
other therapies administered.
Possible
Follows a reasonable temporal sequence from administration but may have also 
been produced by the patient's clinical state, environmental factors, or other 
therapies administered.
Probable
Clear-cut temporal association with administration with improvement on cessation 
of investigational medicinal product or reduction in dose. Reappears upon 
rechallenge. Follows a known pattern of response to the investigational medicinal 
product.
Definitely
There is evidence of exposure to the test product, for example, reliable history or 
acceptable compliance assessment; the temporal sequence of the AE onset relative 
to the drug is reasonable; the AE is most likely to be explained by the drug treatment 
than by another cause; the challenge is positive; re-challenge (if feasible) is positive; 
the AE shows a pattern consistent with previous knowledge of the drug treatment.
AEs with the causality assessed as unrelated or unlikely are categorized as not related to study 
medication.
AEs with the causality assessed as possible, probable, or definitely are categorized as related to 
study medication and adverse drug reactions.
All SAEs must be reported immediately (no more than 24 hours after becoming aware of the event) 
by entering the information about the event in the eCRF forms. The 
safety contact will be 
notified of the event by the eCRF system. The information must be provided by the completion of 
the SAE investigator form. At a later date, the 
Safety Contact will report all information to 
Chiesi Global Pharmacovigilance, the Clinical Project Manager and the Sponsor Medical Expert. 
In case the eCRF system is not available, the Investigator must immediately contact the assigned 
CRO safety contact (no later than 24 hours of becoming aware of the event). A paper back-up SAE 
form will be distributed to the sites, and will be used in case of eCRF unavailability. 
Reporting of SAEs from the Treating Physician is from the time of patient’s informed consent 
signature and until the patient’s treatment participation ends. After this date, even if no active 
monitoring of patient is required, SAEs occurring to a patient should be reported if the Treating 
Physician becomes aware of them. 
Up to the closure of the site, SAE reports should be reported to 
Safety Contact. New 
serious adverse events occurring after the site is closed should be reported directly to Chiesi Safety 
Contact
Contact information
E-mail
During active study participation:
Safety Contact
 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 29 of 66
 
After site closure:
Chiesi Safety Contact
 
The Sponsor or designated CRO will report SAEs events to the regulatory authorities in 
compliance with the timelines and standards of reporting according to local regulations, as well as 
to the Investigators and Central IRB/EC, if applicable, by MedWatch/CIOMS form. The 
Investigator (or Sponsor/CRO where required) must inform the IRB per Sponsor instruction upon 
receipt of the SUSAR notification. With regard to regulations in force for Pharmacovigilance, the 
Investigator must fulfil his/her obligation according to the law in force in his/her country.
8.2.3.3
Acute Kidney Injury
Episodes of Acute Kidney Injury (AKI) will be considered and reported as adverse events. AKI will 
be defined by a 1.5-fold or greater increase in serum creatinine from the previous laboratory value 
within the priors seven days or an increase in serum creatinine by ≥ 0.3 mg/dl (≥26.5 µmol/l) 
within 48 hours. Sponsor’s Medical Expert will work with the investigator to ensure that such 
changes in renal function are thoroughly evaluated.
8.2.3.4
Pregnancy
Although pregnancy as such is not considered an AE or SAE, within 24 hours of when s/he is 
made aware of the pregnancy to the 
 Safety Contact using the paper Pregnancy Report 
Form. The 
Safety Contact will inform Chiesi of the pregnancy within one working day of 
being notified.
The Pregnancy Report Form will be filled as initial report by the Investigator as soon as s/he 
becomes aware of the pregnancy, and as a follow-up report any time there is a new information, 
or at least once at each trimester and at the end of the pregnancy, if applicable. 
If the pregnancy meets the criteria for immediate classification of a SAE (e.g. spontaneous or 
therapeutic abortion, stillbirth, neonatal death, congenital anomaly, birth defect) the Treating 
Physician should follow the procedure for reporting SAEs.
Any live birth will have a follow up at year one to record the child’s development.
If a male patient’s female partner is found to be pregnant while the male patient is on active 
treatment, the same procedure regarding pregnancy reporting is to be followed and the Pregnancy 
Report Form should be completed.

        Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 30 of 66
 
9.
STUDY PROCEDURES AND FLOW CHART
9.1
Study Flow Chart
Visit Number
Activity
Screening
Visits:
1 to 209
Visits: 
3 and 10
Visits: 
20, 33, 46 ,60, 
72, 86, 99, 
112,124, 137, 
150, 163, 176, 
189, and 202
Visit: 7
Visits: 
14, 40, 66, 
92,118, 144, 
170 and 196
Visit: 20
Visits: 
27,79, 131 
and 183
Visits: 
53, 105,
, 157 and 
209 or Last 
Visit
Sign IC
X
Inclusion/Exclusion 
Criteria
X
Physical Examination
X1
X3
X
X
X
Body Weight
X1
X
X
X
Vital Signs
X1
X
Current Medications / 
Pain Medications / 
Pre-Medications Use
X1
X
Review of Adverse 
Events
X1
X
Urine Protein/Creatinine 
Ratio (UPCR)
X1
X3
X
X
X
Local Hematology
X1
X3
X
X
X
Central Biochemistry4
X1
X3
X
X
X
Serum Creatinine and 
Cystatin C4
X1,7
X3
X3
X
X3
X
X
Urinalysis – dipstick4
X1
X3
X
X
X
Urine pregnancy test8
X1
X3
X
X
X

        Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 31 of 66
 
Visit Number
Activity
Screening
Visits:
1 to 209
Visits: 
3 and 10
Visits: 
20, 33, 46 ,60, 
72, 86, 99, 
112,124, 137, 
150, 163, 176, 
189, and 202
Visit: 7
Visits: 
14, 40, 66, 
92,118, 144, 
170 and 196
Visit: 20
Visits: 
27,79, 131 
and 183
Visits: 
53, 105,
, 157 and 
209 or Last 
Visit
Mainz Severity Score 
Index (MSSI)
X1
X
X
Short Form Brief Pain 
Inventory (BPI)
X1
X
X
X
Anti-Drug Antibodies 
(IgG)4
X1
X3
X3
X
X3
X
X
Electrocardiography 
(ECG)
X1
X3
X
X
X
Quality of Life 
(EQ-5D-5L)
X1,7
X
X
X
Cardiac MRI or 
Echocardiogram (for 
patients that receive a 
waiver for the Cardiac 
MRI)
X1
X
X
Cardiac function (Stress 
test)
X1
X
X
Brain MRI
X1
X
Plasma Lyso-Gb34
X1
X3
X
X3
X
X
Plasma Gb3 
concentration4
X3
X
X3
X
X
Follow-up call5
X
X6
Study Drug IV Infusion
X2
Note: The flow chart was built to outline the assessments expected per visit and to cover a treatment period potentially up to 98 months (209 visits). The 98 months 
is estimated to cover commercial availability in all countries participating in the study (per end of study in section 6.1). 

        Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 32 of 66
 
1
Screening visit will happen at the last visit of the previous study; all information will be copied to protocol PB-102-F60.
2
The first infusions of patients enrolled from PB-102-F20 will be performed at the site according to Appendix 6 to evaluate the tolerability of the infusions and 
discontinuation of pre-medications if used.
3
Only applicable for patients who completed PB-102-F20 study.
4
Will be performed pre-infusion.
5
A follow-up call should take place with the patients on the Home Care program.
6
Phone call at Visit 7 applicable only for patients who completed PB-102-F30 and PB-102-F03 studies.
7
Patients who complete PB-102-F03 need to perform in addition to the procedures from the last visit at the study (Visit 131 or rollover visit) - Sample for 
serum creatinine and Cystatin C and Quality of life.8 Females of childbearing potential only

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 33 of 66
 
9.2
Study Visits
9.2.1
Screening Visit (Visit 53 of PB-102-F20 Study / Visit 27 of PB-102-F30 Study / Last 
Visit of PB-102-F03 Study)

Confirm the patient’s eligibility by reviewing the inclusion/exclusion criteria.

Obtain written informed consent from the patient 
Patient ID will be identical to the one used in the previous study.
All information from Visit 53 of PB-102-F20 study, Visit 27 of PB-102-F30 study, or the last Visit 
of PB-102-F03 will be copied by the system to the Screening visit of CLI-06657AA1-04 
(previously PB-102-F60) study.
Patients who completed PB-102-F03 study need to perform at the screening visit the following 
additional assessments:

A sample for serum creatinine and Cystatin C.

Quality of life (Appendix 7. EQ-5D-5L).
9.2.1.1
Visit 53 of PB-102-F20 Study and Missed Assessments Due to COVID-19 
Pandemic
Due to the COVID-19 Pandemic local restrictions or patient-related issues, some of the 
assessments done at Visit 53 of the PB-102-F20 Study could be postponed. In such cases, the 
assessments will be completed during PB-102-F60 Study. In case the delay in performing the 
assessments is more than two months into CLI-06657AA1-04 (previously PB-102-F60) Study, the 
case should be discussed with the Sponsor’s Medical Expert to decide if whether or not to complete 
these assessments at a later time.
9.2.2
Visits 1-209 (Infusions, ± 3 Days)
Pegunigalsidase alfa will be administered by IV infusion every two weeks (±3 days) until 
commercially available to the patient (approximately 209 infusion visits). Refer to Appendix 1 for 
the calculation of patient infusion rates.
For patients enrolled from PB-102-F20 study, initial infusions will be managed to evaluate the 
tolerability and the need for premedication, if used, while in PB-102-F20 study. Therefore, the 
first infusion of pegunigalsidase alfa will be administered intravenously over 3 hours with 2 hours 
of post dosing clinical observation. From the second infusion onwards, the infusion will be 
managed according to Appendix 6, PI evaluation.
With the first infusions, premedication, if used as part of PB-102-F20 infusions, will be continued 
and then tapered down at the Investigator's discretion pending the patient's tolerability and 
according to Appendix 6.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 34 of 66
 
The patient will return to the previous treatment set up, either home infusion or predefined infusion 
center, once the Investigator agrees that it is safe to do so.
Patients who completed PB-102-F30 Study can continue the infusions at the same duration 
achieved in PB-102-F30 but not less than 60 minutes, with a post-dosing clinical observation time 
of an additional 60 minutes and the same premedication if used at PB-102-F30.
Patients who completed at least 48 months in PB-102-F03 Study can continue the infusions at the 
same duration achieved in PB-102-F03 but not less than 60 minutes, with post-dosing clinical 
observation time of an additional 60 minutes and the same premedication if used at PB-102-F03.
Reduction of the infusion time from 90 to 60 minutes will be conducted in a step-wise manner 
pending tolerability.
At each visit, all the following activities will be performed:
1. Infusion of the study drug.
2. Collection of new concomitant medications and:

Review of ongoing medications.

Review of pain medication.

Review of premedication.
3. Collection of any information on new and review ongoing AEs.
4. Vital signs will be evaluated before starting the infusion, every 30 minutes during the first 
hour of infusion, then every 60 minutes until the end of the clinical observation time, and 
at the end of the observation time.
5. The injection site will be evaluated for any signs of reactivity to the infusion.
6. After reducing the infusion time, patients will be observed clinically for a minimum of 
one hour post-dosing.
9.2.3
Visits 3 and 10 (±3 d), Applicable for Patients Enrolling from PB-102-F20 Study

Laboratory tests (pre-infusion):
o
Anti-pegunigalsidase alfa antibodies.
o
Sample for serum creatinine and Cystatin C.

All activities related to the infusion as described in Section 9.2.2.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 35 of 66
 
9.2.4
Visits: 20, 33, 46, 60, 72, 86, 99, 112,124, 137, 150, 163, 176, 189, and 202 (±6 d)
Follow-up call applicable for patients in the Home Care program.
9.2.5
Visit 7 (Only Applicable for Patients who Completed PB-102-F20 Study) (± 6 Days)

Physical examination.

ECG.

Laboratory tests (pre-infusion):
o
Hematology– local laboratory.
o
Biochemistry- Central laboratory.
o
Urinalysis– dipstick, local laboratory and urine pregnancy test, if female of 
childbearing potential.
o
Plasma Lyso-Gb3 concentration.
o
Plasma Gb3 concentration.
o
Urine protein/creatinine ratio (UPCR), spot urine sample.
o
Anti-pegunigalsidase alfa antibodies.
o
Sample for serum creatinine and Cystatin C.

A phone call will be performed at this visit only for patients who completed PB-102-F30 
and PB-102-F03 studies.

All activities related to the infusion as described in Section 9.2.2.
9.2.6
Visits 14, 40, 66, 92,118, 144, 170 and 196 (±3 d)

Physical examination.

Bodyweight.

ECG.

BPI (Appendix 5. Brief Pain Inventory- BPI (Short Form)).

Quality of life (Appendix 7. EQ-5D-5L).

Laboratory tests (pre-infusion):

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 36 of 66
 
o
Hematology– local laboratory.
o
Biochemistry–Central laboratory.
o
Urinalysis – dipstick, local laboratory and urine pregnancy test, if female of 
childbearing potential.
o
Plasma Lyso-Gb3 concentration.
o
Plasma Gb3 concentration.
o
Urine protein/creatinine ratio (UPCR), spot urine sample.
o
Anti- pegunigalsidase alfa antibodies.
o
Sample for serum creatinine and Cystatin C.

All activities related to the infusion as described in Section 9.2.2.
9.2.7
Visits 20 (±3 d) Applicable for Patients Enrolling from PB-102-F20

Laboratory tests (pre-infusion):
o
Anti-pegunigalsidase alfa antibodies.
o
Sample for serum creatinine and Cystatin C.
o
Plasma Lyso-Gb3 concentration.
o
Plasma Gb3 concentration.

All activities related to the infusion as described in Section 9.2.2.
9.2.8
Visits 27,79, 131 and 183 (± 6 Days)

Physical examination.

Bodyweight.

ECG.

BPI (Appendix 5. Brief Pain Inventory- BPI (Short Form)).

MSSI (Appendix 4. The Mainz Severity Score Index (MSSI)).

Quality of life (Appendix 7. EQ-5D-5L).

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 37 of 66
 

Cardiac MRI or Echocardiogram for patients that have a waiver not to perform an MRI.

Stress test for cardiac function.

Laboratory tests (pre-infusion):
o
Hematology– local laboratory.
o
Biochemistry– Central laboratory.
o
Urinalysis – dipstick, local laboratory and urine pregnancy test, if female of 
childbearing potential.
o
Plasma Lyso-Gb3.
o
Plasma Gb3 concentration.
o
Urine protein/creatinine ratio (UPCR), spot urine sample.
o
Anti- pegunigalsidase alfa antibodies.
o
Sample for serum creatinine and Cystatin C.

All activities related to the infusion as described in Section 9.2.2.
9.2.9
Visits 53, 105, 157 and 209 (± 6 Days)

Physical examination.

Bodyweight.

ECG.

BPI (Appendix 5. Brief Pain Inventory- BPI (Short Form)).

MSSI (Appendix 4. The Mainz Severity Score Index (MSSI)).

Quality of life (Appendix 7. EQ-5D-5L).

Cardiac MRI or Echocardiogram for a patient that has a waiver not to perform an MRI.

Stress test for cardiac function.

Brain MRI.

Laboratory tests (pre-infusion):

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 38 of 66
 
o
Hematology– local laboratory.
o
Biochemistry– Central laboratory.
o
Urinalysis – dipstick, local laboratory and urine pregnancy test, if female of 
childbearing potential.
o
Plasma Lyso-Gb3 concentration.
o
Plasma Gb3 concentration.
o
Urine protein/creatinine ratio (UPCR), spot urine sample.
o
Anti- pegunigalsidase alfa antibodies.
o
Sample for serum creatinine and Cystatin C.

All activities related to the infusion as described in Section 9.2.2.
9.2.10 Premature Withdrawal Visit
All attempts should be made to perform all the tests for the last visit (Visit 209) for patients 
terminating the study early. At the withdrawal visit, an infusion will not be performed.
9.2.11 Unscheduled Visit
Unscheduled visit was created for the documentation of assessments or study activities that due to 
different reasons are not performed in the time window defined by the protocol.
10.
STATISTICAL METHODS PLANNED AND SAMPLE SIZE
A detailed statistical analysis plan (SAP) containing the analysis information in detail including 
the definition of the analysis populations, derivation of variables, convention of analysis scope, 
and statistical methodology for the analyses of safety and efficacy parameters of pegunigalsidase 
alfa based on the data collected per the study protocol will be issued prior to the data base lock. In 
case of disagreement between the SAP and the Clinical Study Protocol, the SAP prevails.
10.1 Determination of Sample Size
This extension study's sample size depends on the number of patients who completed PB-102-F20 
study PB-102-F30 study or PB-102-F03 and enrolled into this study; up to 110 male and/or female 
patients.
10.2 Patient Populations
10.2.1 Intent-to-Treat Population

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 39 of 66
 
Intent-to-treat (ITT) population is defined as patients who received any dose (including a partial 
dose) of study medication.
10.2.2 Per Protocol Population
The Per Protocol (PP) population is defined as patients who complete the study with no major 
protocol violations.
10.2.3 Safety Population
The safety population is defined as all patients who received at least one dose (partial or complete) 
of the study medication.
10.3 Analysis
10.3.1 Vital Signs and Physical Examination
For physical examination and vital signs, the frequency count of normal or abnormal by treatment 
will be tabulated for each body system.
10.3.2 Medications
Summary and/or data listings of the prior, concomitant medication and class of medication will be 
provided.
10.3.3 Efficacy Variables
For each efficacy variable, the actual and percent change from baseline to each visit the specific 
variable is measured will be calculated and summarized with descriptive statistics (n, mean and its 
standard error, median, standard deviation, range, and interquartile range).
eGFR is calculated from the serum creatinine according to the CKD-EPI formula:
eGFR (ml/min/1.73 m2) = 141 × min(Scr/κ,1)α × max(Scr/κ, 1)-1.209 × 0.993Age × 1.018 [if female]
* 1.159 [if black]
Scr = serum creatinine; κ = 0.7 for females and 0.9 for males; α = -0.329 for females and -0.411 
for males, min indicates the minimum of Scr/κ or 1. max indicates the maximum of Scr/κ or 1.
10.4 Safety Analysis
Safety will be assessed by evaluating AEs, injection site reactions, ECG, clinical laboratory results, 
brain MRI, anti-pegunigalsidase alfa antibodies ability to taper off infusion pre-medication, and 
requirement for using premedication to manage infusions reactions.
10.4.1 Adverse Events

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 40 of 66
 
AEs will be coded to system organ class and preferred term using a medical dictionary for regulatory 
activities (MedDRA) version 19.0. All AEs occurring after the study treatment (TEAEs) will be 
reported, including events present at baseline that worsened during the study.
AEs will be summarized with respect to the incidence of AEs (the number of patients reporting at 
least one episode of a specific AE), the incidence of AEs by severity within the body system, the 
incidence of AEs by attribution within the body system, and incidence of AEs causing withdrawal 
and incidence of SAEs. Regarding severity and attribution summaries, the most extreme outcome 
(highest severity and closest to study drug-related) will be used for those patients who experience 
the same AE on more than one occasion.
Hypersensitivity reactions will be analyzed as AEs of particular interest using descriptive statistics.
Written narratives will be provided for all serious, unexpected, or other significant AEs judged to 
be of particular interest because of their clinical importance.
10.4.2 Clinical Laboratory
Clinical Laboratory examination will be performed prior to treatment and during treatment.
Descriptive statistics will be presented for the value and abnormality of each of the clinical 
laboratory results by visit. Shift tables describing abnormality shifts from baseline to after 
treatment and follow-up will be created.
10.5 Interim Analysis
Interim analyses may be conducted for administrative purposes.
11.
QUALITY CONTROL AND QUALITY ASSURANCE
11.1 Source Data and Records
Source data are all the information in original records and certified copies of original records of 
clinical findings, observations, laboratory reports, data sheets provided by the Sponsor, or other 
activities in the study, which are necessary for the reconstruction and evaluation of the study. The 
investigator will permit study-related monitoring, audit(s), IRB review(s), and regulatory 
inspection(s), with direct access to all the required source records.
All study records will be retained for a period of time as defined by the regulatory authority for 
the country in which the investigation is conducted. Generally, this means at least two years 
following the date on which the drug is approved by the regulatory authority for marketing for the 
purposes that were the patient of the investigation. In other situations (e.g., where the investigation 
is not in support of or as part of an application for a research or marketing permit), a period of 2 
years following the date on which the entire clinical program is completed, terminated or 
discontinued, or the investigational application under which the investigation is being conducted 
is terminated or withdrawn by the regulatory authorities.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 41 of 66
 
In case the Investigator retires, relocates, or for any other reason withdraws from the responsibility 
for maintaining records for the period of time required, custody of the records may be transferred 
to any other person who will accept responsibility for the records. Notice of such a transfer must 
be given in writing to the Sponsor. The Investigator must contact the Sponsor prior to disposal of 
any records related to this study.
11.2 Reporting of Results
The CRF is an integral part of the study and subsequent reports. Therefore, the CRF must be used 
to capture all study data recorded in the patient's medical record. In addition, the CRF must be kept 
current to reflect patient status during the study. Only a patient screening and treatment number 
will be used to identify the patient
The monitor is responsible for performing on-site monitoring at regular intervals throughout the 
study to verify adherence to the protocol; verify adherence to local regulations on the conduct of 
clinical research; and ensure completeness, accuracy, and consistency of the data entered in the 
CRF.
Chiesi or their designated CRO will monitor completed CRFs. A case report form will be provided 
for each screened patient.
All protocol-required information collected during the study must be entered by the Investigator, 
or designated representative, in the 
e*CRF™, an Internet-based electronic data collection 
system. All details of the CRF completion and correction will be explained to the investigator. The 
management module of 
 e*CRF™ includes edit check and query systems that seamlessly 
integrate with the data entry system. All modifications to the data in the eCRF are tracked by an 
electronic audit trail (the date and identity of the person making the change are instantaneously 
recorded). 
 is 21CFR Part 11 compliant.
If the Investigator authorizes other persons to make entries in the eCRF, these persons' names, 
positions, and signatures must be supplied to the Sponsor.
The Investigator, or designated representative, should complete the eCRF as soon as possible after 
information is collected, preferably on the same day that a study patient is seen for an examination, 
treatment, or other study procedure. Any outstanding entries must be completed immediately after 
the final examination. In addition, an explanation must be provided for all missing data, altered 
data, and/or out-of-range data by design.
The completed case report form must be reviewed and signed by the Investigator named in the 
study protocol or by a designated sub-investigator.
Final monitored and audited eCRFs will be provided by the Sponsor to the sites at the end of the 
study in a PDF file format.
11.3 Confidentiality of Patient Data

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 42 of 66
 
The investigator will ensure that the confidentiality of the patients' data will be preserved. In the 
CRF or any other documents submitted to the Sponsor, the patients will not be identified by their 
names but by an identification system consisting of a number in the study. In addition, the 
investigator will maintain documents not meant for submission to the Sponsor, e.g., the confidential 
patient identification code and the signed informed consent forms, in strict confidence.
12.
REPORTING AND PUBLICATION
12.1 Confidentiality of Study Data
Any information relating to the study product or the study, including any data and results from the 
study, will be the exclusive property of the Sponsor. The investigator and any other persons 
involved in the study will protect the confidentiality of this proprietary information belonging to 
Chiesi Farmaceutici S.p.A.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 43 of 66
 
13.
REFERENCES
1.
Aerts JM, Groener JE, Kuiper S, et al. Elevated globotriaosylsphingosine is a hallmark of 
Fabry disease. Proc Natl Acad Sci USA. 2008;105(8):2812-17.
2.
Barton NW, Brady RO, Dambrosia JM, et al. Replacement therapy for inherited enzyme 
deficiency--macrophage-targeted glucocerebrosidase for Gaucher's disease. N Engl J Med. 
1991;324(21):1464-70.
3.
Benichou B, Goyal S, Sung C, Norfleet AM, O'Brien F. A retrospective analysis of the 
potential impact of IgG antibodies to agalsidase beta on efficacy during enzyme 
replacement therapy for Fabry disease. Mol Genet Metab. 2009;96(1):4-12.
4.
Bishop DF and Desnick RJ. Affinity purification of alpha-galactosidase A from human 
spleen, placenta, and plasma with eliminating pyrogen contamination. Properties of the 
purified splenic enzyme compared to other forms. J Biol Chem. 1988;256(3):1307-16.
5.
Blom D, Speijer D, Linthorst GE, Donker-Koopman WG, Strijland A, Aerts JM. 
Recombinant enzyme therapy for Fabry disease: absence of editing of human 
alphagalactosidase A mRNA. Am J Hum Genet. 2003;72(1):23-31.
6.
BPI- 
Brief 
Pain 
Inventory, 
Short 
Form. 
https://www.mdanderson.org/documents/Departments- 
and-Divisions/Symptom-
Research/BPI_UserGuide.pdf. Accessed 28-Feb-2018.
7.
Deegan PB. Fabry disease, enzyme replacement therapy and the significance of antibody 
responses. J Inherit Metab Dis. 2012;35(2):227-43.
8.
El Dib RP, Pastores GM. Enzyme replacement therapy for Anderson-Fabry disease. 
Cochrane Database Syst. 2010:Rev May 12; (5):CD006663.
9.
Eng CM, Banikazemi M, Gordon RE, et al. A phase 1/2 clinical trial of enzyme 
replacement in Fabry disease: Pharmacokinetic, substrate clearance, and safety studies. Am 
J Hum Genet. 2001;68:711-22.
10.
Eng CM, Guffon N, Wilcox WR, et al. Safety and efficacy of recombinant human alpha-
galactosidase A- replacement therapy in Fabry's disease. N Engl J Med. 2001;345(1):9-16.
11.
Garman SC, Garboczi DN. The molecular defect is leading to Fabry disease: structure of 
human alpha-galactosidase. J Mol Biol. 2004;337(2):319-35.
12.
Genzyme 
FDA, 
Fabrazyme 
2003. 
https://www.accessdata.fda.gov/drugsatfda_docs/label/2003/
agalgen042403LB.pdf. Accessed28-Feb-2018.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 44 of 66
 
13.
Germain DP, Waldek S, Banikazemi M, et al. Sustained, long-term renal stabilization after 
54 months of agalsidase beta therapy in patients with Fabry disease. J Am Soc Nephrol. 
2007;18(5):1547-57.
14.
Hoffmann B, Mayatepek E. Fabry disease-often seen, rarely diagnosed. Dtsch Arztebl Int. 
2009;106(26):440-7.
15.
Hollak CE, Aerts JM, Goudsmit R, et al. Individualised low-dose alglucerase therapy for 
type 1 Gaucher's disease. Lancet 1995;345(8963):1474-78.
16.
Hollak CE, Linthorst GE. Immune response to enzyme replacement therapy in Fabry 
disease: impact on the clinical outcome? Mol Genet Metab. 2009;96(1):1-3.
17.
Hughes DA, Barba Romero MA, Hollak CE, Giugliani R, Deegan PB. Response of women 
with Fabry disease to enzyme replacement therapy: comparison with men, using data from 
FOS--the Fabry Outcome Survey. Mol Genet Metab. 2011;103(3):207-14.
18.
Kizhner T, Azulay Y, Hainrichson M, et al. Characterization of a chemically modified 
plant cell culture expressed human alpha-galactosidase-A enzyme for the treatment of 
Fabry disease, Mol Genet Metabolism. 2015;114(2):259-67.
19.
Lidove O, West ML, Pintos-Morell G, et al. Effects of enzyme replacement therapy in 
Fabry disease--a comprehensive review of the medical literature. Genet Med. 
2010;12(11):668-79.
20.
Lin HY, Chong KW, Hsu JH, et al. High incidence of the cardiac variant of Fabry disease 
revealed by newborn screening in the Taiwan Chinese population. Circ Cardiovasc Genet. 
2009;2(5):450- 6.
21.
Linthorst GE, Hollak CE, Donker-Koopman WE, Strijland A, Aerts JM. Enzyme therapy 
for Fabry disease: neutralizing antibodies toward agalsidase alpha and beta. Kidney Int. 
2004;66(4):1589- 95.
22.
Meikle PJ, Hopwood JJ, Clague AE, Carey WF. Prevalence of lysosomal storage disorders. 
JAMA. 1999;281(3):249-54.
23.
National Kidney Foundation (2002). KDOQI Clinical Practice Guidelines for Chronic 
Kidney Disease: Evaluation, Classification, 
and 
Stratification. 
http://www.kidney.org/professionals/
kdoqi/guidelines_ckd/toc.htm Accessed 28-Feb-2018.
24.
Replagal®. 
Annex 
1. 
Summary 
of 
product 
characteristics: 
http://www.ema.europa.eu/docs/en_GB/
document_library/EPAR_Product_Information/human/000369/WC500053612.pdf. 
Accessed 28-Feb-2018.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 45 of 66
 
25.
Rombach SM, Dekker N, Bouwman MG, et al. Plasma globotriaosylsphingosine: 
diagnostic value and relation to clinical manifestations of Fabry disease. Biochim Biophys 
Acta. 2010;1802(9):741- 48.
26.
Rozenfeld P, Feriozzi S. Contribution of inflammatory pathways to Fabry disease 
pathogenesis. 
Mol 
Genet 
Metabolism. 
2017;122(3):19–27. 
DOI: 
https://doi.org/10.1016/j.ymgme.2017.09.004.
27.
Schaefer RM, Tylki-Szymanska A, Hilz MJ. Enzyme replacement therapy for Fabry 
disease: a systematic review of available evidence. Drugs. 2009;69(16):2179-2205.
28.
Schiffmann R, Murray GJ, Treco D, et al. Infusion of a-galactosidase A reduces tissue 
globotriaosylceramide storage in patients with Fabry disease. PNAS. 2000;97(1):365–70.
29.
Schiffmann R, Ries M, Timmons M, Flaherty JT, Brady RO. Long-term therapy with 
agalsidase alfa for Fabry disease: safety and effects on renal function in a home infusion 
setting. Nephrol. Dial. Transplant. 2006;21(2):345-54.
30.
Schiffmann R, Askari H, Timmons M, et al. Weekly enzyme replacement therapy may 
slow the decline of renal function in patients with Fabry disease who are on long-term 
biweekly dosing. J Am Soc Nephrol. 2007;18(5):1576-83.
31.
Schiffmann R. Fabry disease. Pharmacol Ther. 2009;122(1):65-77. Shire EMA, Replagal® 
2006.
32.
Smid BE, Hoogendijk SL, Wijburg FA, Hollak CE, Linthorst GE. A revised home 
treatment algorithm for Fabry disease: influence of antibody formation. Mol Genet 
Metabolism. 2013;108(2):132-7.
33.
Spada M, Pagliardini S, Yasuda M, et al. High incidence of later-onset Fabry disease 
revealed by newborn screening. Am J Hum Genet. 2006;79(1):31-40.
34.
U.S. Department of Health and Human Services. National Institutes of Health. National 
Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0 
Published: May 28, 2009 (v4.03: June 14, 2010).
35.
Van Breemen MJ, Rombach SM, Dekker N, et al. Reduction of elevated plasma 
globotriaosylsphingosine in patients with classic Fabry disease following enzyme 
replacement therapy. Biochimica et Biophysica Acta. 2011;1812:70–6.
36.
Vedder AC, Breunig F, Donker-Koopman WE, et al. Treatment of Fabry disease with 
different dosing regimens of agalsidase: effects on antibody formation and GL-3. Mol. 
Genet. Metab. 2008;94(3):319-25.
37.
Veronese FM, Pasut G. Pegylation, successful approach to drug delivery. Drug Discov 
Today. 2005;10(21):1451-58.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 46 of 66
 
38.
Veronese FM, Mero A. The impact of Pegylation on biological therapies. Bio drugs. 
2008;22(5):315-29.
39.
Wilcox WR, Banikazemi M, Guffon N, et al. Long-term safety and efficacy of enzyme 
replacement therapy for Fabry disease. Am J Hum Genet. 2004;75(1):65-74.
40.
Wilcox WR, Oliveira JP, Hopkin RJ, et al. Females with Fabry disease frequently have 
major organ involvement: lessons from the Fabry Registry. Mol Genet Metab. 
2008;93(2):112-8.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 47 of 66
 
14.
APPENDICES
14.1 Appendix 1. Tolerability and Infusion Rate Algorithm
The infusion rate (IR) may be adjusted according to individual patient symptoms and signs. The 
assumptions with respect to adverse experiences to the infusion are:
1. Most of the patients will tolerate the infusion without any unusual symptoms or events.
2. Patients presenting symptoms and signs of severe hypersensitivity will be evaluated 
according to the CTCAE Drug Toxicity criteria, and there may be discontinuation of 
treatment according to the protocol.
3. Patients may present signs and symptoms that will respond to reducing the infusion rate 
and may not appear at the next infusion.
4. Tolerability and the patient-specific infusion rate will be assessed and decided by the 
Investigator according to the patient's vital signs and clinical status.
Definitions to be applied regarding the tolerability of infusions are as follows:
Good Tolerability
Partial Tolerability
Poor Tolerability
The infusion was performed 
without signs and symptoms (such 
as burning, pruritus, flushing, 
discomfort, or change in vital 
signs).
Signs and symptoms appeared 
during the infusion and resolved 
after slowing infusion rate or at 
the end of the infusion.
Signs and symptoms meeting the definitions 
of CTCAE Grade 1 or 2 toxicity responding 
to reduction of infusion rate or responding to 
treatment (example, an antihistamine for 
urticaria).

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 48 of 66
 
The specific algorithm for infusion rates to be followed:
Changes in Infusion Rates According to the Protocol:
Signs and symptoms will determine the tolerability of the infusions in these patients during the 
infusion and observation time.
The infusion rate should be adjusted according to patient tolerability as described above; 
continuation of the infusion rate should be agreed upon between the PI and the Sponsor’s Medical 
Expert as needed.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 49 of 66
 
14.2 Appendix 2. Pegunigalsidase alfa Hypersensitivity Evaluation and Treatment 
Algorithm
During and after infusion of pegunigalsidase alfa, the following algorithm will be followed to 
monitor and manage the occurrence of hypersensitivity, anaphylaxis, or anaphylactoid reactions. 
The Investigator can follow an alternative treatment algorithm when used by the local institution. 
Laboratory assessment, described in this appendix, should be collected in any case. Sponsor’s 
Medical Expert will be notified and available for consultation if needed. 
14.2.1 Clinical Signs
Early:
•
A sensation of warmth and itching
•
Feelings of anxiety Moderate
•
Pruritus
•
Flushing
•
Urticaria
•
Chest discomfort
•
Mild Hypotension Progressive
•
Erythematous or massive urticarial rash
•
Edema of face, neck, soft tissues Severe
•
Hypotension
•
Bronchospasm (wheezing)
•
Laryngeal edema (dyspnea, stridor, aphonia, drooling)
•
Arrhythmias
14.2.2  Treatment Algorithm
With the onset of any of the above clinical signs, immediately discontinue study drug 
administration and initiate the following monitoring.
1. Continuous electrocardiographic monitoring.
2. Continuous pulse oximetry.
3. Measure blood pressure every 5 minutes
4. Perform chest auscultation every 5 minutes
5. Collect blood samples for Tryptase (29-33), antibodies, and complement C3, 
C4. Tryptase samples need to be withdrawn at:
-
1st sample to be taken 0.25-3 hours after onset of symptoms.
-
2nd sample to be taken between 3-6 hours.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 50 of 66
 
-
3rd sample to be taken 24-48 hours to verify the return to baseline.
Suspected Hypersensitivity Reactions at Home Care:
In the case that a reaction, suspected to be a result of hypersensitivity, occurs during a home care 
visit, the following steps need to be performed:
The study nurse should inform the site and treat the patient according to 
Investigator's Emergency Treatment Plan.
The next infusion needs to be scheduled and performed at the site.
14.2.3  Treat as Follows
Urticaria or Edema of the Face, Neck, or Soft Tissues:
Epinephrine 1:1000 solution, 0.5 mL subcutaneously, repeat as needed every 
5-10 minutes.
Antihistamines.
Corticosteroids.
Hypotension (Systolic Blood Pressure (SBP) ≤ 90 mmHg):
Isotonic sodium chloride solution, 1 L every 30 minutes as needed to 
maintain SBP > 90 mmHg.
Epinephrine 1:10,000 solution given IV at 1 μg/minute initially, then 2-10 
μg/minute to maintain SBP > 90 mmHg.
Norepinephrine 4 mg in 1 L 5% dextrose in water given IV at 2-12 μg/min to 
maintain SBP> 90 mmHg.
Glucagon 1 mg in 1 L 5% dextrose in water give IV at 5-15 μg/minute for 
refractory hypotension.
Bronchospasm:
Oxygen by face mask at 6-8 L/minute to maintain oxygen saturation at > 
90%.
Epinephrine 1:1000 solution, 0.5 mL subcutaneously.
Albuterol 0.5 mL of 0.5% solution, in 2.5 mL of sterile saline, every 15 
minutes, up to three doses.
Inhaled beta-agonists.
Corticosteroids Laryngeal edema.
Epinephrine 1:1000 solution, 0.5 mL subcutaneously, repeat as needed every 
5 to 10 minutes.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 51 of 66
 
Corticosteroids.
If symptoms resolve within a single study visit and the investigator determines the symptoms were 
not an occurrence of progressive or severe hypersensitivity, anaphylaxis, or anaphylactoid 
reactions, then administration of the drug may continue according to the algorithm provided above, 
and at the discretion of the Investigator.
14.2.4  Premedication
Premedication for subsequent PRX-102 infusions may be considered at the investigator's 
discretion for patients experiencing early clinical signs of hypersensitivity or rash/urticaria that 
respond promptly to oral antihistamine administration (see  for adjustment of infusion rate). The 
premedication will be administered according to the following steps as needed to prevent 
progressive hypersensitivity:
1. Antihistamine (H1 blocker: diphenhydramine, hydroxyzine, cetirizine, loratadine, 
desloratadine) at a standard dose, 12 hours and 2 hours before starting of the infusion.
2. H1 blocker plus H2 blocker (ranitidine, cimetidine, famotidine) at standard doses 12 hours 
and 2 hours before the start of the infusion.
H1 blocker plus H2 blocker plus prednisone up to 50 mg administered 12 hours and 2 hours before 
the start of the infusion.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 52 of 66
 
14.3 Appendix 3. Cardiac MRI
14.3.1 Patients and Sites
For each cardiac MRI to be conducted throughout the study, the test will be performed after the 
Investigator reviews the patient’s kidney function.
For patients who may present one of the following conditions, the performance of the Cardiac MRI 
may be discussed with the Sponsor’s Medical Expert as needed:
•
GFR < 30 mL/min/1.73m2 based on the last serum creatinine value, or
•
Suspected AKI
Gadolinium Warnings from USPI
14.3.2 Magnetic Resonance Imaging Data
Each patient enrolled in this trial will have a cardiac MRI at the Screening Visit (Visit 53 in PB-
102- F20, Visit 27 in PB-102-F30, or at the last visit of PB-102-F03 study) in order to reference 
further MRI evaluations in the study. A set of ECG gated cine and delayed contrast-enhanced MRI 
sequences (SSFP resp. Inversion recovery Gradient echo) will be acquired. A gadolinium-based 
contrast agent will be used during image acquisition of the delayed contrast-enhanced scan.
The sequences will be defined based on the equipment and ability to provide sufficient image 
quality and contrast for myocardium and fibrosis detection and quantification in Fabry’s disease 
patients.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 53 of 66
 
14.3.3 MRI Evaluation Parameters
The following MRI parameters will be evaluated during this trial:
•
Number and location of left ventricular segments with fibrosis.
•
Percentage and mass of cardiac fibrosis (in grams).
•
Left ventricular myocardial mass (in grams).
•
Left ventricular myocardial mass index.
•
Left ventricular ejection fraction.
14.3.4  Sites and Image Data Management
All image management activities will be centralized and conducted by an independent imaging 
Contract Research Organization (CRO) with operational capabilities in Europe and the United 
States in compliance with all regulatory requirements. An overview of the main activities 
performed by the imaging CRO is provided in the following sections.
14.3.4.1 Standardization of Image Acquisition, Initial Site Qualification
This is an extension study which includes patient from PB-102-F20, PB-102-F30 and PB-102-F03 
studies. The imaging during PB-102-F60 study will be performed in the same facilities approved 
for the previous studies.
14.3.4.2 Subject Sedation
Subjects may require sedation in order to obtain the high-quality images required. Sites may use 
standard sedation protocols approved by the institution.
14.3.4.3 Quality Control of Image Data and Site Quality Assurance
The image data will be collected, and quality controlled by the imaging CRO for checking the 
technical adequacy, the compliance of data acquisition with the study imaging protocol, the 
anonymization of the images, and the diagnostic quality of the images (their appropriateness for 
centralized evaluations). If the imaging CRO detects any quality-related issue, specific queries will 
be sent to the sites to implement appropriate corrective (including potential repeat scans if needed) 
and preventive actions.
14.3.5  Image Processing and Centralized Analysis
14.3.5.1 Cardiac MRI Assessment
Analysis of the cine short-axis and delayed contrast-enhanced images of the left ventricle will be 
performed with dedicated MRI quantification software.
Myocardial contours will be detected semi-automatically and manually edited and quality 
controlled by an expert technician at the imaging CRO.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 54 of 66
 
The left ventricular contours will be submitted for final approval to an independent and blinded 
reader.
Based on approved contours, the left ventricular mass and % and mass of the fibrotic area are 
calculated automatically by the software algorithm.
14.3.5.2 Centralized and Blinded Image Review by Independent Readers
The MRI data will be centrally evaluated, in a fully blinded manner, by an independent reader. The 
reading sessions will be organized at the imaging CRO site. The same image evaluation procedure 
will be used for all patients’ MRI scans in this trial.
14.3.5.3 The Expertise of Independent Readers, Training Sessions
The reader will be a Cardiologist with a significant experience in cardiac MRI. The reader will be 
trained prior to the start of centralized image review sessions.
He/she will be provided with a Read Rules document and will be given training on using the 
software. Test cases representing non-study Fabry patients will be used for the training. Main 
consensus issues (contour detection in apical and basal LV slices, trabeculae and papillary muscles, 
the threshold for delayed enhanced areas, etc.) will be discussed with the reader and documented.
14.3.5.4 Conduct of the Centralized Image Review Sessions
The reader will be fully blinded to, patient ID, and site number. The images will have been pre-
analyzed by experienced image analysis technologists from the imaging CRO.
The image review sessions by the cardiologist will include:
14.3.5.5 Efficacy Image Review
MRI analysis results at baseline will act as a reference for further MRI evaluations done in this 
study.
14.3.6  Data and Report Transfers to Sponsor
•
Efficacy image Review sessions will be exported to the Sponsor using a predefined, 
standardized, and secure data transfer procedure.
•
The final Study database will be submitted to the Sponsor in digital format.
14.3.7 Direct Access to Study Data
Direct access to study data will be made possible by the imaging CRO for audit purposes. Such 
study data include:

Information related to interactions between the imaging CRO and the sites (Queries, Data 
Clarification Forms, test data submitted by the sites, etc.)

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 55 of 66
 

Native MRI data

Data processed and generated by the imaging CRO

Data generated by the blinded reader

Audit trails
14.3.8  Unevaluable MRI
Unevaluable MRI data can result from a poor-quality image due to patient motion, improper left 
ventricular coverage, technical problems with the image transmission to the imaging CRO, etc. 
The imaging CRO procedures for ensuring quality images are meant to reduce or eliminate such 
poor-quality images (Section 14.4.4.3 above).
If an adequate patient image cannot be obtained for a given time point in the study, the problem 
with the image will be documented at the imaging CRO. In addition, the imaging CRO will 
document all attempted corrective actions with the investigative site imaging center.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 56 of 66
 
 
 
 
 
 
 
 
 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 57 of 66
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
hypertrophy; MRI, magnetic resonance imaging; TIA, transient 
ischemic attack.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 58 of 66
 
14.5 Appendix 5. Brief Pain Inventory- BPI (Short Form)
(www.mdanderson.org/education-and-research/symptom-assessment-tools/BPI User Guide.pdf) 
The short form of the BPI will be performed every six months in this study.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 59 of 66
 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 60 of 66
 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 61 of 66
 
14.6 Appendix 6. Guide for the Transition of Infusion Time
Guide for the transition of infusion time and premedication for patients who completed the PB-
102-F20 study and enrolled in the PB-102-F60 study.
14.6.1  Introduction
PB-102-F20 is a double-blind study in which patients are treated with pegunigalsidase alfa or 
agalsidase beta (Fabrazyme). The following procedures described in this appendix were designed 
to keep the blindness of PB-102-F20 study, which is ongoing while recruiting patients to 
PB-102-F60 study.
The patients completing PB-102-F20 study can be divided into four different groups based on the 
infusion procedures:
A. Patients whose infusions duration is 1.5 hours and are not treated with premedications.
B. Patients whose infusions duration is 1.5 hours and are treated with premedications.
C. Patients whose infusions duration is > 1.5 hours and are not treated with premedications.
D. Patients whose infusions duration is > 1.5 hours and are treated with premedications.
First infusions should be implemented according to the following guidelines. Then changes in 
infusion rate need to be implemented according to the patient tolerability.
A. Patients whose infusions duration is 1.5 hours and are not treated with premedications:
1. The first infusion will be administered over 3 hours.
2. If the tolerability is acceptable to the investigator, the second infusion length could be 
reduced to 1.5 hours.
3. If the tolerability is uncertain, the reduction of the infusion time will be made stepwise 
pending tolerability. The time of infusion can be decreased by 30 minutes every third 
infusion, up to a minimum infusion time of 1.5 hours or best tolerable infusion time 
achieved under the agreement of the Investigator.
4. After achieving an infusion length of 1.5 hours, the infusion length can be further decreased 
to 1 hour (60 minutes) pending patient tolerability.
B. Patients whose infusions duration is 1.5 hours and are treated with premedications:
1. The first infusion will be administered over 3 hours.
2. After the first infusion, an attempt to reduce premedications will be made stepwise at the 
infusion rate of 3 hours.
3. If the tolerability is acceptable to the investigator, the next step is to reduce the infusion 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 62 of 66
 
length to 1.5 hours in the following infusion.
4. If the tolerability is uncertain, the infusion time reduction will be made step-wise pending 
tolerability. The infusion time can be decreased by 30 minutes every third infusion up to a 
minimum infusion time of 1.5 hours or best tolerable infusion time achieved under the 
agreement of the Investigator.
5. After achieving an infusion length of 1.5 hours, the infusion length can be decreased to 1 
hour (60 minutes) pending patient tolerability.
C. Patients whose infusions duration is > 1.5 hours and are not treated with premedications:
1. The first infusion will be administered over 3 hours.
2. If the tolerability is acceptable, infusion # 2 will be administered at the same rate as the last 
visit of PB-102-F20:
a.
If infusion #2 tolerability is acceptable, infusion #3 can be administered over 1.5 hours.
b. If infusion #2 tolerability is uncertain, the infusion time reduction will be step-wise 
pending the patient’s tolerability. 
The infusion time can be decreased by 30 minutes every third infusion, up to a minimum infusion 
time of 1.5 hours or best tolerable infusion time achieved and under the agreement of the 
Investigator.
3. After achieving an infusion length of 1.5 hours, the infusion length can be further decreased 
to one hour (60 minutes) pending the patient’s tolerability.
4. If the patient were infused in PB-102-F20 over 3 hours or more, the patient’s infusion 
management would be discussed with the Investigator and Sponsor’s Medical Expert if 
needed.
D. Patients whose infusions duration is > 1.5 hours and are treated with Premedication:
1. The first infusion will be administered over 3 hours.
2. After the first infusion, reducing the premedication will be made stepwise and pending the 
patient’s tolerability over 3 hours.
3. After the attempt to reduce premedication, if the tolerability is acceptable, the next infusion 
will be administered for the same rate given at the last PB-102-F20’s visit:
a.
If the tolerability is acceptable, the following infusions can be administered over 1.5 
hours.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 63 of 66
 
b. If the tolerability is uncertain, the infusion time reduction will be made stepwise, 
pending the patient’s tolerability. The infusion time can be decreased by 30 minutes 
every third infusion, up to a minimum infusion time of 1.5 hours or optimal tolerated 
infusion time achieved, under the agreement of the Investigator.
4. After achieving an infusion length of 1.5 hours, the infusion length can be further decreased 
to one hour (60 minutes) pending the patient’s tolerability.
5. If the patient were infused at PB-102-F20 over 3 hours or more, the patient’s infusion 
management can be discussed with the Sponsor’s Medical Expert.

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 64 of 66
 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 65 of 66
 

Clinical Study Protocol
Study Code No.: CLI-06657AA1-04
EudraCT 2018-001148-67             
CONFIDENTIAL                                                                                                                Page 66 of 66