An Open-Label Phase 2 Study of ManNAc in Subjects With GNE Myopathy
Phase: PHASE2
Conditions: GNE Myopathy
Sponsor: National Human Genome Research Institute (NHGRI)

 
 
An Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
PROTOCOL NUMBER: 15-HG-0068 
Version Date: 
Version A – November 26, 2014 
Version B -Amendment - January 16, 2015  
Version C – Expedited Amendment - March 22, 2015  
Version D – Amendment (extension to 12 months)- June 19, 2015  
Version E – Amendment (extension to 18 months) – March 22, 2016  
Version F - Amendment (extension to 24 months) – September 6, 2016 
Version G - Amendment (extension to 30 months) – February 16, 2017 
Version H - Amendment – July 27, 2017 
Version I - Amendment - December 7, 2017  
Sponsor: 
William A. Gahl, MD, PhD 
Clinical Director 
National Human Genome Research Institute 
10 Center Drive, Building 10, Room 10C-103 
Bethesda, Maryland 20892-1851 
Office: (301) 402-2739.  Fax: (301) 402-2740 
IND No. 
078091 
Principal Investigator:
 
 
Nuria Carrillo, MD 
National Human Genome Research Institute 
10 Center Drive, Building 10, Room 9N256C 
Bethesda, MD 20892 
Office: (301) 402-2324.  Fax: (301) 402-0006 
Associate Investigators: 
William A. Gahl, MD, PhD, Clinical Director, NHGRI   
Kennan S. Bradley, BS, MPH, NHGRI, NIH 
Carla Ciccone, BS, MS, MGB, NHGRI 
John D. Heiss, MD, NINDS 
Marjan Huizing, PhD, MGB, NHGRI 
Galen Joe, MD, Rehabilitation Medicine, Clinical Center, NIH 
Chia-Ying Liu, PhD, Radiology, Clinical Center, NIH 
May Christine Malicdan, MD, PhD, MGB, NHGRI 
Rebecca A. Parks, MS, OTR/L, BCP, FAOTA, CC, NIH 
John R. Perreault, CRNP, NICHD, NIH 
Joseph A. Shrader, Rehabilitation Medicine, CC, NIH 
Christina Slota, PhD, MBE, RN, NICHD, NIH 
Christi Piper Hayes, MSN, CRNP, NINDS, NIH 
Collaborating Institutions None 
 
Confidentiality Statement 
This confidential information in this document is provided to you as an Investigator or consultant for review by you, your 
staff, and the applicable Institutional Review Board/Independent Ethics Committee. Your acceptance of this document 
constitutes agreement that you will not disclose the information contained herein to others without written authorization of 
the Sponsor. 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
PROTOCOL SUMMARY 
 
Full Title: 
An Open-Label Phase 2 Study of ManNAc in Subjects with GNE 
Myopathy  
 
Principal Investigator: 
Nuria Carrillo, M.D. 
 
Sample Size: 
N= 12  
 
Accrual Ceiling: 
 
30, with estimated 60% ineligible during screening  
 
Study Population: 
Subjects with GNE myopathy, either gender, age 18-80 years. 
 
Accrual Period: 
 
January 2015- June 2015  
 
Study Design: 
 
Phase 2, open-label, single-center study of ManNAc in subjects with 
GNE myopathy. The study will characterize the safety, tolerability and 
PK of multiple doses of ManNAc and long-term safety and efficacy of 
ManNAc. 
 
Study Duration: 
 
Start Date: January 2015. Projected End Date: July 2018  
 
Primary Objective: 
 
To assess the long-term safety, tolerability, pharmacokinetics,  
pharmacodynamics and biochemical effect of oral ManNAc to subjects 
with GNE myopathy. 
 
Secondary Objectives:  
To evaluate the effect of ManNAc on clinical measures and biomarkers 
of GNE myopathy and to identify clinical endpoints suitable for 
subsequent clinical trials. 
 
Endpoints: 
 
Safety evaluations, PK, PD, muscle strength, muscle MRI, functional 
measures, patient-reported outcomes, and biomarkers. 
 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
List of Abbreviations 
 
Abbreviation  
Explanation 
AMAT 
ARM 
adult myopathy assessment tool 
Advancement of Research for Myopathies 
ADL 
activities of daily living 
AE 
adverse event 
ALT 
alanine aminotransferase 
α-DG 
alpha-dystroglycan 
AST 
aspartate aminotransferase 
AUC 
area under the curve 
AUCEXT 
percentage of the AUC that is extrapolated beyond the last measurable 
concentration 
AUCINF 
area under the plasma concentration time curve from time 0 (predose) to 
infinity 
AUCLAST 
AUC from time 0 to time of last measurable plasma concentration  
BID 
twice daily 
BUN 
blood urea nitrogen 
CBC 
complete blood count 
CC 
Clinical Center 
CD 
Clinical Director 
CFR 
Code of Federal Regulations 
CK 
creatine kinase 
Cl 
chloride 
CL/F 
apparent systemic clearance 
CLIA 
Clinical Laboratory Improvement Amendments 
CMAX 
maximum observed plasma concentration 
CMP 
cytidine 5’-monophosphate 
CMP-Neu5Ac 
CMP-sialic acid 
CO2 
carbon dioxide 
CPK 
creatine phosphokinase 
CRF 
clinical report forms 
CRIS 
Clinical Research Information System 
CRU 
clinical research unit 
CTCAE 
Common Terminology Criteria for Adverse Events 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
CTDB 
Clinical Trial Database  
CV 
coefficient of variation 
DEX-M74 
Drug product of ManNAc 
DMRV 
Distal Myopathy with Rimmed Vacuoles 
DNA 
deoxyribonucleic acid 
DSMB 
Data Safety Monitoring Board 
ECG 
electrocardiogram 
ESR 
erythrocyte sedimentation rate 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GGTP 
gamma-glutamyl transpeptidase 
GlcNAc 
N-acetylglucosamine 
GLP 
Good Laboratory Practice 
GMBB 
Genetics and Molecular Biology Branch 
GNE 
human gene encoding the GNE protein, when mutated, causes GNE myopathy 
Gne 
murine gene encoding the mouse Gne protein  
GNE 
UDP-N-acetylglucosamine-2-epimerase/N-acetylmannosamine kinase 
Gne 
murine UDP-N-acetylglucosamine-2-epimerase/N-acetylmannosamine kinase 
enzyme 
HAP 
Human Activity Profile 
hCG 
human chorionic gonadotropin 
HED 
human equivalent dose 
HIBM 
Hereditary Inclusion Body Myopathy 
HIPAA 
Health Insurance Portability and Accountability Act  
hr 
hour 
IB 
Investigator Brochure 
IBM2 
Inclusion Body Myopathy 2 
IBMFRS 
Inclusion Body Myositis Functional Rating Scale  
ICF 
informed consent form 
ICH 
International Conference on Harmonisation 
IND 
Investigational New Drug 
IRB 
Institutional Review Board 
IV 
intravenous 
IVIG 
intravenous immunoglobulin 
K  
potassium 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
Kg 
kilograms 
LC-MS/MS  
liquid chromatography and tandem mass spectrometry 
LD 
lactate dehydrogenase  
MAD 
multiple ascending dose 
ManNAc 
N-acetyl-D-mannosamine  
MCH 
mean corpuscular hemoglobin 
MCHC 
mean corpuscular hemoglobin concentration 
MCV 
mean corpuscular volume 
mg 
milligram 
MGB  
Medical Genetics Branch  
MMT 
Manual Muscle Testing 
MTD 
maximum tolerated dose 
MVIC 
maximal voluntary isometric contraction 
n 
number 
Na 
sodium 
NCATS 
National Center for Advancing Translational Sciences 
NDF 
Neuromuscular Disease Foundation 
Neu5Ac 
N-acetylneuraminic acid or sialic acid 
NHGRI 
National Human Genome Research Institute 
ng 
nanogram 
NIH 
National Institutes of Health 
NINDS 
National Institute of Neurological Disorders and Stroke 
NOAEL 
no observable adverse effect level 
PD 
Pharmacodynamics(s) 
PDS 
Pharmaceutical Development Service at NIH 
PEP 
phosphoenolpyruvate 
PI 
Principal Investigator 
PIB 
powder in bottle 
PII 
personally identifiable information 
PK 
pharmacokinetic(s) 
PROs 
patient-reported outcomes 
PSA-NCAM 
polysialylated neuronal cell adhesion molecule 
PT 
prothrombin time 
PTT 
partial thromboplastin time 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
QMA 
Quantitative Muscle Assessment  
RBC 
red blood cell 
RNA 
ribonucleic acid 
SAD 
single ascending dose 
SAE 
serious adverse event 
SD 
standard deviation 
SGOT 
serum glutamic-oxaloacetic transaminase 
SGPT 
serum glutamic-pyruvic transaminase 
SRC 
Safety Review Committee 
STIR 
short tau inversion recovery 
t½ 
terminal-phase half-life 
TMAX 
time to CMAX 
TRND 
Therapeutics for Rare and Neglected Diseases  
UDP-GlcNAc 
uridine diphospho-N-acetylglucosamine 
Vz/F 
apparent volume of distribution, terminal phase 
WBC 
white blood cell 
λz 
elimination rate constant 
 
 
 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
 
TABLE OF CONTENTS 
1. 
Precis .............................................................................................................................. 1 
2. 
Objectives and Specific Aims ....................................................................................... 2 
2.1. Primary Objectives ................................................................................................ 2 
2.2. Secondary Objectives ............................................................................................ 2 
3. 
Brief Rationale and Background ................................................................................. 3 
3.1. GNE Myopathy ...................................................................................................... 3 
3.2. ManNAc Description and Pathway ....................................................................... 4 
3.3. Natural History Study ............................................................................................ 4 
3.3.1. Progression Model GNE Myopathy ........................................................... 4 
3.4. Nonclinical Studies of ManNAc ............................................................................ 6 
3.4.1. Efficacy of ManNAc in Mouse Models ...................................................... 6 
3.5. Clinical Use of ManNAc ....................................................................................... 7 
3.5.1. 1966 Study in Humans ............................................................................... 7 
3.5.2. Anecdotal Use of ManNAc ......................................................................... 7 
3.5.3. Clinical Study 12-HG-0207 ....................................................................... 7 
3.6. Pharmacokinetics and Pharmacodynamics ............................................................ 7 
3.7. Biomarkers ............................................................................................................. 9 
3.7.1. Intracellular Biomarkers ........................................................................... 9 
3.7.2. Lectin Staining of Muscle Biopsies ............................................................ 9 
3.7.3. Plasma Sialylated Proteins ........................................................................ 9 
3.8. Safety of ManNAc ................................................................................................. 9 
3.8.1. Nonclinical Safety Evaluation ................................................................... 9 
3.8.2. Clinical Safety .......................................................................................... 10 
3.8.3. Preliminary Findings 15-HG-0068 Open-Label Phase 2 Study.............. 11 
3.8.4. Pharmacokinetic Model for ManNAc and Sialic Acid in GNE Myopathy 
Subjects .................................................................................................... 11 
3.8.5. Muscle Strength ....................................................................................... 12 
4. 
Study Design ................................................................................................................ 13 
4.1. Study Overview ................................................................................................... 13 
4.2. Sample Size ......................................................................................................... 13 
4.3. Visit Schedule ...................................................................................................... 13 
4.4. Dose and Frequency ............................................................................................ 14 
4.4.1. Dose Levels .............................................................................................. 14 
4.4.2. Dose Frequency ....................................................................................... 14 
4.5. Dose Administration ............................................................................................ 15 
4.5.1. Inpatient Drug Administration ................................................................ 15 
4.5.2. Drug Administration after Discharge ...................................................... 16 
4.5.3. Drug Administration During Terminal Half-Life PK Determination ...... 16 
4.6. Concomitant Medications .................................................................................... 16 
4.7. Safety Evaluations ............................................................................................... 17 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
4.8. Dose Escalation ................................................................................................... 17 
4.8.1. Escalation and Continuation Rules for Cohort A .................................... 17 
4.8.2. Initiation and Continuation Rules for Cohort B ...................................... 17 
Withdraw the subject, and ................................................................................... 18 
Withdraw the subject, and ................................................................................... 18 
Evaluate the risk/benefit profile in other subjects for dose escalations to or 
above the dose resulting in Grade 3 toxicity, and ................................... 18 
4.9. Dose Modification ............................................................................................... 19 
4.10. Subject Compliance ............................................................................................. 19 
4.11. Randomization and Blinding ............................................................................... 19 
5. 
Description of Procedures .......................................................................................... 20 
5.1. Medical Information ............................................................................................ 20 
5.2. Diagnostic Studies ............................................................................................... 20 
5.2.1. Procedures ............................................................................................... 20 
5.2.2. Clinical Laboratory Studies ..................................................................... 23 
5.2.3. Pharmacokinetics .................................................................................... 24 
5.2.4. Lectin and Antibody Labeling of Muscle Biopsies .................................. 24 
5.2.5. Potential Biomarkers ............................................................................... 24 
5.3. Biological Specimens .......................................................................................... 26 
5.3.1. Samples for Safety, Pharmacokinetic, and Pharmacodynamic 
Evaluations .............................................................................................. 26 
5.3.2. Research Samples .................................................................................... 26 
5.3.3. Collaborating Laboratories ..................................................................... 27 
5.4. Approved Drugs ................................................................................................... 27 
5.5. Unapproved Drugs ............................................................................................... 27 
5.5.1. Identity of Investigational Product .......................................................... 27 
5.5.2. Packaging, Labeling, and Storage of Clinical Supplies .......................... 27 
5.5.3. Drug Accountability ................................................................................. 28 
5.6. Results Given to Participants ............................................................................... 28 
5.7. Questionnaires ..................................................................................................... 28 
5.8. Genetic Counseling .............................................................................................. 28 
5.9. Criteria for Withdrawal ........................................................................................ 28 
6. 
Description of Study Population ................................................................................ 29 
6.1. Estimated Number of Participants ....................................................................... 29 
6.2. Eligibility Criteria ................................................................................................ 29 
6.2.1. Inclusion Criteria ..................................................................................... 29 
6.2.2. Exclusion Criteria .................................................................................... 29 
6.2.3. Justification of Inclusion/Exclusion Criteria ........................................... 30 
6.3. Location of Study ................................................................................................ 30 
6.4. Recruitment Strategies ......................................................................................... 31 
6.5. Existing Sample/Data Sets ................................................................................... 31 
6.6. Financial Compensation ...................................................................................... 31 
7. 
STATISTICAL CONSIDERATIONS ....................................................................... 32 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
7.1. Statistical Plan ..................................................................................................... 32 
7.1.1. General Reporting Conventions .............................................................. 32 
7.2. Statistical Methods and Evaluations .................................................................... 32 
7.2.1. Demographic and Baseline Characteristics ............................................ 32 
7.2.2. Safety Evaluations ................................................................................... 32 
7.2.3. Pharmacokinetic Analysis ....................................................................... 32 
7.2.4. Pharmacodynamics .................................................................................. 33 
7.2.5. Lectin Staining on Muscle Biopsies ......................................................... 33 
7.2.6. Quantitative Muscle Strength .................................................................. 33 
7.2.7. Other Rehabilitation Medicine Evaluations ............................................ 33 
7.3. Determination of Sample Size ............................................................................. 33 
7.4. Interim Analysis ................................................................................................... 33 
7.5. Deviation from Original Analysis Plan ............................................................... 34 
8. 
Potential Benefits ......................................................................................................... 35 
8.1. Direct benefits to participants .............................................................................. 35 
8.2. Collateral Benefit to Participants ......................................................................... 35 
8.3. Benefits to Society ............................................................................................... 35 
9. 
Likelihood and Seriousness of Harms and Means to Maximize Safety ................. 36 
9.1. Therapeutic Interventions .................................................................................... 36 
9.1.1. Risks of ManNAc/ManNAc ...................................................................... 36 
9.2. Diagnostic Interventions ...................................................................................... 36 
9.2.1. Medical Evaluations ................................................................................ 36 
9.2.2. Serum Pregnancy Testing ........................................................................ 36 
9.2.3. ECG ......................................................................................................... 36 
9.2.4. Placement of a Peripheral Intravenous Line ........................................... 36 
9.2.5. Phlebotomy .............................................................................................. 37 
9.2.6. Muscle Biopsy .......................................................................................... 37 
9.2.7. Muscle MRI .............................................................................................. 37 
9.2.8. Activity monitor ....................................................................................... 37 
9.3. Radiation .............................................................................................................. 38 
9.4. Sedation ............................................................................................................... 38 
9.5. Psychological Harms ........................................................................................... 38 
9.6. Risk to Family Relationships ............................................................................... 38 
9.7. Discrimination ..................................................................................................... 38 
10. 
Privacy and Confidentiality of Medical Information and Biological Specimens .. 39 
10.1. Participant Identifiers Attached to Data .............................................................. 39 
10.2. Clinical/Demographic Information ...................................................................... 39 
10.3. How might information make specific individuals identifiable? ........................ 39 
10.4. Access to the key for subject identification ......................................................... 39 
10.5. Will pedigrees be published? ............................................................................... 39 
10.6. Will results be provided to participants? ............................................................. 39 
10.7. Will Identifiable Information be Released to Third Parties? ............................... 39 
10.8. Sharing of Data/Samples with Other Researchers ............................................... 40 
10.9. Additional Features to Protect Confidentiality .................................................... 40 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
11. 
Assessment of Risk/Benefit Ratio ............................................................................... 40 
12. 
Collection, Monitoring, Analysis and Reporting of Adverse Events and Protocol 
Deviations ..................................................................................................................... 41 
12.1. Adverse Events .................................................................................................... 41 
12.1.1. Monitoring and Reporting of Adverse Events ......................................... 41 
12.1.2. Review of Safety and Tolerability ............................................................ 42 
12.2. Monitoring and Reporting Plan ........................................................................... 42 
12.2.1. Notification about Serious Adverse Reaction and Serious and 
Unexpected Suspected Adverse Reactions ............................................... 44 
12.2.2. Reporting to Regulatory Agencies and IRB ............................................. 44 
12.3. Safety Monitoring Committee/ Data Safety and Monitoring Board (DSMB) .... 44 
12.3.1. Safety Review Committee (SRC) .............................................................. 44 
12.3.2. Data and Safety Monitoring Board (DSMB) ........................................... 44 
13. 
Alternatives to Participation ...................................................................................... 44 
14. 
Consent Process ........................................................................................................... 45 
14.1. Who Will Obtain Consent? .................................................................................. 45 
14.2. Setting of Consent ................................................................................................ 45 
14.3. Consent Information ............................................................................................ 45 
14.4. Protections for Vulnerable Participants ............................................................... 45 
14.5. Special Circumstances ......................................................................................... 45 
15. 
Financial compensation .............................................................................................. 46 
16. 
References .................................................................................................................... 47 
Appendix A. 
Protocol Synopsis ................................................................................... 49 
Appendix B. 
STUDY DESIGN ................................................................................... 52 
Appendix C. 
Schedule of Events ................................................................................. 53 
Appendix D. 
Blood/Urine Sampling Schedule ........................................................... 54 
Appendix E. 
Investigational Agent(s) Information for Pharmacy .......................... 56 
Appendix F. 
90-Day Toxicology Studies .................................................................... 57 
Appendix G. 
Long-term Toxicology studies .............................................................. 59 
Appendix H. 
Signature of Investigator ....................................................................... 61 
 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
TABLE OF FIGURES 
Figure 1. Sialic Acid Biosynthetic Pathway ................................................................................... 3 
Figure 2. Expected Progression of Muscle Groups ........................................................................ 5 
Figure 3. Interpretation of treatment effect (γ) in the Disease Progression Model ......................... 6 
Figure 4. ManNAc and Neu5Ac Plasma Concentration after Single Oral Dose of ManNAc 
Administered to Fasting GNE Myopathy Subjects ......................................................... 8 
Figure 5. Simulated Concentration-Time Profiles for Plasma (A) ManNAc and (B) Free 
Neu5Ac with ManNAc 6,000 mg BID in Subjects with GNE Myopathy .................... 15 
Figure 6. Dosing Escalation/De-escalation ................................................................................... 18 
Figure 7. MRS of GNE Myopathy Muscle ................................................................................... 21 
Figure 8. Muscle Lectin Histochemistry ....................................................................................... 25 
 
TABLES 
 
Table 1. PK and PD Parameters for Single Dose of Oral ManNAc to Fasting GNE 
Myopathy Subjects .......................................................................................................... 8 
Table 2. Maximum Recommended Starting Dose Based on 90-Day Toxicology Studies ........... 10 
Table 3. Maximum Recommended Starting Dose Based on Long-Term Toxicology Studies .... 10 
Table 4. Simulations of ManNAc Dose and Frequency using the Semi-Mechanistic 
Population PK Model for GNE Myopathy. ................................................................... 12 
Table 5. Brief Visit Schedule ........................................................................................................ 13 
Table 6. Dose Escalation/De-escalation Rules ............................................................................. 18 
Table 7. Blood Volume ................................................................................................................. 26 
Table 8. Collaborations ................................................................................................................. 27 
Table 9. Summary table of findings from 26-Week Rat oral toxicity studies of ManNAc. ......... 59 
Table 10. Summary table of findings from 39-Week Dog oral toxicity study of ManNAc ......... 60 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
1 
1. 
PRECIS 
GNE myopathy, previously known as hereditary inclusion body myopathy (HIBM), is a rare, autosomal 
recessive myopathy with onset in early adulthood that is characterized by progressive muscle weakness 
and atrophy, which leads to wheelchair use and dependent care. The causative gene, GNE, encodes the 
rate-limiting enzyme in the biosynthesis of sialic acid. While the exact pathophysiology of GNE 
myopathy remains unknown, decreased sialic acid production and subsequent hyposialylation of muscle 
glycoproteins are thought to be key factors leading to muscle deterioration in GNE myopathy. This 
hypothesis is supported by prevention of disease after administration of N-acetyl-D-mannosamine 
(ManNAc) in mouse models of GNE myopathy. A first-in-human, Phase 1 single ascending dose study 
evaluated the safety, pharmacokinetics, and pharmacodynamics of a single dose of 3,000, 6,000, or 
10,000 mg drug product-grade ManNAc in subjects with GNE myopathy (ClinicalTrials.gov 
NCT01634750; IND No.78,091). ManNAc was safe and well-tolerated in all subjects who participated in 
this study. In this Phase 2, open-label, single-center study we propose to administer ManNAc orally to 12 
subjects for days (30 months). The objectives of the study are to assess the safety, tolerability, 
pharmacokinetics, pharmacodynamics and biochemical efficacy of orally administered ManNAc in GNE 
myopathy subjects and to evaluate disease-related biomarkers and relevant clinical endpoints.  In the first 
phase of pharmacokinetic assessment, two cohorts of 6 subjects will receive ManNAc at doses of 3,000 
mg twice a day (6,000 mg per day) or 6,000 mg twice a day (12,000 mg per day) for 7 days while 
admitted to the NIH Clinical Center to assess PK and safety. Safety and tolerability will be assessed on an 
individual basis. In the second phase of the study, all subjects will receive treatment with ManNAc at a 
dose of 6,000 mg twice daily for the remainder of the study. Follow-up safety and efficacy evaluations 
will occur at 42 days, and at 91 (3 months), 182 (6 months), 365 (12 months), 548 (18 months), 730 (24 
months) and 912 (30 months) days. Safety lab evaluation will be performed also at 456 (15 months), 638 
(21 months) and 820 (27 months) days either at the NIH clinical center or subjects’ home laboratory or 
physician’s office. Final dosing will occur at the 30-month visit. After the final dose, all Grade ≥2 AEs at 
least possibly related to study drug will be followed to resolution. Safety will be evaluated by adverse 
events (AEs), clinical laboratory tests, vital signs, and physical examinations. PK will be assessed for 
plasma ManNAc and Neu5Ac. Biochemical efficacy will be measured by change in the sialylation of 
proteins and clinical efficacy will be assessed using a battery of clinical assessments deemed to be 
relevant based on disease natural history. 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
2 
2. 
OBJECTIVES AND SPECIFIC AIMS 
2.1. 
Primary Objectives 
The primary objectives of this study are: 
• To assess the safety and tolerability of multiple doses of orally administered ManNAc to subjects 
with GNE myopathy; 
• To examine plasma pharmacokinetics (PK) and pharmacodynamics (PD) of multiple doses of 
orally administered ManNAc to subjects with GNE myopathy; 
• To determine the biochemical effect of ManNAc, as assessed by sialylation of proteins.  
2.2. 
Secondary Objectives 
The secondary objectives of this study are: 
• To evaluate the effect of ManNAc on disease-relevant biomarkers;  
• To measure the effect of ManNAc on clinical aspects of GNE myopathy and identify clinical 
endpoints suitable for subsequent clinical trials. 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
3 
3. 
BRIEF RATIONALE AND BACKGROUND 
3.1. 
GNE Myopathy 
GNE myopathy is a rare autosomal recessive muscular disease1-3 with an estimated prevalence of 
~6:1,000,0004.  Previous names of the disease include Hereditary Inclusion Body Myopathy (HIBM), 
Inclusion Body Myopathy 2 (IBM2), Distal Myopathy with Rimmed Vacuoles (DMRV), Nonaka 
Myopathy or quadriceps-sparing myopathy (Q-IBM). To avoid confusion, an international consortium has 
recently unified the nomenclature to GNE myopathy5. Patients present in early adulthood with distal 
weakness (foot drop), secondary to anterior tibialis muscle involvement. The disease slowly progresses to 
cause atrophy and weakness of the distal muscles of the lower extremities, followed by thigh muscles, 
with relative sparing of the quadriceps1, 6. The upper extremities are affected typically 5-10 years after 
onset of symptoms1. Findings on muscle biopsy typically include ‘rimmed” vacuoles, lack of 
inflammation and hyposialylation. This relentlessly progressive disease results in marked disability, 
including wheelchair use within 1 or 2 decades after the onset of symptoms, and ultimately dependent 
care in some patients1, 7. There is no treatment available for GNE myopathy, but there is encouraging 
preclinical evidence that sialylation-increasing therapies, including sialic acid or N-acetyl-D-
mannosamine (ManNAc) could provide benefit for affected individuals (Section 3.3). 
Figure 1. Sialic Acid Biosynthetic Pathway 
 
GNE myopathy is caused by 
biallelic mutations in GNE, the 
gene that encodes the rate-
limiting bifunctional enzyme in 
sialic acid biosynthesis, UDP-N-
acetylglucosamine (GlcNAc) 2-
epimerase/N-acetylmannosamine 
(ManNAc) kinase8 (Figure 1). 
Over 150 GNE gene mutations 
have been reported in GNE 
myopathy patients worldwide, in 
either the epimerase or the kinase 
encoding domains of the 
enzyme4. N-acetylneuraminic 
acid (Neu5Ac, generally referred 
to as ‘sialic acid’) is the most 
abundant mammalian sialic acid 
and the precursor of most other 
sialic acids. Sialic acids are negatively charged terminal sugar moieties on glycoproteins and glycolipids9, 
10, where they mediate several biological processes and play essential roles in disease processes9-11. 
Sialylation appears to be critical for mouse development, since the Gne knock-out results in embryonic 
lethality in the mouse model12. GNE mutations decrease sialic acid production and, consequently, 
sialylation is decreased, i.e., the incorporation of sialic acid into glycoproteins and glycolipids13, 14. 
Hyposialylation appears to be a major cause of the myopathy of GNE deficiency, since administration of 
sialic acid or its precursor, ManNAc, prevents or arrests the development of disease in mouse models of 
The initiation of sialic acid (Neu5Ac) 
biosynthesis occurs in the cytoplasm. 
The main substrate for this pathway is 
UDP-GlcNAc, which is derived from 
glucose. In the rate-limiting step of 
the pathway, UDP-GlcNAc is 
converted into ManNAc by UDP-
GlcNAc 2-epimerase, encoded by the 
epimerase domain of GNE. ManNAc 
is phosphorylated by ManNAc kinase 
encoded by the kinase domain of 
GNE. Sialic acid becomes “activated” 
by CMP-sialic acid synthetase in the 
nucleus.  CMP-sialic acid acts as a 
sialic acid donor to sialylate glycans 
on nascent glycoproteins and 
glycolipids in the Golgi apparatus; it 
also acts as a cytoplasmic feedback 
inhibitor of the UDP-GlcNAc 2-
epimerase enzyme by binding to its 
allosteric site.  

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
4 
GNE myopathy15, 16.  Although overall sialylation in GNE myopathy cells and tissues may appear 
normal17, 18, specific glycoproteins and glycolipids are hyposialylated in GNE myopathy muscle, 
including alpha-dystroglycan (α-DG)19, polysialic acid on neural crest adhesion molecule (PSA-
NCAM)20, neprilysin21, the GM3 ganglioside22, or O-linked glycans in general23 (See Figure 8). 
3.2. 
ManNAc Description and Pathway 
N-acetyl-D-mannosamine monohydrate (ManNAc) has a molecular weight of 239.2 g/mol. ManNAc will 
be used in this study as drug product of ManNAc. ManNAc is a naturally occurring uncharged 
monosaccharide, the first committed precursor for the biosynthesis of Neu5Ac (sialic acid), and a 
substrate of the GNE enzyme (Figure 1). Neu5Ac is a negatively charged molecule, which consists of 
ManNAc in an ether linkage with D-pyruvic acid.  In contrast to Neu5Ac, which is a negatively charged 
molecule, ManNAc is the only neutral molecule in the sialic acid biosynthesis pathway. As such, it is 
expected to readily reach the intracellular space, as confirmed by in vitro studies2, 24.  
3.3. 
Natural History Study 
Patients with GNE myopathy have been followed on a prospective, single-center Natural History Study, 
NIH Protocol 11-HG-0218 “A Natural History Study of GNE Myopathy” (ClinicalTrails.gov Identifier: 
NCT01417533), hereafter referred to as the “Natural History Study” at the NIH Clinical Center (NIH 
CC). This study started in September 2011 to define the progression, potential endpoints and biomarkers 
of GNE myopathy.  
3.3.1. Progression Model GNE Myopathy 
A disease progression model was developed utilizing the natural history data of 32 GNE myopathy 
subjects, to determine the average rate of decay of selected muscle groups. The primary endpoint used 
was Quantitative Muscle Assessment (QMA)25. For each available QMA measurement a corresponding 
predicted muscle score is calculated based on the subject’s age, gender and BMI26 and the proportion of 
QMA muscle score relative to the predicted score, referred to as proportion of strength, was used. The 
primary endpoint of the disease progression model is the proportion of strength across the primary muscle 
groups: 1) Ankle dorsiflexion (anterior tibialis muscle), 2) Knee flexion (hamstrings), 3) Grip, 4) Hip 
extension, and 5) Knee extension (quadriceps), and 6) Shoulder abduction (deltoid).  
The stage of disease varies among subjects, so the model accommodates subjects at varying stages of the 
disease by estimating a disease age for each subject based on their decline in the proportion of muscle 
strength (QMA muscle score relative to predicted muscle score) within 5 primary muscle groups. Disease 
age zero is defined when knee flexion is .50 of the maximum muscle strength. Given this estimate of 
disease age we are able to align the subjects and estimate an expected decay of each of the 5 primary 
muscle groups relative to one another and as a function of disease age (Figure 2). This allows us to 
understand the rate of progression of muscles groups relative to one another and to make subject-specific 
predictions of their decline.   

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5 
Figure 2. Expected Progression of Muscle Groups  
3.3.1.1. 
Determining Treatment Effect using the Progression Model GNE Myopathy 
The disease progression model can be used to determine whether an intervention changes the rate of 
disease progression compared to the natural progression under no intervention.  The rate of decay for each 
muscle (at any given disease age) is estimated in the model.  To determine whether a therapy affects 
disease progression, the model incorporates a treatment effect parameter (referred to as gamma, γ) that 
determines whether the intervention slows the rate of decline compared to no intervention. If γ is equal to 
1 there is no treatment effect (as the rate of progression is the same with intervention than with no 
intervention). If γ is less than 1, an intervention slows the rate of progression as compared to no 
intervention. If γ = 0.5, the treatment slows the rate of muscle progression by 50%. If γ equals zero, the 
treatment has stopped the rate of progression (Figure 3). 
We have determined that using muscle strength as measured by QMA as a primary endpoint and the 
progression model as primary analysis, significantly increases power and reduces the number of subjects 
required to determine treatment effect in clinical trials when compared to other tested endpoints. To 
inform the design of the clinical trial to determine efficacy of a potential therapy for GNE myopathy, 
utilizing the primary efficacy endpoint and analysis described above, simulations of the design under 
multiple scenarios were performed. Scenarios included different treatment effects (γ), number of patients, 
duration of treatment, randomization and frequency of visits. For each scenario 1,000 trials were 
simulated. It was determined that a trial enrolling 50 subjects, a 3:1 randomization (treatment:placebo), 
The expected proportion of 
muscle strength for each of the 
5 primary muscle groups is 
plotted on the y-axis and the 
disease age is plotted on the x-
axis. Note the slow progression 
of Knee Extension (quadriceps) 
when compared to other muscle 
groups.  
Abbreviations: Dorsiflex: Ankle 
Dorsiflexion; Flex: Flexion; 
Ext: Extension 
 
 

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6 
duration of 2 years and follow-up visits every 6 months would have the following conditional 
probabilities of trial success: if the treatment slows the rate of decline by ≥50% (γ≥0.5), 25% (γ =0.25) 
and 0% (γ =0), the probabilities of trial success would be ~98.8%, 75.5% and <1%, respectively. 
Therefore, the probabilities of trial success are conditional of an assumed effect size.  By extending the 
current study, we will gain understanding of the magnitude of effect size of ManNAc, giving us important 
information to refine the design of our upcoming pivotal clinical trial.  
Figure 3. Interpretation of treatment effect (γ) in the Disease Progression Model 
 
The solid line corresponds to progression of muscle decline without an intervention. The dashed-lines represent different 
treatment effects, γ.  If γ is equal to 1 there is no treatment effect. If γ is less than 1, the treatment slows the rate of progression. 
If γ = 0.5, the treatment slows the rate of muscle progression by 50%. If γ equals zero, the treatment has stopped the rate of 
progression. 
3.4. 
Nonclinical Studies of ManNAc 
3.4.1. Efficacy of ManNAc in Mouse Models 
There is in vitro and in vivo evidence that ManNAc restores sialic acid production and increases the 
sialylation of hyposialylated glycoproteins and glycolipids (glycans) in disease models of GNE myopathy.  
Selected studies of ManNAc are summarized below. Additional details are located in the Investigator 
Brochure (IB). 
• A gene-targeted knock-in Gne mouse homozygous for the Persian-Jewish GNE myopathy founder 
mutation, p.M743T (hGNE2 protein nomenclature, GenBank accession NP_001121699; in previous 
GNE nomenclature called p.M712T)5, died within 72 hours after birth. Oral administration of 
1,000 mg/kg/day of ManNAc (Human Equivalent Dose (HED) 5,600 mg/day) to pregnant and nursing 
mice rescued survival of mutant pups beyond 72 hours and was associated with increased enzymatic 
activity of UDP-GlcNAc 2-epimerase27.  
• A transgenic mouse model for a founder mutation in Japanese patients on a Gne null background 
(Gne-/-hGNED207V-Tg) (originally called Gne-/-hGNED176V-Tg), recapitulated the muscle 
phenotype of GNE myopathy, developing progressive muscle weakness starting at 10 weeks and by 
40 weeks of age showing significant changes in muscle pathology and biochemistry similar to that of 
GNE myopathy patients. Prophylactic continuous oral treatment of these mice with ManNAc at 20 
mg/kg/day (HED 112 mg/day), 200 mg/kg/day (HED 1120 mg/day), and 2,000 mg/kg/day (HED 

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7 
11,200 mg/day), starting at week 5 resulted in prevention of muscle weakness and atrophy (reduced or 
absent rimmed vacuoles and intracellular amyloid inclusions), improved survival, and improved 
sialylation of membrane-bound glycans in muscle and other tissues. All treatment groups had an 
improved muscle phenotype and increased sialylation after ManNAc administration16.  
3.5. 
Clinical Use of ManNAc  
3.5.1. 1966 Study in Humans  
There is a single 1966 report of 6 subjects receiving single oral doses of ManNAc. Two subjects received 
single 5,000 mg oral doses and 4 subjects received single 10,000 mg oral doses. ManNAc was reported to 
have a “pleasant bland sweetish” taste and no side effects were reported28.  
3.5.2. Anecdotal Use of ManNAc 
There is some anecdotal evidence of GNE myopathy patients using ManNAc (in doses up to 
approximately 12,000 mg per day) from a non-pharmaceutical source and without medical supervision. In 
general, ManNAc was well tolerated. Available information on these patients is provided in the IB.  
3.5.3. Clinical Study 12-HG-0207 
This single-ascending dose (SAD) study (ClinicalTrials.gov Identifier: NCT01634750) that evaluated the 
safety, tolerability, PK, and PD of ManNAc in subjects with GNE myopathy started in September 2012 
and completed dosing in May 2013. ManNAc was used in this study at doses of 3,000 mg, 6,000 mg and 
10,000 mg. Cohort 1 included 6 subjects randomized in a 2:1 ratio to receive either ManNAc (n=4) or 
mannitol as placebo (n=2). Cohorts 2 and 3 included 8 subjects each randomized in a 3:1 ratio to receive 
either ManNAc (n=6) or placebo (n=2). PK analysis from the SAD study showed that ManNAc was well-
absorbed and free Neu5Ac concentrations in plasma increased after ManNAc administration and were 
maintained for 24-48 hours (Table 1). 
3.6. 
Pharmacokinetics and Pharmacodynamics 
Quantification of ManNAc and Neu5Ac in human plasma was performed using a validated liquid 
chromatography and tandem mass spectrometry (LC-MS/MS) method with an assay range of 10 to 5,000 
ng/mL. As part of the SAD study,  mean plasma ManNAc levels observed in plasma controls (n=6) was 
43.5 ng/mL (SD 4.47; CV 10.3%). The mean pre-dose plasma ManNAc concentration was 53 ng/mL in 
GNE myopathy subjects (n=24). The mean plasma Neu5Ac concentration in plasma controls (n=6) and 
pre-dose in GNE myopathy subjects (n=24) was 130 ng/mL, and 150 ng/mL, respectively. Plasma 
ManNAc and Neu5Ac concentrations did not increase in GNE myopathy subjects that received mannitol 
as placebo (n=6), indicating that mannitol had no effect on plasma ManNAc or Neu5Ac concentration.  
Oral ManNAc was absorbed rapidly and exhibited a short half-life (~2.4 h). Following administration of a 
single dose of ManNAc, there was a significant and sustained increase in plasma unconjugated free sialic 
acid (Neu5Ac) (Tmax of 8-11 h). Neu5Ac levels remained above baseline 48 h post-dose in subjects who 
received a dose of 6,000 or 10,000 mg (Figure 4). Since the excretion of Neu5Ac is very rapid, with 70% 
of the sialic acid is found in the urine within 30–60 min after intragastric administration16, our findings 
strongly suggest that orally-administered ManNAc is effectively used as a substrate for intracellular 
Neu5Ac biosynthesis in subjects with GNE myopathy, including subjects homozygous for kinase domain 
mutations in the GNE gene. These findings provide further evidence that kinases other than ManNAc 

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8 
kinase, which is deficient in GNE myopathy, can phosphorylate ManNAc29.  Following a single dose of 
ManNAc, in vivo exposures (Cmax and AUC) of ManNAc increased less than dose-proportionally (Table 
1), suggesting a rate-limiting effect in either the membrane transport of ManNAc or on the enzymatic 
activity of the Neu5Ac biosynthesis pathway. The PK parameters of a single dose of ManNAc 
administered orally (fasted) to subjects with GNE myopathy are shown in Table 1.  
Figure 4. ManNAc and Neu5Ac Plasma Concentration after Single Oral Dose of ManNAc Administered to 
Fasting GNE Myopathy Subjects 
Table 1. PK and PD Parameters for Single Dose of Oral ManNAc to Fasting GNE Myopathy Subjects 
 
Dose 
Tmax1 
Cmax2 
Cmax Ratio 
Mean AUC0-∞ 
AUC Ratio 
(mg) 
(hr) 
(ng/mL) 
Dose Compared 
Ratio 
(ng*hr/mL) 
Dose Compared 
Ratio 
Plasma ManNAc 
3,000 
2 
1,451 
6,000 mg/3,000 mg 
0.9 
8,244 
6,000/ 3,000 mg 
1.2 
6,000 
2.5 
1,336 
10,000 mg/6,000 mg 
1.9 
9,552 
10,000/6,000 mg 
1.5 
10,000 
2 
2,585 
10,000 mg/3,000 mg 
1.8 
14,161 
10,000/3,000 mg 
1.7 
Plasma Free Neu5Ac 
3,000 
10 
115 
6,000 mg/3,000 mg 
1.6 
2147 
6,000/ 3,000 mg 
1.9 
6,000 
11 
181 
10,000 mg/6,000 mg 
0.8 
4171 
10,000/6,000 mg 
0.7 
10,000 
8 
143 
10,000 mg/3,000 mg 
1.2 
3007 
10,000/3,000 mg 
1.4 
1Median; 2 Geometric Mean. PK calculations were conducted with baseline adjustment by subtracting ManNAc or 
Neu5Ac concentrations at t=0 for each subject. 
Mean (±SD) corrected concentration-time profiles. Correction was made by subtracting ManNAc or Neu5Ac concentration 
(C0) at t=0 for each subject. 
          A. ManNAc (Mean ±SD) 
 
 
 
B. Neu5Ac (Mean ±SD) 
  

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9 
3.7. 
Biomarkers 
3.7.1. Intracellular Biomarkers 
Plasma concentrations of free Neu5Ac in subjects with GNE myopathy did not differ significantly from 
controls (see Section 3.5.3.2) likely because the intracellular biosynthesis only accounts for a proportion 
of the plasma sialic acid. Therefore, the measurement of intracellular biomarkers may be a more sensitive 
measurement in subjects with GNE myopathy. CMP-sialic acid is the end-product of the sialic acid 
biosynthesis pathway. This nucleotide-activated form of sialic acid is the donor of sialic acid to nascent 
glycoconjugates in the Golgi apparatus (Figure 1) and therefore may serve as a marker of successful 
restoration of the intracellular synthesis of biologically active sialic acid. The cellular CMP-sialic acid 
level is approximately 4-fold greater than free sialic acid. An LC-MS/MS method is being developed and 
validated to measure intracellular CMP-sialic acid and Neu5Ac levels in human white blood cells (WBC) 
pellets.  
3.7.2. Lectin Staining of Muscle Biopsies 
Hyposialylation of muscle proteins is thought to play a major role in GNE myopathy, re-sialylation of 
muscle proteins would prove biological efficacy. Furthermore, hyposialylation has been correlated with 
decreased muscle performance in heterozygous GNE knockout mice30. Lectin staining has been useful to 
demonstrate hyposialylation particularly of O-linked glycans in the muscle of the mouse model and 
subjects with GNE myopathy1, 23, 31. Sialylation of muscle glycans recovered to normal levels in our GNE 
myopathy mouse model after ManNAc therapy31. This method is the only reported reproducible, 
quantifiable assessment of muscle glycan hyposialylation in GNE myopathy to date. We feel that these 
convincing lectin-staining data justify acquiring muscle biopsies from GNE myopathy subjects in this 
study at baseline and after 3 months of therapy (see Section 5.2.4.) 
3.7.3. Plasma Sialylated Proteins 
Proteins that become sialylated in the Golgi and secreted in the plasma may serve as markers of the 
protein sialylation, in particular those with mucin-like O-glycan structures.  We have data that show the 
ratio of the plasma O-glycan structures Thomson-Friedenreich (T)-antigen versus Sialyl T-antigen (T/ST 
ratio) is abnormal in subjects with GNE myopathy32. We have anecdotal evidence that the plasma T/ST 
ratios normalized in GNE myopathy subjects that received sialylation-increasing therapies (including 
IVIG, off-label ManNAc, sialic acid). Exploratory glycan analysis can also be performed in subjects’ 
blood as a way of identifying hyposialylated proteins that may serve as biomarkers.  
3.8. 
Safety of ManNAc 
3.8.1. Nonclinical Safety Evaluation  
3.8.1.1. 
90-Day Rat and Dog Oral Toxicology Studies 
The safety of  ManNAc has been demonstrated by nonclinical 90-day toxicology studies conducted to 
support the use of  ManNAc in rats (IND 78,091_vol08_11.2.4.3A_2012 06 27.pdf) and dogs (IND 
78,091_vol11_11.2.4.6A_2012 06 27.pdf). Adverse effects noted were mainly gastrointestinal and 
included loose feces, mild mucosal hyperplasia of the colon, mild increase in alanine transaminase (ALT) 
and minimal to mild hepatocellular hypertrophy. The doses and length of the trial proposed in this 
protocol are supported by these 90-day toxicology studies (see Appendix L).  

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10 
Table 2. Maximum Recommended Starting Dose Based on 90-Day Toxicology Studies 
Species 
NOAEL 
(mg/kg) 
Conversion 
factor 
HED 
(mg/kg)  
Safety 
factor 
MRSD 
(mg/kg) 
MRSD *70 kg 
(mg/day) 
Rats 
12,000 
*0.16 
1,920  
10 
192 
13,440 
Dogs 
6,000 
*0.54 
3,240 
10 
324 
22,680 
To convert Animal Dose in mg/kg to Human Equivalent Dose (HED) in mg/kg, multiply 
animal dose by conversion factor based on Body Surface Area. 
Maximum Recommended Safe Dose (MRSD) in mg/kg = HED/safety factor  
Given the findings in the toxicology studies, effects that may be seen in humans include loose stools, 
anemia, decreased albumin, increased BUN, increased transaminases and abnormal urinalysis, all of 
which are monitored as part of this protocol (See 5.2.2). Given our prior experience on the Single 
Ascending Dose trial (See 3.7.2.1) loose stools may be expected. 
3.8.1.2. 
26-Week Rat and 39-Week Dog Oral Toxicology Studies 
The safety of ManNAc has been demonstrated by nonclinical toxicology studies of 26-weeks in rats and 
39-weeks in dogs (Summarized in Appendix L; Tables 6 and 7): 
• HLS study number BEQ0001 “Toxicity Study by Oral Gavage Administration to Beagle Dogs for 39 
Weeks Followed by a 4 Week Recovery Period”, Huntingdon Life Sciences (final report issued 
October 17, 2014): The administration of ManNAc (ManNAc) was well tolerated and did not result in 
any evidence of treatment-related adverse toxicity in Beagle dogs after 39 weeks of oral gavage 
administration with N-Acetyl-D-mannosamine monohydrate (ManNAc) at doses of up to 4,500 
mg/kg/day (1,500 mg/kg/dose three times daily), or after the 4 week recovery period. 
• HLS study number BEQ0005 “Toxicity Study by Oral Gavage Administration to Sprague Dawley 
Rats for 26 Weeks Followed by a 4 Week Recovery Period”, Huntingdon Life Sciences (final report 
issued December 9, 2014) 
Table 3. Maximum Recommended Starting Dose Based on Long-Term Toxicology Studies 
Species 
NOAEL 
(mg/kg/d) 
Conversion 
factor 
HED 
(mg/kg/d)  
Safety 
factor 
MRSD 
(mg/kg) 
MRSD 
*70 kg 
(mg/day) 
Target 
Organs 
Rats 
12,000 
*0.16 
1,920 
10 
192 
13,400 
GI, liver, 
adrenal, kidney 
Dogs 
4,500 
*0.54 
2,430 
10 
243 
17,000 
GI, liver, 
kidney 
* Equivalent surface area conversion factor 
Maximum Recommended Safe Dose (MRSD) in mg/kg = HED/safety factor  
Given the findings in the toxicology studies, effects that may be seen in humans include loose stools, 
anemia, decreased albumin, increased BUN, increased transaminases and abnormal urinalysis, all of 
which are monitored as part of this protocol (See 5.2.2). Given our prior experience on the Single 
Ascending Dose trial (See 3.7.2.1) loose stools may be expected. 
3.8.2. Clinical Safety 
3.8.2.1. 
12-HG-0207 (ClinicalTrials.gov Identifier: NCT01634750) 

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11 
On the single-ascending dose (SAD) study, ManNAc was safe and well tolerated. All adverse events 
(AEs) observed in the study were Common Terminology Criteria for Adverse Events (CTCAE) Grade 1 
or 2. There were no serious adverse events (SAEs). The frequency of AEs in Cohorts 1 and 2 (75% and 
33%, respectively) was not higher than the frequency of AEs in subjects who received placebo (83%). 
Half of the subjects at the received 10,000 mg dose, had a single, self-resolving episode of loose stools 
(Grade 1) shortly after ingestion of ManNAc, which was not associated with abdominal pain or other 
gastrointestinal symptoms. Diarrhea was not reported at lower doses (Cohorts 1 and 2) or in the placebo 
group and was likely caused by unabsorbed ManNAc in the gastrointestinal tract, suggesting that 
absorption of ManNAc is saturated when giving 10,000 mg as a single dose. Therefore a single dose of 10 
grams was considered the Maximum Tolerated Dose. See Appendix F for a list of study AEs. 
3.8.2.2. 
15-HG-0068 Open-Label Phase 2 Study (ClinicalTrials.gov Identifier: NCT02346461) 
There have only been no Serious Adverse Events observed as part of this Open-Label Phase 2 Study. The 
SRC review included safety through 24 months on all subjects. The reviewed safety information included 
adverse events (AEs), ECGs, vital signs, physical assessments and clinical laboratory data. Eight subjects 
remain on 6 grams twice daily. Four subjects have withdrawn consent, two of which discontinued due to 
gastrointestinal tolerability, another planning on getting pregnant and another was withdrawn due to 
noncompliance. AEs for the cohort from the latest SRC review are in Appendix G. Due to 8 out of 12 
subjects participating in this trial, demonstrated gastrointestinal tolerability issues or AEs related to 
ManNAc and 16% had tolerability issues significant enough to discontinue their participation, we have 
attempted to better understand the etiology of the decreasd tolerability.  The clinical manifestations 
together with PK evaluations, strongly suggest that unabsorberd ManNAc in the gastrointestinal tract is 
the likely cause. As discussed below in Section 3.9.1, we believe absorption of ManNAc can be increased 
by 20% by giving the same daily dose of ManNAc (12 grams) divided three times (4 grams TID) instead 
of twice daily (6 grams BID). 
One subject in the study had Grade 3 hypertryglyceridemia which was determined to be probably related 
to ManNAc. As higher triglycerides were also seen in toxicology studies (see Table 10), 
hypertriglyceridemia is a risk associated with ManNAc. 
3.8.3. Preliminary Findings 15-HG-0068 Open-Label Phase 2 Study 
3.8.4. Pharmacokinetic Model for ManNAc and Sialic Acid in GNE Myopathy Subjects 
Serial-sampled plasma ManNAc and Neu5Ac concentrations obtained from the SAD study (see Section 
3.5.3) and from this Open-Label Phase 2 study were used to develop a semi-mechanistic population 
model to simultaneously characterize ManNAc and Neu5Ac plasma concentrations following single or 
repeated oral doses of ManNAc to GNE myopathy subjects. The model showed that oral bioavailability of 
ManNAc decreased with increase in oral dose, likely due to decreased absorption. Simulations using this 
PK model also demonstrated that administering the same daily dose divided in three doses (4,000 mg 
every 8 hours) rather than twice daily can improve tolerability, increase bioavailability by ~20%, and 
boost ManNAc and Neu5Ac exposures (See Table 4). Based on this, we will evaluate the PK of 4 grams 
TID dosing during the 30-month visit. 
 

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12 
Table 4. Simulations of ManNAc Dose and Frequency using the Semi-Mechanistic Population PK Model for 
GNE Myopathy. 
ManNAc dose 
and frequency 
ManNAc CSS ave  
Mean (ng/mL) 
Neu5Ac CSS ave 
Mean (ng/mL) 
 
on Day 1 
On Day 30 
on Day 1 
on Day 30 
4,000 mg TID 
923 
1150 
189 
965 
6,000 mg BID 
878 
952 
219 
826 
12,000 mg QD 
693 
698 
254 
645 
*Based on simulation run N=90 in a structural PK/PD model. 
Abbreviations: CSS, steady state concentration; TID, three times daily; BID, twice daily; QD, once daily.  
3.8.5. Muscle Strength 
One of the secondary objectives of the Phase 2 study is to evaluate suitable endpoints for future trials. 
Because there is muscle atrophy and replacement of muscle by fibro-fatty tissue as part of the disease 
process, reversal of disease progression is unlikely. Rather, a slowing in the rate of progression is the 
expected treatment effect.  
As part of this, muscle strength measured by QMA has been collected at every visit.  All 12 patients 
participating in the open-label study were prior participants of the Natural History Study, and therefore, 
their ‘natural history’ rate of progression (prior to ManNAc administration) has been determined.  
To evaluate the performance of the disease progression model when incorporating treatment effect, data 
from the Phase 2 was tested in the model, to compare the rate of progression after initiation of ManNAc to 
the rate of progression before intervention. At 182 days (6 months), a preliminary analysis shows a 
posterior mean of γ=0.49 (95% CI: .02-1.35).  At 182 days (12 months), another preliminary analysis 
shows the current mean estimate for γ is approximately 0.61 (95% CI (0.09, 1.27), and the posterior 
probability that γ is less than 1 is 0.89. The most recent analysis at 548 days (18 months), shows a γ=0.55 
with a posterior probability that γ is less than 1 is 0.966. This means, the model estimates a 45% slowing 
in the rate of decline on subjects receiving ManNAc with a probability that there has been slowing in 
progression of 96.6%. 

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13 
4. 
STUDY DESIGN 
4.1. 
Study Overview  
This is a Phase 2, open-label, single-center study of ManNAc in subjects with GNE myopathy. The study 
will characterize the safety, tolerability and PK of multiple doses of ManNAc (Pharmacokinetic Phase), 
intermediate (90-day), and long-term (912 days; 30 months) safety and efficacy of ManNAc (Safety and 
Efficacy Phase). Twelve subjects will be enrolled into the trial.  
Before dosing, subjects will undergo baseline evaluations that include clinical laboratory tests, muscle 
biopsy, Quantitative Muscle Assessment (QMA), muscle MRI, muscle biopsy and patient-reported 
outcomes (PROs). 
In the pharmacokinetic (PK) phase, subjects will receive one of two doses: 3,000 mg (Cohort A) or 6,000 
mg (Cohort B) ManNAc twice daily (BID) for total daily doses of 6,000 and 12,000 mg, respectively for 
7 days while admitted to the NIH Clinical Center to assess for PK and safety. Safety and tolerability will 
be assessed on an individual basis. 
In the Safety and Efficacy Phase, if ManNAc was safe and well-tolerated in the PK phase, subjects on 
Cohort A will be escalated to 6,000 mg BID on Day 7, and safety of the new dose-level will be assessed 
until discharge on Day 10.  Subjects on Cohort B will be maintained at 6,000 mg BID, and if well 
tolerated they may be discharged on Day 7. After discharge, subjects will self-administer ManNAc at a 
dose of 6,000 BID for a total dosing duration of 912 days (30 months).  
Follow-up visits to the NIH Clinical Center will occur on Day 45 (±7), Day 85 (±7), Day 180 (±14), Day 
365 (±14), Day 548 (-30), Day 730 (-30 days) and Day 912 (-30 days). PK, PD and safety will be 
evaluated at all visits. Muscle biopsy will be performed only at the baseline and Day 85 visits.  
Follow-up phone calls for safety will occur at approximately Days 28, 63, 120, 240, 300, 400, 638, and 
820 (±30 days). After Day 912 all Grade ≥2 AEs at least possibly related to study drug will be followed to 
resolution. 
4.2. 
Sample Size 
A sample size of 12 GNE myopathy subjects was selected for this study to provide information on the 
safety, PK and biochemical efficacy of ManNAc.   
4.3. 
Visit Schedule 
Table 5. Brief Visit Schedule 
Window 
Description 
Relative Day 
Min 
Max 
Day -30 to -1 
Screening Phase 
-30 
-1 
Day -7 to 0 
Baseline Phase  
-7 
0 
Day 1-90 
Treatment Phase 
 
 
Day 1-7 
PK Phase (inpatient) 
1 
7 
Day 7-90 
Safety/Efficacy Phase 
7 
90 
Day 45 (± 7 days) 
Follow-up Evaluation 
38 
52 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
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14 
Day 85 (± 5 days) 
3 month Follow-up evaluation 
80 
90 
Day 180 (± 14 days) 
6 month Follow-up evaluation 
166 
194 
Day 365 (± 14 days) 
12 month Follow-up evaluation 
351 
365 
Day 450 (± 30 days) 
Optional for blood draw 
 
 
Day 548 (- 30 days) 
18 month Follow-up evaluation 
534 
562 
Day 638 (± 30 days) 
Safety labs and phone or email follow-up 
608 
668 
Day 730 (- 30 days) 
24 month Follow-up evaluation at NIH CC 
700 
730 
Day 820 (± 30 days) 
Safety labs and phone or email follow-up 
790 
850 
Day 912 (- 30 days) 
30 month Follow-up evaluation at NIH CC 
882 
912 
See Appendix C for the Schedule of Events and Appendix D for blood and urine sampling schedule. 
4.4. 
Dose and Frequency 
4.4.1. Dose Levels 
The ManNAc doses to be investigated (3,000 and 6,000 mg BID for a total daily dose of 6,000 and 12,000 
mg, respectively) are based on the safety and PK data collected in NIH Study 12-HG-0207 (See Section 
3.5.3). In that study, a single dose of 10,000 mg ManNAc was associated with diarrhea and there was no 
difference in the Cmax or AUC of plasma Neu5Ac between the doses of 6,000 or 10,000 mg, suggesting 
saturation in the enzymatic rate of the Neu5Ac biosynthesis pathway or the transport of ManNAc into the 
cell. Therefore, the maximum single dose of ManNAc to be used in this study will be 6,000 mg per dose, 
for a total of 12,000 mg per day.  
The administration of maximum dose of 12,000 mg ManNAc per day for 90 days is covered by the 90-
day toxicology studies performed in rats and dogs. As mentioned in Section 3.8 and shown in Appendix 
L, effects on the gastrointestinal tract were the most prominent toxicology findings, and included loose 
and discolored feces, mild liver enlargement, and mucosal hypertrophy of the colon. Given these findings, 
the NOAEL was determined to be 12,000 mg/kg/day in rats and 6,000 mg/kg/day in dogs. It was 
determined that the human equivalent dose (HED) is 1,714 mg/kg/day, or approximately 12,000 mg/day 
based on the NOAEL observed in rats, the most sensitive species, with a 10-fold safety factor. 
Administration of a maximum dose of 12,000 mg ManNAc for up to one year is covered by the long- 
term toxicology studies performed in rats (26 weeks) and dogs (39 weeks), as shown in Appendix M.  
If any safety issues occur during the pharmacokinetic phase (Day 1-10) either detected clinically or based 
on laboratory values, those subjects will be continued on a lower dose for the safety and efficacy phase of 
the trial. 
4.4.2. Dose Frequency  
A ManNAc dose frequency of every 3,000 or 6,000 mg every 12 hours (BID) was selected based on the 
sustained elevation of plasma free Neu5Ac with a Tmax of 8-11 hours (Table 1), and levels returning to 
baseline by 24 hours after a single dose of 3,000 mg of ManNAc but remaining above baseline values by 
48 hours after single dose of 6,000 or 10,000 mg of ManNAc (Figure 4) and supported by simulated 
plasma concentration-time profiles of ManNAc and free Neu5Ac after 6,000 mg of ManNAc BID (12,000 
mg per day) were generated to estimate the time to reach steady-state after multiple doses (Figure 5). No 

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15 
significant accumulation of ManNAc is predicted following BID dosing of 6,000 mg of ManNAc due to 
the short half-life of ManNAc (2-3 hours), and supported by the rat and dog toxicokinetic reports; 
however, an accumulation for free Neu5Ac is desired and expected due to its longer half-life (Figure 5), 
although it does not increase above a certain threshold, as evidenced in the toxicokinetic reports in rats 
(IND 78,091_vol08_11.2.4.3A_2012 06 27.pdf) and dogs (IND 78,091_vol11_11.2.4.6A_2012 06 
27.pdf), likely due to the feedback inhibition in the sialic acid biosynthetic pathway (Figure 1).  
Figure 5. Simulated Concentration-Time Profiles for Plasma (A) ManNAc and (B) Free Neu5Ac 
with ManNAc 6,000 mg BID in Subjects with GNE Myopathy 
 
 
4.5. 
Dose Administration 
4.5.1. Inpatient Drug Administration 
Inpatient drug administration will be performed with the purpose of determining PK parameters. The 
study drug will be prepared in individual doses of powder in bottle (PIB) by the NIH Pharmacy and sent 
to the inpatient unit. The study drug will be administered orally by the CC nursing staff BID on Days 1-7, 
or TID starting on Day 912-914 (+/- 30 days). Subjects will take study drug on an empty stomach, at least 
2 hours before a meal and 1 hour after a meal. Water may be taken at all times.  
For the morning dose on Days 1 and 7, and Days 912-914, the dose will be given after an overnight fast.  
Breakfast on Days 1 and 7 may be eaten 1 hour after the morning dose is given. The sample schedule 
below will be followed, whenever possible; when there is a modification in dosing or other unforeseen 
delay, the schedule will be adjusted accordingly: 
Day 1 
 
Day 2-6 (days with PK trough only) 
Midnight-0900: 
0800: 
0800-0900: 
0900-1800: 
1800–2000: 
2000: 
2000–2100: 
2100: 
Water only 
Morning DOSE 
Water only 
Regular diet (no 
restrictions) 
Water only 
Evening DOSE 
Water only 
0500-0600 
0600-0900 
0800: 
0800-0900: 
0900-1800: 
1800–2100: 
2000: 
2000–2100: 
Breakfast. No food after 0700 
Water only 
Morning DOSE 
Water only 
Regular diet (no restrictions) 
Water only 
Evening DOSE 
Water only 
Time (hr)
0
20
40
60
80
100
120
140
160
180
Concentration (ng/mL)
10
100
1000
10000
Time (hr)
0
20
40
60
80
100
120
140
160
180
Concentration (ng/mL)
10
100
1000
10000

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16 
Bedtime snack (if 
desired) 
2100: Bedtime snack (if desired) 
Day 7 
5-7 days before Day 
912 
 
Midnight-0900: 
0800: 
0800-0900: 
0900: 
Water only 
Last DOSE 
Water only 
May resume regular diet 
 
No ManNAc intake 
Days 912-914 
 
 
Midnight-0800: 
0800: 
0800-0900: 
0900-1400: 
1400-1600: 
1600: 
1600-1700: 
Water only 
Morning DOSE 
Water only 
Regular diet  
Water only 
Afternoon DOSE 
Water only 
1700-2200: 
2200-2400: 
2400: 
2400-: 
 
Regular diet (no restrictions) 
Water only 
Evening DOSE 
Water only 
 
4.5.2. Drug Administration after Discharge 
After completion of PK studies on Day 1-7, subjects will be discharged and study drug will be self-
administered while not admitted to the NIH CC. The study drug will be provided as a canister of bulk 
powder that will be measured with a Spatula Balance™. During the inpatient stay, subjects will be taught 
proper dosing and administration techniques. Subjects will take the study drug BID within 15 minutes of 
breakfast and dinner.  
Subjects returning to their 30-month visit will be asked to stop the intake of ManNAc for 5-7 days before 
admission to perform PK testing of TID dosing. 
4.5.3. Drug Administration During Terminal Half-Life PK Determination 
Terminal half-life will be determined during the Day 85 visit. While the subject is inpatient, the study 
drug will be withheld for 72 hours with the purpose of determining terminal half-life PK parameters. 
Day 85 
 
 
Midnight-0 0: 
0800: 
0800-0900: 
0900: 
Water only 
Terminal half-life DOSE 
Water only 
May resume regular diet 
 
 
4.6. 
Concomitant Medications 
Subjects must be willing to stop treatment with ManNAc, sialic acid, IVIG, and/or other supplements 
containing sialic acid (e.g., St John’s wort, sialyllactose) 90 days before initial dosing and remain off 
these medications for the duration of the trial. Prescription medications and supplements will be 

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17 
maintained at a constant level throughout the duration of the study, unless dose adjustment is clinically 
necessary. Such adjustments will be recorded in the patient’s CRF.  
4.7. 
Safety Evaluations 
Safety will be assessed by adverse events (AEs), vital signs, physical examinations, and clinical 
laboratory tests (See 5.2.2) and classified based on the Common Terminology Criteria for Adverse Events 
(CTCAE), Version 4.03. 
4.8. 
Dose Escalation 
Subjects in Cohort A will receive 3,000 mg of ManNAc BID for 7 days before they are escalated on Day 
7 to receive 6,000 mg BID for the rest of the trial. The evaluation of a dose escalation/de-escalation for an 
individual will initially be reviewed by the Principal Investigator, according to the criteria in Table 5 and 
reviewed by the Safety Review Committee (SRC) when the Cohort is completed or safety issues arise. 
The safety information to be reviewed will include AEs, physical exams, vital signs, and clinical 
laboratory data.  
4.8.1. Escalation and Continuation Rules for Cohort A 
Subjects in Cohort A will receive 3,000 mg of ManNAc BID for 7 days before they are escalated to 
receive 6,000 mg BID for the rest of the trial:  
a. Subjects in Cohort A will be escalated to 6,000 mg BID on Day 7 if no serious AEs and no more 
than 2 Grade 2 drug-related AEs occur.   
b. If subjects experience ≥2 Grade 2 drug-related AEs or ≥ 1 drug-related SAE at 3,000 mg BID, the 
SRC will be convened to make escalation/de-escalation decisions based on Table 5. 
c. The subjects will continue on 6,000 mg BID until they experience ≥2 Grade 2 drug-related AEs or 
≥ 1 drug-related SAE.  In this case, the SRC will be convened to make decisions based on Table 5. 
4.8.2. Initiation and Continuation Rules for Cohort B 
The SRC will review all available safety data for Cohort A of subjects prior to making a decision to 
initiate Cohort B. The SRC will convene when at least 14 days of safety have been collected on the last 
subject dosed in Cohort A. 
a. Cohort B will be initiated at 6,000 mg BID provided that there are <2 subjects in Cohort A that 
experienced ≥2 Grade 2 drug-related AEs or ≥ 1 drug-related SAE. 
b. If subjects experience ≥2 Grade 2 drug-related AEs or ≥ 1 drug-related SAE, the SRC will be 
convened to make decisions based on Table 6. 

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18 
Figure 6. Dosing Escalation/De-escalation 
 
Table 6. Dose Escalation/De-escalation Rules 
Safety Profile*  
Safety Review Committee Decisions* 
No SAEs and  
Any number of CTCAE Grade 1 drug-related AEs 
or ≤ 1 CTCAE Grade 2 drug-related AE 
Continue per protocol 
 
2 CTCAE Grade 2 drug-related AEs 
Continue per protocol, or 
study a lower dose§, 
≥ 3 CTCAE Grade 3 drug-related AEs  
 
Study a lower dose§, or  
Withdraw the subject, and 
Convene SRC to evaluate the risk/benefit profile for dose 
escalation of other subjects 
Any CTCAE Grade 4 AE;  
or 
≥ 1 drug-related SAE 
Determination that the limit of safety and/or 
tolerability has been reached  
 
Withdraw the subject, and 
Evaluate the risk/benefit profile in other subjects for dose 
escalations to or above the dose resulting in Grade 3 
toxicity, and  
Discontinue study if 2 subjects develop the same Grade 3 
toxicity or if any subject develops a Grade 4 toxicity  
The safety decisions in this table apply only to safety and tolerability in an individual subject. If a decision is made that the 
dose escalation stopping criteria have been met, this does not preclude the use of the remaining subjects to evaluate the 
safety, PK, and PD effects of lower doses of ManNAc with the assessments described in this protocol.  
*Note: Subjects from both Cohort A and Cohort B on 6,000 mg BID count toward the number of subjects experiencing 
toxicity. 
§ Lower doses to study may include 4,500 mg BID, 3,000 mg BID or 2,000 mg BID depending on dose level where 
toxicity occurred. 
 
 
Maintain 
dose or study 
 
 
Cohort 2 
6,000mg BID ManNAc 
orally (12,000 mg) for 7 
Increase dose 6,000 
mg BID 
(12 000 mg/day) for
Maintain 
dose or 
study lower
 
Maintain dose 6,000 mg 
BID 
Cohort 1 
3,000 mg BID ManNAc orally 
(6 000 mg/day) for 7 days
 
Well-
Poorly 
tolerat
Well-
Not 
well
Well-tolerated
Poorly 
tolerated

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19 
4.9. 
Dose Modification 
If a subject experiences >2 Grade 2 drug-related AE’s or any Grade 1 or Grade 2 drug-related AE’s that 
limit tolerability, the SRC will be convened and dose modification considered with a goal of improving 
tolerability. 
4.10. 
Subject Compliance 
Subjects will have directly observed therapy of drug doses administered while inpatient. CC nursing staff 
will document doses in CRIS.  
A diary will be provided to subjects so that AEs, compliance, concomitant medications and other issues 
can be recorded during the treatment phase while they are at home (Appendix K). The diary will be in 
paper format, and will be reviewed by a member of the study team during every study visit.  
Adverse events, compliance with study procedures, concomitant medications and other issues will also be 
recorded by a member of the study team during the treatment phase on CRFs. 
4.11. 
Randomization and Blinding  
There will be no blinding or randomization. 

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20 
5. 
DESCRIPTION OF PROCEDURES 
A Schedule of Events is provided in Appendix C, and the blood and urine sampling schedule in Appendix 
D. 
5.1. 
Medical Information 
A medical history, weight, height, vital signs, and physical exam will be conducted after admission to the 
NIH CC and enrollment into the study. For subjects who are co-enrolled on the Natural History protocol 
11-HG-0218, data collected for the Natural History study may be used in the screening/baseline phase if 
collected within 30 days prior to dosing Day 1.  
Physical examinations will be standardized and performed by a credentialed nurse practitioner or 
physician who is an investigator in this protocol. This will document baseline status and ensure that the 
subject’s medical health is adequate to undergo the proposed research procedures.  
Subjects will undergo clinical evaluations while admitted by CC nursing staff or a member of the study 
team. Vital signs will be performed according to the unit schedule while inpatient and at least daily while 
outpatient. Medical evaluations and vital signs will be performed at other times if clinically indicated, or 
if the ongoing review of the data suggests a more detailed assessment of the vital signs is warranted.  
All medical information, including physical examination, AEs, compliance with study procedures, 
concomitant medications, and other issues will be recorded during the treatment phase on CRFs by the 
study team. 
5.2. 
Diagnostic Studies 
During the interventional phase, blood and urine will be collected for safety, PK, and PD evaluations. 
Safety will also be assessed by AEs, physical examinations, vital signs, and clinical laboratory tests. No 
radiation or sedation will be used as part of this study unless clinically indicated. Other diagnostic studies 
may be performed, if clinically indicated.  
5.2.1. Procedures 
5.2.1.1. 
Muscle Biopsy 
Muscle biopsies will be performed for research purposes. Muscle biopsies will only be performed at the 
baseline and 91 day (3-month) visits; therefore a maximum of 4 incisions will be done per patient. 
Muscles to be biopsied include 1) the biceps brachii in the upper extremity and 2) a lower extremity 
muscle that has been determined as suitable for biopsy by MRI. Two biopsy sites are necessary to have a 
homogenous sampling from all subjects (through the biceps brachii, a muscle that is easily accessible and 
only affected in the advanced stage of the disease), and to further test if ManNAc supplementation could 
reverse the STIR-bright areas that are consistently seen in GNE myopathy subjects. Both upper (biceps 
brachii) and lower extremity muscle biopsies will be performed at the same time to decrease the subject’s 
discomfort. Repeat MRI at 91 days (3 months) will guide the selection of the muscle to be biopsied for 
the 91 day (3-month) visit (see Section 5.2.1.1.1). A total of four muscle biopsies will be performed for 
each subject: two biopsies at baseline and two biopsies at 91 days (3 months).  

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5.2.1.1.1. Selection of Muscle Biopsy Site 
The selection of muscles to be biopsied will be performed by identifying the following characteristics on 
muscle MRI: 1) Minimal or no fatty replacement and 2) Presence of hyperintense short tau inversion 
recovery (STIR). Fatty tissue is not informative and STIR hyperintensity is a signal of disease activity. 
Whenever possible, we will avoid performing biopsies of the quadriceps muscle, as disease characteristics 
are not likely to be significant in this muscle group. An MRI will be repeated before the 91 day (3-month) 
muscle biopsy to identify the area for biopsy; if feasible, the 91 day (3-month) biopsy will be the 
contralateral muscle biopsied at baseline.  
5.2.1.1.2. Method for obtaining muscle biopsy 
Muscle will be obtained by open muscle biopsy. This procedure is used because it allows safe access to 
muscles while carefully avoiding local blood vessels and nerves.  
An open-muscle biopsy is a minor surgical procedure performed by a qualified neurologist or 
neurosurgeon with expertise in this technique. It is performed in the operating room under local 
anesthesia. After the skin is cleaned and draped, the skin will be infiltrated with local anesthetic which 
may cause mild discomfort. After a small (approximately 1.5 inches long) skin incision, the desired tissue 
(muscle) is isolated and biopsied. Two clamped muscles samples, each no greater than 0.5 inches 
(longitudinal axis) X 0.25 inches (cross-sectional diameter), will be obtained from each biopsy site. The 
incision site will be closed by a method according to the surgeon’s preference. 
The biopsy samples will be placed on sterile, saline-dampened gauze and will be processed immediately 
after collection.  
5.2.1.2. 
Muscle Magnetic Resonance Imaging and Spectroscopy (MRI/MRS) 
Muscle MRI/MRS will be performed at baseline, 91 days (3 months) and 365 days (12 months) in lower 
extremity muscles to monitor areas of disease activity. Findings are characterized by T2-weighted STIR 
hyperintensity of muscles actively affected, followed by fatty-fibrous replacement on T1-weighted 
imaging33. MRS will noninvasively monitor muscle metabolism and degree of involvement (Figure 7). 
Figure 7. MRS of GNE Myopathy Muscle 
 

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22 
5.2.1.3. 
Quantitative Muscle Strength Assessment (QMA) 
Muscle strength will be evaluated at baseline and at every follow-up visit utilizing the Quantitative 
Muscle Strength Assessment (QMA) which measures maximal voluntary isometric contraction (MVIC) in 
kilograms (kg) using a fixed frame dynamometer, a strain gauge tensiometer, and a computer-aided 
acquisition system (Aeverl Medical, Gainesville GA, USA) to measure maximal strength25 in 13 muscles 
groups. The muscle strength in kg is compared to predicted strength26, 34-36 for age, gender, height and 
weight to generate a proportion of predicted strength value.  
5.2.1.4. 
Other Rehabilitation Medicine Assessments 
Other assessments may be performed at baseline and follow-up visits and will include muscle strength 
using the 10-point manual muscle testing (MMT-28) scale, Adult Myopathy Assessment Tool (AMAT), 
6-min walk test (may be replaced by 10-meter walk test), timed up-and-go test, forward/functional reach 
test. The Jebsen Standarized Hand Function test will be done at baseline, 365 days (12 months) and 730 
days (24 months). 
5.2.1.5. 
Activity Monitor 
Changes in daily activity will be measured using a Fitbit OneTM activity monitor (Fitbit Inc., San 
Francisco, CA) in ambulatory subjects who also possess a compatible home computer.  Recent studies 
have demonstrated that consumer-grade activity monitors reliably measure activity (steps taken, stairs 
climbed, and distance walked) in persons with disabilities when compared to the Step Activity Monitor, 
which has been validated in various disabled populations for more than a decade. The Fitbit will allow 
measurement of activity at a substantially reduced cost. Subjects will wear the device on a waistband, in a 
pocket, or with a necklace or wristband.  They will use the monitor throughout the study.  The subjects 
will register the device’s software on their home computer in an anonymized fashion.  They will use a 
study identifier for their name and will not use their own home address. Anonymized e-mail addresses 
will be created for subjects by the research team. Subjects’ activity (walking, steps taken, distance 
walked) will be automatically uploaded to the anonymous profile. Fitbit data from each subject will be 
migrated to the study’s database (Fitbase) for future analysis. 
5.2.1.6. 
Patient-Reported Outcomes 
Patient-Reported Outcomes will be collected at the time of study enrollment (baseline) and at each return 
visit unless otherwise indicated in the Table below. These will include the Human Activity Profile (HAP), 
the Inclusion Body Myositis Functional Rating Scale (IBMFRS), the Activity Balance Confidence (ABC) 
Scale, the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires, 
Global Rate of Change questionnaire, AMAT Anchor, and Functional Questionnaire.  
Questionnaire 
Concept 
Burden 
Human Activity Profile 
(HAP) 
Energy expenditure/ physical fitness 
94 items/ 5-7 minutes 
Inclusion Body Myositis 
Functional Rating Scale 
Function specific  
10 item/  <5 minutes 
Activity Balance Confidence 
Risk for falls 
10 items <5 minutes 

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23 
Global Rate of Change 
Assess patient-reported changes 
between start of trial and follow-up 
visits 
4 items/ <5 minutes 
Only at follow-up visits 
PROMIS questionnaire 
Emotional and psychosocial well-
being, and fatigue and sleep 
32 items/ ~10 minutes 
AMAT Anchor 
Patient-reported outcome for muscle 
strength measure validation 
6 items/ <5 minutes 
Only visit Day 85 
Functional Questionnaire 
Assess device use, employment 
status, disability status 
4 items/ <5 minutes 
Only at baseline 
5.2.2. Clinical Laboratory Studies 
Clinical laboratory samples will be collected at pre-dose (baseline) and for safety evaluations on Days 2, 
5, 8, and 10 (±1) and at 456 (15 months), 638 (21 months) and 820 (27 months) days (at the NIH clinical 
center or subjects’ home lab or physician) and at every follow-up visit (see Appendix D). For subjects 
who are co-enrolled on the Natural History protocol 11-HG-0218 and combine a natural history visit with 
this study, clinical laboratory tests collected for the Natural History study may be used as the pre-dose 
evaluation for this trial if within 30-days prior to initial dosing. Clinical laboratory tests will be evaluated 
and noted in a CRIS progress note. Laboratory results outside of CC normal parameters but not of clinical 
significance will be noted in the CRIS progress note. 
5.2.2.1. 
Hematology/Chemistry 
Blood samples for the clinical laboratory tests will be collected by CC phlebotomy or nursing staff using 
either an indwelling peripheral catheter or by venipuncture. Testing will include the following: 
• Hematology: complete blood count (CBC) with differential, platelet count, reticulocyte count and 
erythrocyte sedimentation rate (ESR), C-reactive protein, prothrombin time (PT), and partial 
thromboplastin time (PTT).  
• Serum chemistry: acute care panel (sodium, potassium, chloride, carbon dioxide, glucose, 
creatinine, blood urea nitrogen (BUN)), mineral panel (albumin, calcium, magnesium, 
phosphorus), hepatic panel (alkaline phosphatase, alanine aminotransferase (ALT), aspartate 
aminotransferase (AST), direct bilirubin), lipid panel, creatine kinase, c-reactive protein, and 
cystatin-C. 
5.2.2.2. 
Pregnancy Testing 
A urine human chorionic gonadotropin (hCG) test will be required at screening/baseline in female 
subjects with childbearing potential and be repeated within 7 days prior to starting administration of study 
drug. Subjects will not be eligible for the study if the pregnancy test is positive. Urine hCG will be 
repeated at every follow-up visit. 
5.2.2.3. 
Urinalysis 
Urinalysis will assess urine protein, glucose, ketones, hemoglobin, urobilinogen, leukocyte esterase, 
nitrite, red blood cells (RBC’s) and WBC’s. 

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24 
5.2.3. Pharmacokinetics  
Plasma concentrations of ManNAc and free Neu5Ac will be quantified using validated LC-MS/MS 
methods (Y. Shi et al., unpublished data).  The method has been validated thoroughly to support clinical 
trials and has a calibration range of 10 to 5000 ng/mL.  
We will administer multiple doses of ManNAc to achieve steady state. Plasma concentrations of ManNAc 
and free Neu5Ac will be measured at 0 (pre-dose), 0.5, 1, 2, 3, 4, 6, 8, 10 and 12 hours after the first study 
drug administration (Day 1). On Day 2-7, and 45 (±7), morning Ctrough (i.e., immediately before 
administering the morning dose of the study drug) measurements will be performed. Ctrough will be 
collected pre-dose on Days 180, 365 and prior to the final dose of study drug. (See Appendix D for time 
points).  
At the 30 month visit, plasma samples for ManNAc and Neu5Ac PK under TID dosing will be collected 
at 0 (pre-dose), 2, 4, 6, 8, 24 and 48 hours after the first study drug administration on TID dosing. Plasma 
will be collected right before ManNAc dose (trough) at the 8, 24 and 48 hour timepoints. Patient will 
avoid ingestion of ManNAc for 5-7 days prior to pre-dose PK draw on TID dosing. 
The primary PK parameters that will be assessed for both plasma ManNAc and free Neu5Ac include: 
• Maximum observed plasma concentration (Cmax), 
• Time to Cmax (Tmax), 
• Area under the plasma concentration-time curve from time 0 to infinity (AUC0-∞),  
• Area under the plasma concentration-time curve from time 0 to time of last measurable plasma 
concentration (AUClast),  
• Area under the plasma concentration-time curve within the dosing interval (AUCt),  
• Plasma elimination half-life (t½).  
A pre-dose sample may be evaluated to investigate allelic variants of drug metabolism enzymes, if 
variable PK data are encountered in subjects.  
5.2.4. Lectin and Antibody Labeling of Muscle Biopsies 
Frozen slides acquired from subjects’ muscle biopsies will be stained with fluorescent-labeled lectins and 
imaged by (quantitative) confocal microscopy. As mentioned, we and others have demonstrated by lectin 
staining that in particular O-linked glycans in GNE myopathy subjects and in a GNE myopathy mouse 
model are hyposialylated1, 23, 31. Sialylation of muscle glycans recovered to normal levels in our GNE 
myopathy mouse model after ManNAc therapy31. This method is the only reported reproducible, 
quantifiable assessment of muscle glycan hyposialylation in GNE myopathy to date (Figure 8).  
5.2.5. Potential Biomarkers 
5.2.5.1. 
Intracellular Biomarkers 
We will use white blood cell pellets to explore the intracellular concentrations of ManNAc, Neu5Ac and 
CMP-Neu5Ac after administration of ManNAc. CMP-Neu5Ac, the end product of the sialic acid 
biosynthesis pathway and the donor of sialic acid to nascent glycoproteins and glycolipids in the Golgi 
apparatus, may be a useful marker of improved intracellular sialic acid biosynthesis (Figure 1). An LC-
MS/MS method is being developed to quantify ManNAc, Neu5Ac and CMP-Neu5Ac in human WBCs. 
Samples from this study will be stored and tested when the method is validated.  

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25 
5.2.5.2. 
Blood Biomarkers 
Plasma sialylated proteins are being explored as potential biomarkers, in particular those with mucin-like 
O-glycan structures.  We have data that show the ratio of the plasma O-glycan structures Thomson-
Friedenreich (T)-antigen versus Sialyl T-antigen (T/ST ratio) is abnormal in subjects with GNE 
myopathy32. We have anecdotal evidence that the plasma T/ST ratios normalized in GNE myopathy 
subjects that received sialylation-increasing therapies (including IVIG, off-label ManNAc, sialic acid). 
Exploratory glycan analysis will be performed on subjects’ blood to identify biomarkers and assess their 
response to ManNAc therapy.  
5.2.5.3. 
Urine Biomarkers 
Exploratory glycan analysis will be performed on subjects’ urine to identify (sialylated) biomarkers and 
assess their response to ManNAc therapy.  
 
Figure 8. Muscle Lectin Histochemistry 
 
A. Human muscle sections from biceps (Control and Patient 1) and gastrocnemius (Patient 2) were stained with three lectins (green) 
informative for sialylation status and co-stained with the nuclear dye DAPI (blue). GNE myopathy muscle specimens show selective 
hyposialylation compared to control muscle, demonstrated by apparent normal staining of WGA (Wheat Germ Agglutinin, binding to most 
sialic acid groups, independent of linkage), but decreased staining of SNA (Sambucus Nigra Agglutinin, predominantly binding sialic acids 
in a α(2,6)-linkage to their underlying monosaccharide; this linkage is abundant on O-linked glycans). In addition, staining of VVA (Vicia 
Villosa Agglutinin, predominantly binding terminal GalNAc, without sialic acid attached, O-linked to serine or threonine residues of 
glycoproteins) was increased in GNE myopathy muscle specimen compared to control, indicating hyposialylation of O-linked glycans (see 
also refs1, 23, 31, 32.   
B. Mouse muscle sections (gastrocnemius) from ~ 6 months old GNE myopathy mice (-/-, unfed) showed similar hyposialylation of O-linked 
glycans as human GNE myopathy subjects (see A) when compared to an age-matched control (Control unfed). Oral supplementation of 
ManNAc (1 g/kg/day) or for 12 weeks restored the muscle sialylation status back to the normal range (-/- + ManNAc), demonstrated by 
increased SNA and decreased VVA signal intensities similar to control specimens (see ref 32).  
All images are 1D projections of confocal Z-stacks. All imaging was performed at the same microscope intensity settings per lectin per 
species (with a 63 × objective). 
 

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26 
5.3. 
Biological Specimens 
5.3.1. Samples for Safety, Pharmacokinetic, and Pharmacodynamic Evaluations 
Blood and urine will be collected for safety, PK and PD evaluations (see Appendix D for timepoints). The 
blood draw for safety labs at Day 450, 638 and 912 (±30) will be performed at the NIH clinical center, or 
the subject’s home physician office or local laboratory. Samples will be stored without personally 
identifiable information (PII) per the lab manual. Collection, handling, and shipping procedures for 
plasma samples for PK are provided in the Laboratory Manual. 
5.3.2. Research Samples 
At the discretion of the investigator, blood and urine (first morning void) may be collected for future 
research. The amount of blood that may be drawn for research purposes shall not exceed 10.5 mL/kg or 
550 mL, whichever is smaller, over any eight-week period. This is in compliance with the NIH Clinical 
Center guidelines.  
Blood, urine, and derivatives thereof (e.g., RNA/DNA, platelets, red blood cells, white blood cells, urine 
exosomes) collected under this protocol will be stored for future research not specifically outlined in this 
protocol. Such research could involve, but is not limited to, molecular, proteomic, biochemical, glycomic, 
and metabolomic analyses of these samples. Future research using these samples will relate to GNE 
myopathy. 
For subjects also enrolled in the ongoing Natural History study (11-HG-0218), sample volume safety 
limits will take into account both protocols. 
Table 7. Blood Volume 
Sample 
(Day) 
Hematology1 
ESR 
PT/PTT 
Chemistry2 
PK 
PD 
Future 
Research  Total daily volume 
Volume 
3 
3 
4.5 
4 
3 
20 
10-50 
-- 
D0 
3 
3 
4.5 
4 
  
20 
50 
84.5 
D1 
  
  
  
  
30 
80 
  
110 
D2 
  
  
  
  
3 
  
  
3 
D3 
3 
3 
4.5 
4 
3 
20 
20 
57.5 
D5 
  
  
  
  
3 
  
  
3 
D7 
3 
3 
4.5 
4 
30 
20 
30 
94.5 
D9 
3 
3 
4.5 
4 
  
20 
20 
54.5 
D45 
3 
3 
4.5 
4 
3 
20 
50 
87.5 
D85 
3 
3 
4.5 
4 
3 
20 
40 
77.5 
D90 
  
  
  
  
30 
20 
  
50 
D91 
  
  
  
  
3 
  
  
3 
D92 
3 
3 
4.5 
4 
3 
20 
40 
77.5 
D93 
  
  
  
  
3 
  
  
3 
D180 
3 
3 
4.5 
4 
3 
20 
40 
77.5 
D365 
3 
3 
4.5 
4 
3 
20 
40 
77.5 

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D450 
3 
3 
4.5 
4 
  
  
  
14.5 
548 
3 
3 
4.5 
4 
3 
20 
40 
77.5 
638 
3 
3 
4.5 
4 
  
  
  
14.5 
730 
3 
3 
4.5 
4 
3 
20 
40 
77.5 
820 
3 
3 
4.5 
4 
  
  
  
14.5 
912 
3 
3 
4.5 
4 
3 
- 
- 
17.5 
 
5.3.3. Collaborating Laboratories 
After establishing appropriate material transfer agreements and/or contracts, biospecimens collected under  
this protocol may be sent to the following investigators: 
 
Table 8. Collaborations 
Sample 
Laboratory 
Location 
PK and intracellular PD 
Alliance Pharma 
Malvern, PA 19355 
Hematology, ESR, 
PT/PTT and Chemistry  
Quest Diagnostics 
Multiple locations 
Additional laboratories can be added by amendment of this protocol, if they require a material transfer 
agreement. 
5.4. 
Approved Drugs 
No approved drugs will be used as part of this study. 
5.5. 
Unapproved Drugs 
ManNAc drug substance grade ManNAc and other forms of ManNAc are not approved for any indication. 
The Investigational New Drug (IND) application number for this product is IND #78091.  
5.5.1. Identity of Investigational Product 
ManNAc (N-acetyl-D-mannosamine monohydrate; trade name ManNAc) will be supplied as a powder by 
New Zealand Pharmaceuticals. The study drug will be prepared by the NIH Clinical Center Pharmacy as 
powder-in-bottle. The pharmacy will add 200 mL of water, shake to dissolve the drug, and re-label the 
bottles appropriately for delivery to the subjects. See Appendix E.  
5.5.2. Packaging, Labeling, and Storage of Clinical Supplies 
ManNAc will be supplied as a powder, packaged in 8 oz. amber plastic prescription bottles (Berry Plastics 
Part # PB-8) with a removable label and labeled as an investigational product. 
Storage conditions for the study drug will be 2 to 8 °C. For additional details, refer to Appendix E.  

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5.5.3. Drug Accountability 
The study drug will be registered and tracked with the NIH Pharmaceutical Development Service (PDS). 
Drug supply will be managed by the NIH CC Pharmacy Department. The NIH pharmacy is responsible 
for the accountability of the investigational product. This will include documentation of receipt, storage, 
and dispensing of the investigational agent. The NIH pharmacy will return or destroy (per instruction of 
the IND sponsor) unused investigational drug at the conclusion of the study. 
An order for study drug administration will be entered into CRIS by the study staff. The NIH Pharmacy 
will prepare and send the study drug to the unit. After administration of the study drug, the CC nursing 
staff will log the administration into CRIS. The empty container will be discarded. 
5.6. 
Results Given to Participants 
Subjects enrolled in this study will be told of their medically relevant laboratory results and the results of 
consultations. They will eventually be informed of the overall results of the study.  
5.7. 
Questionnaires 
A diary will be provided to subjects so that symptoms can be recorded after the administration of study 
drug (Appendix K). Patient reported outcomes mentioned in Section 5.2.1.6 will be administered as 
questionnaires. 
5.8. 
Genetic Counseling 
In cases where subjects have not received genetic counseling in the past, the Investigator or one of the 
genetic counselors in the Office of the Clinical Director will perform this service. 
5.9. 
Criteria for Withdrawal 
Subjects will be informed that they have the right to withdraw from the study at any time for any reason 
without prejudice to their medical care. 
Subjects may be withdrawn from the study for any of the following reasons: 
• Subject request 
• Subject is unwilling or unable to comply with the protocol 
• Medical reason, at the discretion of the Investigator 
In addition, the Sponsor may terminate this study at any time for safety or administrative reasons. The 
Sponsor will terminate the study if the occurrence of AEs or other findings suggests an unacceptable risk 
to the health of the subjects. 
Subjects who withdraw from the study early should undergo all safety evaluations prior to discharge from 
the unit. Subjects who withdraw will be replaced. The reason for subject withdrawal must be recorded in 
the subject’s CRF. The Investigator must notify the Sponsor immediately when a subject has been 
discontinued/withdrawn due to an AE. Subjects who withdraw from the study may request that samples 
be destroyed. 

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6. 
DESCRIPTION OF STUDY POPULATION 
6.1. 
Estimated Number of Participants 
This study will enroll 12 subjects with GNE myopathy divided into two dosing cohorts (cohort size = 6) 
assigned to receive ManNAc at either 3,000 mg BID or 6,000 mg BID for a 7-day pharmacokinetics 
study, for a total of 6,000 mg or 12,000 mg per day, respectively. All patients receive 6,000 mg BID for 
the remainder of the study beyond 7 days. Accrual ceiling will be set at 30 subjects to allow for subject 
replacement if needed. We anticipate enrollment of the 12 subjects within 1 year. 
6.2. 
Eligibility Criteria 
6.2.1. Inclusion Criteria 
1. Subject is age 18-60 years, inclusive, and of either gender. 
2. Subject has a diagnosis of GNE myopathy based upon a consistent clinical course and 
identification of two GNE gene mutations.  
3. Subject must be willing to stop any treatment with ManNAc, sialic acid, intravenous 
immunoglobulin (IVIG), and/or other supplements containing sialic acid (e.g. St. John’s wort, 
sialyllactose) 90 days prior to dosing and remain off such treatment for the duration of the trial. 
4. Subjects must have a body mass index (BMI) between 18 and 30 kg/m2, with a bodyweight of >50 
kg 
5. Subjects must meet one of the criteria below on at least one of the following muscle groups: 1) 
ankle dorsiflexion, 2) knee flexion, 3) hip extension, 4) grip, 5) elbow flexion, 6) shoulder 
abduction: 
a. 20-75% of predicted strength measured by QMA at baseline, or  
b. If predicted muscle strength above 75%, a documented change of at least 10% per year. 
6. Subject has the ability to travel to the NIH Clinical Center for admissions. 
7. Subject has an INR ≤1.5 and must have stopped warfarin and other anticoagulants 2 weeks prior 
and after muscle biopsy procedures. Aspirin and clopidogrel should be stopped 3 days and 5 days 
before the procedure, respectively.  
8. Subject must be able to comply with requirements of the protocol, including blood collection, drug 
administration, muscle MRI/MRS, muscle biopsy and muscle strength assessments.  
9. If a woman of reproductive age, subject must be willing to use an effective method of 
contraception for the duration of the trial. 
10. Subject must be able to provide informed consent. 
6.2.2. Exclusion Criteria 
1. Subject had a clinical significant infection or medical illness 30 days prior to the first protocol 
visit.  
2. Subject has a psychiatric illness or neurological disease that would interfere with the ability to 
comply with the requirements of this protocol. This includes, but is not limited to, 

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30 
uncontrolled/untreated psychotic depression, bipolar disorder, schizophrenia, substance abuse or 
dependence, antisocial personality disorder, panic disorder, or behavioral problems, which 
interfere with effective communication. 
3. Subject has hepatic laboratory parameters (AST, ALT, GGTP) or renal laboratory parameters 
(creatinine, BUN) greater than 3 times the upper limit of normal. 
4. Subject has known adverse reactions to anesthetic or sedatives utilized for muscle biopsy. 
5. Subject is anemic (defined as Hematocrit <30%) or has platelets <100,000 or white blood cell 
count less than 3,000. 
6. Subject shows evidence of clinically significant cardiovascular, pulmonary, hepatic, renal, 
hematological, metabolic, or gastrointestinal disease, or has a condition that requires immediate 
surgical intervention. 
7. Subject is pregnant or breastfeeding at any time during the study. 
8. Subject has received treatment with another investigational drug, investigational device, or 
approved therapy for investigational use less than 90 days prior to the first protocol visit. 
9. Subject has hypersensitivity to ManNAc or in the judgment of the investigator, has a condition 
that places the subject at increased risk for adverse effects. 
10. The presence of persistent diarrhea or malabsorption that could interfere with the subject’s ability 
to absorb drugs or to tolerate ManNAc therapy. 
6.2.3. Justification of Inclusion/Exclusion Criteria 
The rationale for the study population is that individuals with GNE myopathy will likely process sialic 
acid differently from healthy normal volunteers due to the hyposialylation characteristic in GNE 
myopathy, and therefore the PK of ManNAc in healthy normal volunteers may not be predictive of PK in 
GNE myopathy subjects. 
Subjects must be willing to stop treatment with ManNAc, sialic acid, IVIG, and/or other supplements 
containing sialic acid (e.g. St. John’s wort, sialyllactose) 90 days before dosing and remain off these 
medications for the duration of the trial. 
Children are excluded because GNE myopathy generally does not typically manifest in childhood and 
juvenile toxicology studies have not been performed. Subjects with certain psychiatric illnesses will be 
excluded because their symptoms could interfere with compliance or communication with health care 
personnel and therefore the integrity of the trial.  
Subjects with coagulation defects or taking anticoagulants are at higher risk of bleeding with muscle 
biopsy. Only those subjects that can safely stop taking such medications, as determined by their treating 
physician, will be eligible for this trial.  
6.3. 
Location of Study 
NIH Clinical Center. 

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31 
6.4. 
Recruitment Strategies 
Subjects will be recruited from patient organizations such as the Neuromuscular Disease Foundation 
(NDF) and Advancement of Research for Myopathies (ARM); from groups of subjects known to the 
Investigators, from individuals previously enrolled in the following studies: 
• Protocol 11-HG-0218: “A Natural History Study of Patients with GNE Myopathy”  
• Protocol 12-HG-0207: “A Phase 1 Randomized, Placebo-Controlled, Double-Blind, Escalating 
Single-Dose Study to Evaluate the Safety, Tolerability, and Pharmacokinetics of ManNAc in 
Subjects with GNE Myopathy or Hereditary Inclusion Body Myopathy (HIBM)”  
The study will include females in this early stage of drug development as encouraged by regulatory 
agencies. Pregnancy tests will be performed before dosing (see 5.2.2.2 and Appendix B). 
We will attempt to recruit all minority subjects we are aware of, including individuals from the Iranian 
Jewish community. A recruitment letter will be mailed to several large minority medical centers to aid 
with the ascertainment of under-represented subjects. These are listed with a sample of the recruitment 
letter in Appendix J. These will include: 
1.  
 
 
Meharry Medical College 
1005 Dr. D.B. Todd, Jr., Blvd., Nashville, TN 37208  
Phone: (615) 327-6111 
 
 
2.  
Morehouse School of Medicine  
720 Westview Drive S.W. Atlanta, GA 30310-1495 
Phone: (404)-752-1500 
 
3.  
Howard University 
2400 Sixth Street, NW, Washington, DC 20059  
Phone: 202-806-6100 
 
4.  
Charles R. Drew University of Medicine and Science 
1731 East 120th Street Los Angeles, CA 90059  
Phone: (323)-563-4800 
 
6.5. 
Existing Sample/Data Sets 
Not applicable.  
6.6. 
Financial Compensation 
None.  

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7. 
STATISTICAL CONSIDERATIONS 
7.1. 
Statistical Plan 
An independent statistical analysis will be performed after the study is completed, queries are resolved 
and the database has been locked. 
7.1.1. General Reporting Conventions 
Standard descriptive statistics will include the number (n), mean and standard deviation (SD), median, 
minimum, and maximum values for continuous variables.  For categorical variables, the frequency of 
subjects will be provided along with the percentage based on the number of subjects with available data. 
Unless otherwise indicated, summaries will be based on observed data (i.e., no missing data will be 
imputed).  
Any statistical testing and/or provided confidence intervals (CI) are provided as an aid in interpreting 
study results and are not intended as claims.  Results from this study may be used in designing future 
studies.   
Summaries will be provided by treatment group for the individual ManNAc treatment groups (6,000 mg 
and 12,000 mg), a combined ManNAc group and the combined control subjects from all two cohorts. 
Analyses will be generated using SAS version 9.2 or higher. Analysis on QMA will be performed using 
R.  
7.2. 
Statistical Methods and Evaluations 
7.2.1. Demographic and Baseline Characteristics 
Baseline and demographic characteristics including age, gender, race, ethnicity, height, weight, BMI, and 
genotype information will be summarized descriptively by treatment group.  The medical history 
summary will include the number and percent of subjects with one or more findings by body system and 
treatment group.  
7.2.2. Safety Evaluations 
All safety data will be listed. AEs, SAEs, unanticipated problems, AEs related to the drug (possible, 
probable, or definite) and CTCAE Grade 3 and 4 AEs will be summarized overall.  These summaries will 
include the number of events and the number and percentage of subjects with a given event. AEs will also 
be summarized by system organ class (SOC) and treatment group to identify AEs that occur at a higher 
frequency in subjects treated with ManNAc at different dose levels.   
7.2.3. Pharmacokinetic Analysis 
Plasma concentrations of ManNAc and free Neu5Ac will be summarized descriptively by collection time 
points, and figures will be provided to plot the mean concentrations over time by dose along with 
individual subject results. Reporting will be carried out according to ICH guidelines (ICH-E3).    
The following PK parameters may be estimated using noncompartmental analyses to assess the 
concentration-time data: Cmax, Tmax, AUClast, AUCt, AUC0-∞, t1/2 and Ctrough plasma concentrations.  
In addition, the Cmax geometric mean and corresponding 95% confidence interval may also be provided.  

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33 
Day 1 and Day 8 data for Cmax and AUCt may be compared to determine the accumulation ratio of the 
compound.  
7.2.4. Pharmacodynamics 
Different dose levels will be evaluated by a statistical dose-response model of the relationship between 
dose and the rate at which plasma free Neu5Ac returns to baseline levels. 
The following PD parameters may be summarized and analyzed by treatment group: Intracellular 
ManNAc, Neu5Ac, CMP-Neu5Ac and plasma sialylation (may include T/ST ratios). A similar statistical 
dose-response model may be used to evaluate these parameters, if appropriate. 
7.2.5. Lectin Staining on Muscle Biopsies 
The fluorescence will be quantified in 5 different images per slide with ≥ muscle cells per field and 
analyzed as a change from baseline to 90 days using a paired t-test.  
7.2.6. Quantitative Muscle Strength  
In our disease progression model specified in 3.3.1, the rate of progression for each muscle was 
determined. Given baseline data for each subject, we can then predict the percentage of strength for each 
primary muscle group for each subject at their follow-up visits. To investigate if ManNAc affects disease 
progression we will provide descriptive statistics of the predicted percentage of strength for each primary 
muscle group versus the measured percentage of strength at every visit. We will also more formally 
explore the possibility of the ManNAc causing a change in the rate of decay of the muscles over a 24-
month period by introducing a proportional treatment effect on the rate of decline (γ) into the disease 
progression at the time of treatment. If γ is equal to 1 there is no effect of the treatment on the disease 
progression model and the treatment effect model is the same as the normal disease progression model. If 
γ is less than one the treatment slows the rate of decay of the muscle group and if γ is equal to zero the 
treatment has stopped the decay of the muscle group altogether. If γ is greater than one the treatment 
increases the rate of decay of the muscle group. Under this treatment effect model we will report the 
posterior mean, and 95% credible interval for γ as well as the posterior probability that the treatment 
slows the rate of decay of the muscle groups (γ is less than one).  
7.2.7. Other Rehabilitation Medicine Evaluations 
Changes in clinical measurements will be analyzed as a change from baseline to last visit using a paired t-
test or Wilcoxon rank sum test based on parametric quality of the data.  
7.3. 
Determination of Sample Size 
Eligible subjects will be enrolled into one of 2 cohorts of 6 subjects each, to receive ManNAc at doses of 
3,000 mg BID (n=6) or 6,000 mg BID (n=6).  Given the rarity of disease and the intent of this study—
determine pharmacokinetics, safety and efficacy using blood based and tissue biomarkers, 12 subjects 
should be suitable.  
7.4. 
Interim Analysis 
Interim analyses are planned after each cohort has completed the pharmacokinetic phase, and after each 
cohort has undergone evaluation at days 182, 365, 548, 730 and 912 (6, 12 18, 24,  and 30 months).  

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34 
7.5. 
Deviation from Original Analysis Plan 
Any deviation from the original statistical plan will be described in the final clinical study report.  

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35 
8. 
POTENTIAL BENEFITS 
8.1. 
Direct benefits to participants 
The benefits of ManNAc are unknown. There may be no direct benefits to subjects participating in this 
study. 
8.2. 
Collateral Benefit to Participants 
The results of clinical testing performed at NIH will provide data for each subject’s medical record. The 
study team may serve as a resource for consultation with each subject’s physician. 
8.3. 
Benefits to Society 
This study will improve understanding of the safety and PK of ManNAc and its results will inform future 
trials to evaluate the efficacy of ManNAc in individuals with GNE myopathy. 

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36 
9. 
LIKELIHOOD AND SERIOUSNESS OF HARMS AND MEANS TO 
MAXIMIZE SAFETY 
Efforts will be made to reduce physical and psychological stress by carefully explaining the study’s 
procedures to the individual subjects.  
Individual procedures and associated personal risks are briefly described below. 
9.1. 
Therapeutic Interventions 
9.1.1. Risks of ManNAc/ManNAc 
A single dose of ManNAc was safe and well tolerated as part of NIH study 12-HG-0207. The only drug-
related adverse event in this study, loose stools shortly after receiving the 10,000 mg as a single dose of 
ManNAc, was likely caused by unabsorbed drug in the gastrointestinal tract. As part of this study, the 
maximum single dose to be given will be 6,000 mg, which was determined to be safe and well tolerated 
on NIH study 12-HG-0207 (See Appendix F).  
One subject participating in study 15-HG-0068 had Grade 3 hypertryglyceridemia which was determined 
to be probably related to ManNAc. As higher triglycerides were also seen in toxicology studies (see Table 
10), the intake ManNAc includes the risk of hypertriglyceridemia. 
As mentioned in Section 3.6 and shown in Appendix L, effects on the gastrointestinal tract were the most 
prominent in the 90-day toxicology studies performed in rats and dogs, and included loose and discolored 
feces, mild liver enlargement and mucosal hypertrophy of the colon. There have been no serious adverse 
events through 24 months of follow-up visit for subjects taking ManNAc. Two subjects have withdrawn 
consent due to gastrointestinal tolerability issues. One subject had a dose reduction due to tolerability 
concerns associated with grades 1 and 2 flatulence and diarrhea, and the subject has had their symptoms 
reach a tolerable level at the reduced dose. 
9.2. 
Diagnostic Interventions 
9.2.1. Medical Evaluations 
There are no significant risks associated with the physical evaluations, or collection of vital signs. 
Multiple independent evaluations may be stressful. 
9.2.2. Serum Pregnancy Testing 
There are no risks involved with taking a serum pregnancy test. Subjects will be informed of a positive 
test. The subject will not be eligible to participate in the study if she is pregnant.  
9.2.3. ECG 
There are no significant risks associated with performing an ECG. 
9.2.4. Placement of a Peripheral Intravenous Line 
A peripheral intravenous line may be placed to allow for blood collection. Risks associated with a 
peripheral intravenous line include a small risk for infection, phlebitis, extravasation, infiltration, air 
embolism, hemorrhage, and formation of a bruise. 

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37 
Because of the risk of insertion-site infection, the catheter needs to be removed within 72 hours.  
9.2.5. Phlebotomy 
Multiple blood draws will be necessary during this study. Phlebotomy is a risk/discomfort of this study. 
An anesthetic cream such as EMLA may be used. Infection and bruising are possible at the site of the 
blood draw. The amount of blood to be drawn will not exceed the NIH CC blood draw limits of 550 mL 
over any 8-week period. Nursing staff will monitor blood-drawing volumes. If blood limits are an issue, 
testing will be prioritized by the investigators. Safety laboratory tests will take priority over 
investigational testing. If a subject is concurrently enrolled in another protocol, the total blood volume 
will not exceed the above limit. 
9.2.6. Muscle Biopsy 
Muscle biopsies will be obtained when technically feasible. A separate NIH Clinical Center surgical 
consent will be used for this procedure. The open muscle biopsy will leave small scars on the skin; 
therefore subjects may have up to four scars, one per biopsy. The rare complications of local infection or 
bleeding will be guarded against by sterile procedures, and careful hemostasis.  The risk of these events is 
minimized by having the procedure performed by a neurosurgeon or neurologist trained to perform 
muscle biopsies and under sterile conditions with adequate anesthesia.  
To further decrease the risk of bleeding associated with muscle biopsy, anticoagulants, aspirin, 
clopidogrel and other medications that increase the risk for bleeding are stopped. Only subjects that can 
safely discontinue such medications, as determined by their treating physician, will be eligible for this 
study. Pre-surgery and post-surgery instructions, including care of the incision site, will be provided to the 
subject. 
9.2.7. Muscle MRI 
Potential risks from MRI include injury from the MRI magnet if they have pacemakers or other implanted 
electrical devices, brain stimulators, dental implants, aneurysm clips (metal clips on the wall of a large 
artery), metallic prostheses (including metal pins and rods, heart valves, and cochlear implants), 
permanent eyeliner, implanted delivery pump, or shrapnel fragments. Welders and metal workers are also 
at risk for injury because of possible small metal fragments in their eyes. Subjects will be screened for 
these conditions prior to the test, and if they have any of these conditions, they will not have an MRI scan. 
In addition, all magnetic objects (for example, watches, coins, jewelry, and credit cards) must be removed 
before entering the MRI scan room. Women who are pregnant are excluded from the MRI. Therefore, all 
women of childbearing potential will have a pregnancy test performed, which must be negative, before 
proceeding. Subjects will be asked to complete an MRI screening form, and to sign a separate MRI 
consent for each MRI. There are no known long-term risks or consequences of MRI scans. 
Holding still during the MRI scan and being placed in a relatively small space can be uncomfortable or 
create anxiety in some subjects, if desired a mild anxiolytic may be prescribed during the test. MRI 
evaluation does not involve any radioactivity.  
9.2.8. Activity monitor 
The only reported adverse event associated with these devices is skin irritation when it is worn against the 
skin. If this occurs, the device can be moved to an alternate site that is not in direct contact with skin. 

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38 
9.3. 
Radiation 
Only medically indicated radiation exposure will be incurred.  
9.4. 
Sedation 
None. 
9.5. 
Psychological Harms 
The main psychological issue will be accepting the possibility that ManNAc administration is not 
beneficial. 
9.6. 
Risk to Family Relationships 
Subjects will have a known genetic condition. No further genetic testing will be performed for this study, 
therefore there is no risk to family relationships.  
9.7. 
Discrimination 
Subjects enrolled in this protocol already have the diagnosis of GNE myopathy, with its attendant risks of 
insurance and employment discrimination. To the fullest extent possible, the investigators will not 
disclose to third parties any information about the participants without their expressed consent. 

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39 
10. 
PRIVACY AND CONFIDENTIALITY OF MEDICAL INFORMATION 
AND BIOLOGICAL SPECIMENS  
10.1. 
Participant Identifiers Attached to Data 
Clinical data will be collected using subjects’ names in a “shadow” file, maintained in a locked cabinet. 
The Principal Investigator and designated Associate Investigators will hold keys to the locked cabinet. 
However, to maintain subject privacy, all CRFs, study drug accountability records, study reports, 
communications, and research blood samples will be identified by the assigned subject number and/or a 
barcode. The linking code, as well as all other data, will be maintained in records in the password-
protected database CTDB. 
10.2. 
Clinical/Demographic Information 
This will be part of the clinical data kept in the medical record and in password-protected database CTDB.   
10.3. 
How might information make specific individuals identifiable? 
Subjects enrolled in this study are from all over the world. It is doubtful that any demographic 
information could identify an individual. Subjects will be notified that registration information, results, 
and other information about this study will be submitted to ClinicalTrials.gov, a publicly available trial 
registry database; however, protected health information of individual subjects will not be used. 
10.4. 
Access to the key for subject identification 
The code to subject identities, as well as other subject data, will be kept in the password-protected 
database CTDB. Access to the code will be restricted to the Principal Investigator, Dr. Nuria Carrillo and 
designated Associate Investigators.  
10.5. 
Will pedigrees be published? 
Pedigrees are not essential for this drug trial. 
10.6. 
Will results be provided to participants?  
All medically relevant data will be given directly to the subjects as they become available. In addition, the 
clinical research data of the individual subject, obtained in our CLIA-certified lab, will be provided to 
interested subjects. 
10.7. 
Will Identifiable Information be Released to Third Parties? 
The Principal Investigator will grant the NIH monitor(s), auditor(s), and regulatory authority(ies) access 
to the subject’s original medical records for verification of data gathered on the CRFs and to audit the data 
collection process. The subject’s confidentiality will be maintained and will not be made publicly 
available to the extent permitted by the applicable laws and regulations. 
The investigators will not disclose to third parties any information about the participants without their 
expressed consent.  

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40 
10.8. 
Sharing of Data/Samples with Other Researchers 
If sent to outside laboratories, samples will be coded and subject identifiers will be removed. The code 
number can be linked to a name only by the Principal Investigator and a designated Associate 
Investigator.  If a biospecimen is sent to a clinical laboratory for testing, identifiers will not be removed 
and the result will become part of the NIH medical record.  
10.9. 
Additional Features to Protect Confidentiality 
The protocol and associated data will be stored on the CTDB. The CTDB is a web-based application that 
supports flexible data capture and reporting. The system is hosted at the NIH in Bethesda, MD.  It is 
accessible via the Internet through the NIH firewall, on both Mac and Windows based computers.  An 
Oracle relational database is utilized to capture and secure data entered through the web interface. The 
following features allow for the safe and secure collection of research variables: an application firewall, 
data encryption and SSL certificates, HIPAA requirements, logical access controls, audit trails. 
Furthermore, only preauthorized users can access the CTDB. The Principal Investigator can determine the 
Associate Investigator’s data access privileges.  
11. 
ASSESSMENT OF RISK/BENEFIT RATIO    
The physical risks of phlebotomy, blood collection, muscle biopsy and ManNAc administration appear 
reasonable compared with the burden of the disease GNE myopathy. The benefits of this study relate to 
the future availability of a therapy for GNE myopathy. The benefit of such a treatment could be enormous 
for the community. 

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12. 
COLLECTION, MONITORING, ANALYSIS AND REPORTING OF 
ADVERSE EVENTS AND PROTOCOL DEVIATIONS 
12.1. 
Adverse Events 
AE definitions and classifications can be found below.  Our safety monitoring plan is based on experience 
from the Phase 1 SAD trial of ManNAc (Section 3.5.3 and Appendix F), the 90-day toxicology studies in 
rat and dogs (See Appendix L) and the long-term toxicology studies in rats and dogs (Appendix M). We 
will monitor clinical laboratory tests including hemoglobin, liver function tests (See 5.2.2) and other 
clinical testing as medically indicated.  
12.1.1. Monitoring and Reporting of Adverse Events  
Subjects will be evaluated and interviewed to identify AEs during the course of the study. AEs may also 
be identified through clinical examinations and laboratory tests. Events occurring after administration of 
the first dose of study medication will be recorded on the AE CRF. All AEs occurring from the time the 
informed consent is signed through the final dose of study drug must be documented, recorded and 
reported. After the final dose, all Grade ≥2 AEs at least possibly related to study drug will be followed to 
resolution. 
A laboratory abnormality should be reported as an AE if it requires an intervention. Interventions include, 
but are not limited to, discontinuation of treatment, dose reduction/delay, additional assessments, or 
concomitant treatment. In addition, any medically important laboratory abnormality may be reported as an 
AE at the discretion of the investigator. This could include a laboratory result for which there is no 
intervention, but the abnormal value suggests disease or organ toxicity. The Investigator will evaluate all 
AEs with respect to Seriousness, Severity (intensity or grade), and Causality (relationship to study agent 
and relationship to research) according to the following guidelines.  
The Medical Dictionary for Regulatory Activities (MedDRA) coding dictionary will be used for coding 
AEs.   
The Investigator will grade the severity of each AE according to the “Common Terminology Criteria for 
Adverse Events (CTCAE)” in effect at the time of protocol activation which can be found at: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm 
Causality (likelihood that the event is related to the study agent) will be assessed considering the factors 
listed under the following categories: 
Definitely Related:  
• clear temporal association 
• follows a known response pattern 
• clear evidence to suggest a causal relationship 
• there is no alternative etiology 
Probably Related: 
• temporal association 
• follows a suspected response pattern (based on similar agents) 

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42 
• a more likely alternative etiology unlikely 
Possibly Related: 
• temporal association 
• evidence exists for alternative etiology 
Unlikely Related 
 
• no clear temporal association  
OR 
• good evidence for a more likely alternative etiology 
Not Related  
• no temporal association          
OR 
• definitely due to an alternative etiology 
Note: Other factors (e.g., dechallenge, rechallenge) should also be considered for each causality category 
when appropriate. Causality assessment is based on available information at the time of the assessment of 
the AE. The investigator may revise the causality assessment as additional information becomes available. 
Pregnancy: Pregnancy itself is not an AE. However, complications of pregnancies are AEs and may be 
SAEs. In the event of pregnancy the following steps will be taken: 
• Discontinuation of the study agent 
• Withdraw from the study but continue in follow up for safety 
• Report to safety oversight committee - SRC and IRB 
• Advise research subject to notify the obstetrician of study agent exposure 
• Safety data will be collected until completion of the pregnancy 
12.1.2. Review of Safety and Tolerability 
The evaluation of a dose for an individual will initially be reviewed by the PI, according to the criteria and 
on an ongoing basis by the SRC.  
12.2. 
Monitoring and Reporting Plan 
AEs, protocol deviations, unanticipated problems (UP), and serious adverse events, are defined in NIH 
HRPP SOP 16 ("Reporting Requirements for Unanticipated Problems, AEs and Protocol Deviations", 
Appendix G).  All AEs occurring from the time the informed consent is signed through the end of the 
follow-up period will be documented, recorded and reported.  
An adverse event (AE) is any unfavorable and unintended sign (including a clinically significant 
abnormal laboratory finding, for example), symptom, or disease temporally associated with a study, use 
of a drug product or device whether or not considered related to the drug product or device.  

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Serious unanticipated problems that are at least possibly related to the research and suggest a greater 
risk or harm than previously known, serious protocol deviations will be reported to the IRB and CD 
(Clinical Director) as soon as possible but not more than 7 days if serious or 14 days if not serious, after 
the PI first learns of the event.   
Not serious unanticipated problems will be reported to the IRB and CD as soon as possible but not 
more than 14 days after the PI first learns of the event.   
Protocol deviations that represent non-compliance (see SOP 16A) will be reported to the IRB and CD 
within 7 days if serious and 14 days if not serious. 
Not serious protocol deviations that do not represent non-compliance will be reported to the IRB as soon 
as possible but not more than 14 days after the PI first learns of the eventpart of the Continuing Review. 
Anticipated deviations in the conduct of the protocol will not be reported to the IRB unless they occur at a 
rate greater than anticipated by the study team. Expected AEs will not be reported to the IRB unless they 
occur at a rate greater than that known to occur in GNE myopathy. If the rate of these events exceeds the 
rate expected by the study team, the events will be classified and reported as though they are 
unanticipated problems.  
Deaths will be reported to the Clinical Director within 7 days after the PI first learns of the event. 
At each contact with the subject, information regarding unanticipated problems and adverse events will be 
elicited by appropriate questioning and examinations. All UPs and AEs will be: immediately documented 
in the subject’s medical record/source document; appropriately recorded on the NIH Problem Report 
Form and on the Adverse Event Case Report Form (AE CRF) or in the electronic database; and reported 
to appropriate entities (e.g., IND Sponsor, IRB, FDA, etc.), within the specified time limits.  
Anticipated deviations in the conduct of the protocol will not be reported to the IRB unless they occur at a 
rate greater than anticipated by the study team. Expected AEs will not be reported to the IRB unless they 
occur at a rate greater than that known to occur in GNE myopathy. If the rate of these events exceeds the 
rate expected by the study team, the events will be classified and reported as though they are 
unanticipated problems.  
The following items will be reported to the NHGRI IRB in summary at the time of Continuing Review: 
• Serious and non-serious unanticipated problems  
• Expected serious adverse events that are possibly, probably, or definitely related to the research 
• Serious adverse events that are not related to the research 
• All adverse events, except expected AEs and deaths granted a waiver of reporting.  
• Serious and Non-Serious Protocol deviations  
• Serious, continuing, and minor non-compliance 
• Any trends or events that in the opinion of the investigator should be reported 
• Any protocol-specific reporting requirements (as applicable). 
AEs that occur following enrollment of the subject (by signing the informed consent) are followed until 
the final outcome is known or until the end of the study follow-up period. SAEs that have not resolved by 
the end of the follow-up period are followed until final outcome is known. If it is not possible to obtain a 

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44 
final outcome for an SAE (e.g., the subject is lost to follow-up), the reason a final outcome could not be 
obtained will be recorded by the investigator on the AE CRF (if the CRF is still open). SAEs that occur 
after the study follow-up period and that are reported to and are assessed by the Investigator to be 
possibly, probably, or definitely related must be reported to the safety oversight committee as described 
above. 
12.2.1. Notification about Serious Adverse Reaction and Serious and Unexpected Suspected 
Adverse Reactions 
Investigators must report any SAE to the Sponsor immediately, whether or not considered drug related, 
including those listed in the protocol or Investigator Brochure.  
All SAEs, regardless of relationship to the study drug will be reported to the FDA within 7 days in an 
expedited report. Investigators must also notify FDA of any unexpected fatal or serious adverse events as 
soon as possible but in no case later than 7 calendar days after the sponsor's initial receipt of the 
information. 
The report must include an assessment of whether there is a reasonable possibility that the drug caused the 
event.  
12.2.2. Reporting to Regulatory Agencies and IRB 
We will follow the reporting requirements as described in NIH HRPP SOP 16 “Reporting Requirements 
for Unanticipated Problems, Adverse Events and Protocol Deviations”. 
The Medical Dictionary for Regulatory Activities (MedDRA) coding dictionary will be used for the 
coding of AEs.   
12.3. 
Safety Monitoring Committee/ Data Safety and Monitoring Board (DSMB) 
12.3.1. Safety Review Committee (SRC) 
An SRC will be convened for the purposes of monitoring individual subject and overall cohort safety. It 
will be composed of the Sponsor, the Principal Investigator, an independent physician, a member of the 
NHGRI IRB, and other members as needed. The SRC will meet on a regular basis to review safety data 
for active subjects in the trial. The SRC will make decisions regarding continuation, termination, and 
modification of the protocol. The SRC will review all AE data of subjects in each cohort to determine 
dose escalation/de-escalation for each cohort.  
12.3.2. Data and Safety Monitoring Board (DSMB) 
The NHGRI DSMB will review all AEs and SAEs on a yearly basis. If 1 or more drug related SAE(s) are 
observed, the DSMB will perform an earlier review. 
13. 
ALTERNATIVES TO PARTICIPATION 
There are no approved therapies for GNE myopathy. Ultragenyx Pharmaceuticals is conducting clinical 
trials to evaluate the use of extended release sialic acid (SA-ER) in subjects with GNE myopathy. 

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45 
14. 
CONSENT PROCESS 
Written informed consent is required from each subject prior to any testing under this protocol, including 
screening tests and evaluations. The informed consent form (ICF), as specified by the NIH IRB, must 
follow the Protection of Human Subjects regulations listed in the Code of Federal Regulations, Title 21, 
Part 50.  
The background of the proposed study and the benefits and risks of the procedures and study must be 
explained to the subjects. The PI or an Associate Investigator will obtain consent and provide the subject 
with a copy of the signed and dated ICF. Confirmation of a subject’s informed consent will also be 
documented in the subject’s medical record prior to any testing under this protocol, including screening 
tests and evaluations. 
For the convenience of enrolled subjects, if an amended consent is not available at the time of a subject’s 
visit to the NIH CC, we will complete the re-consenting process over the telephone. An informed consent 
form will be mailed to the subject, and the subject and a witness will sign, then return via pre-paid mail 
where an investigator will sign and date (SOP 12.15 Obtaining Consent by Telephone). No amended 
procedures will be performed and no drug provided until a signed ICF is received. 
14.1. 
Who Will Obtain Consent? 
The PI, or an associate investigator on the study, will obtain consent from the subjects enrolled in this 
protocol.  
14.2. 
Setting of Consent 
Consent will be obtained at the NIH Clinical Center when feasible.  
14.3. 
Consent Information 
The ICF will be provided to the subjects as a separate document. 
14.4. 
Protections for Vulnerable Participants 
Adult subjects who are unable to provide informed consent will not be enrolled in the study. 
14.5. 
Special Circumstances 
Short Form Consents will be used for the enrollment of a non-English speaking subject. When the PI uses 
the English version of the informed consent document as the written summary, the version of the short 
form consent must match the required informed consent elements in the protocol consent document as 
required by 45 CFR 46 and the Food and Drug Administrative Amendments Act (FDAAA). Version 2 
will be used, which reflects the required elements of informed consent required by 45 CFR 46, in addition 
to the Food and Drug Administrative Amendments Act (FDAAA) when the protocol is known to meet the 
definition of an "applicable clinical trial". The following sentence is generally located on the English 
consent at the end, but before the last page containing "Other Pertinent Information." 
A description of this clinical trial will be available on 
http://www.Clinicaltrials.govhttp://www.Clinicaltrials.gov, as required by U.S. Law. This web site will 
not include information that can identify you. At most the Web site will include a summary of the results. 
You can search this Web site at any time. 

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15. 
FINANCIAL COMPENSATION 
None 

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16. 
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mouse model of GNE myopathy. Mol Genet Metab 2012;107:748-55. 
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APPENDIX A. PROTOCOL SYNOPSIS 
Name of IND Sponsor: 
William A. Gahl, MD, PhD 
Clinical Director, National Human Genome Research Institute 
10 Center Drive, Building 10, Room 10C-103, Bethesda, Maryland 20892-1851 
Office: (301) 402-2739 
Fax: (301) 402-2740 
Name of investigational product: 
ManNAc 
Name of active ingredient: 
N-acetyl-D-mannosamine (ManNAc) 
Title of study:  
An Open-Label Phase 2 Study to Evaluate the Pharmacokinetics, Safety and Efficacy of ManNAc in 
Subjects with GNE Myopathy 
Study center:  
NIH Clinical Center 
10 Center Drive 
Bethesda, MD 20892 
Principal Investigator:  
Nuria Carrillo, MD 
Therapeutics for Rare and Neglected Diseases (TRND) 
National Center for Advancing Translational Sciences (NCATS) 
10 Center Drive Drive, Building 10, Room 9N256, Bethesda, MD 20892 
Office: (301) 402-2324 
Fax: (301)-402-0006 
Phase of development: 2 
Objectives:  
Primary: 
• 
To assess the safety and tolerability of multiple doses of orally administered ManNAc to 
subjects with GNE myopathy; 
• 
To examine plasma pharmacokinetics (PK) and pharmacodynamics (PD) of multiple doses of 
orally administered ManNAc to subjects with GNE myopathy; 
• 
To determine the biochemical effect of ManNAc, as assessed by sialylation of proteins.  
Secondary Objectives 
The secondary objectives of this study are: 
• 
To evaluate the effect of ManNAc on disease-relevant biomarkers;  
• 
To measure the effect of ManNAc on clinical aspects of GNE myopathy and identify clinical 
endpoints suitable for subsequent clinical trials. 
Study Design:  

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This is an open-label Phase 2 study to evaluate the safety, tolerability, PK, and PD of ManNAc in 
subjects with GNE myopathy.  
A total of 12 subjects will be recruited to receive ManNAc (n=6 per cohort) twice daily. In the first 
phase of pharmacokinetic assessment, subjects will receive ManNAc at doses of 3,000 mg twice a day 
(6,000 mg per day- Cohort A) or 6,000 mg twice a day (12,000 mg per day – Cohort B) for 7 days 
while admitted to the NIH Clinical Center to assess PK and safety. Safety and tolerability will be 
assessed on an individual basis. In the second phase of the study, all subjects will receive treatment 
with ManNAc at a dose of 6,000 mg twice daily for the remainder of the study. Follow-up safety and 
efficacy evaluations will occur at 6 and 12 weeks, and at 182, 365, 548, 730, and 912 days (6, 12, 18, 
24 and 30 months). Safety lab evaluation will be also be performed at 456, 638, and 820 days (15, 21 
and 27 months) either at the NIH clinical center or subjects’ home laboratory or physician’s office. 
Safety will be evaluated by adverse events (AEs), clinical laboratory tests, vital signs, and physical 
examinations. PK will be assessed for plasma ManNAc and Neu5Ac. Biochemical efficacy will be 
measured by change in the sialylation of proteins and clinical efficacy will be assessed using a battery 
of clinical assessments deemed to be relevant based on disease natural history.  
Number of subjects (planned): 
12 subjects  
Diagnosis and main criteria for inclusion:  
Inclusion criteria:  
1. Subject is age 18-60 years, inclusive, and of either gender. 
2. Subject has a diagnosis of GNE myopathy based upon a consistent clinical course and 
identification of two GNE gene mutations.  
3. Subject must be willing to stop any treatment with ManNAc, sialic acid, intravenous 
immunoglobulin (IVIG), and/or other supplements containing sialic acid (e.g. St. John’s wort, 
sialyllactose) 90 days prior to dosing and remain off such treatment for the duration of the trial. 
4. Subjects must have a body mass index (BMI) between 18 and 30 kg/m2, with a bodyweight of >50 
kg 
5. Subjects must meet one of the criteria below on at least one of the following: 1) ankle dorsiflexion, 
2) knee flexion, 3) hip extension, 4) grip, 5) elbow flexion, 6) shoulder abduction: 
a. 20-75% of predicted strength measured by QMA at baseline, or  
b. If predicted muscle strength above 75%, a documented change of at least 10% per year. 
6. Subject has the ability to travel to the NIH Clinical Center for admissions. 
7. Subject has an INR ≤1.5 and must have stopped warfarin and other anticoagulants 2 weeks prior 
and after muscle biopsy procedures. Aspirin and clopidogrel should be stopped 3 days and 5 days 
before the procedure, respectively.  
8. Subject must be able to comply with requirements of the protocol, including blood collection, drug 
administration, muscle MRI/MRS, muscle biopsy and muscle strength assessments.  
9. If a woman of reproductive age, subject must be willing to use an effective method of 
contraception for the duration of the trial. 
10. Subject must be able to provide informed consent. 
Exclusion Criteria: 
1. Subject had a clinical significant infection or medical illness 30 days prior to the first protocol visit.  
2. Subject has a psychiatric illness or neurological disease that would interfere with the ability to 
comply with the requirements of this protocol. This includes, but is not limited to, 
uncontrolled/untreated psychotic depression, bipolar disorder, schizophrenia, substance abuse or 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
51 
dependence, antisocial personality disorder, panic disorder, or behavioral problems, which interfere 
with effective communication. 
3. Subject has hepatic laboratory parameters (AST, ALT, GGTP) or renal laboratory parameters 
(creatinine, BUN) greater than 3 times the upper limit of normal. 
4. Subject has known adverse reactions to anesthetic or sedatives utilized for muscle biopsy. 
5. Subject is anemic (defined as Hematocrit <30%) or has platelets <100,000 or white blood cell 
count less than 3,000. 
6. Subject shows evidence of clinically significant cardiovascular, pulmonary, hepatic, renal, 
hematological, metabolic, or gastrointestinal disease, or has a condition that requires immediate 
surgical intervention. 
7. Subject is pregnant or breastfeeding at any time during the study. 
8. Subject has received treatment with another investigational drug, investigational device, or 
approved therapy for investigational use less than 90 days prior to the first protocol visit. 
9. Subject has hypersensitivity to ManNAc/ManNAc or in the judgment of the investigator, has a 
condition that places the subject at increased risk for adverse effects. 
10. The presence of persistent diarrhea or malabsorption that could interfere with the subject’s ability 
to absorb drugs or to tolerate ManNAc therapy. 
Investigational product, dosage, and mode of administration:  
ManNAc (ManNAc) administered orally at either 3,000, or 6,000 mg twice daily (total daily dose of 
6,000 or 12,000 mg, respectively).  
Duration of treatment:  
Study drug will be administered for 912 days.  
Reference therapy, dosage, and mode of administration:  
None  
Criteria for evaluation: 
Safety will be assessed by adverse events, clinical laboratory tests, vital signs and physical exams. 
PK/PD: 
The following parameters will be assessed for plasma ManNAc and free Neu5Ac:  
• 
Maximum observed plasma concentration (Cmax), 
• 
Time to Cmax (Tmax), 
• 
Area under the plasma concentration-time curve from time 0 to infinity (AUC0-∞),  
• 
Area under the plasma concentration-time curve from time 0 to time of last measurable plasma 
concentration (AUClast),  
• 
Area under the plasma concentration-time curve within the dosing interval (AUCt),  
• 
Plasma elimination half-life (t½). 
Other: 
Biochemical efficacy will be measured by change in the sialylation of proteins and clinical efficacy 
will be assessed using a battery of clinical assessments deemed to be relevant based on disease natural 
history. 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
52 
APPENDIX B. STUDY DESIGN 
 
  
 
 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
53 
APPENDIX C. SCHEDULE OF EVENTS 
 
Event 
Baseline 
PK Phase 
Safety/Efficacy Phase 
PK 
Safety/ Efficacy 
Phone 
Follow-up 
Day  
-30 to 0 
Day 
1 
Day
 2-6 
Day  
7 
Day    
8-9 
Day 
10 
(±3) 
Day  
28  
(±7) 
Day  
45  
(±7) 
Day  
63  
(±7) 
Day  
85  
(±5) 
Day 
85-90  
(±5) 
Day 
180 
(±14) 
Day 
365 
(±14) 
Day 450, 
638, 820 
(±30) 
Day 548, 
912  
(-30) 
Day 
730  
(-30) 
Day 120, 240, 
300, 400, 638, 
820 (±30) 
Admission 
X 
 
 
 
 
 
 
X 
 
X 
 
X 
X 
 
X 
X 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eligibility  
X 
X 
 
 
 
 
 
X 
 
X 
 
X 
X 
 
X 
X 
 
Medical history  
X 
 
 
 
 
 
 
X 
 
X 
 
X 
X 
 
X 
X 
 
Physical exam1 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
X 
X 
X 
 
X 
X 
 
Vital signs2 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
X 
X 
X 
 
X 
X 
 
Safety Labs3 
X 
 
X 
 
X 
X 
 
X 
 
X 
X 
X 
X 
X11 
X 
X 
 
Pregnancy test4 
X 
 
 
 
 
 
 
X 
 
X 
 
X 
X 
 
X 
X 
 
12-lead ECG 
X 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
 
X 
 
Muscle MRI/MRS  
X 
 
 
 
 
 
 
 
 
X 
 
 
X 
 
 
X 
 
QMA5 
X 
 
 
 
 
 
 
 
 
X 
 
X 
X 
 
X 
X 
 
Rehab Measures6 
X 
 
 
 
 
 
 
 
 
X 
 
X 
X 
 
X 
X 
 
Muscle Biopsy7 
X 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
Activity Monitor 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
X 
X 
Study drug administration 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
X 
X 
Blood for PK 8 
 
X 
X 
X 
 
 
 
X 
 
X 
X 
X 
X 
 
X 
X 
 
Blood for PD 9 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
X 
X 
X 
 
X 
X 
 
Research samples 
X 
 
X 
X 
 
X 
 
X 
 
X 
X 
X 
X 
 
 
X 
 
Adverse events  
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
X 
X 
PRO10 
X 
 
 
 
 
 
 
X 
 
X 
 
X 
X 
 
X 
X 
 
Medications 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
X 
X 
Discharge 
 
 
 
 
 
X 
 
X 
 
 
X 
X 
X 
 
X 
X 
 
Phone call 
 
 
 
 
 
 
X 
 
X 
 
 
 
 
 
 
 
X 
1 The initial physical exam may be conducted at any time between Screening and up to and including Baseline. 
2 Collect vital signs: temperature, respiration, blood pressure and heart rate at Baseline, pre-dose and at post-dose per unit’s nursing schedule. Weight must be obtained at baseline to verify 
eligibility (required weight > 50 kg) 
3 Blood for clinical laboratory tests and urine for urinalysis. See 5.2.2 for a list of clinical laboratory tests. 
4 Pregnancy test is required in female subjects with childbearing potential within 7 days prior to starting administration of study drug 
5 Quantitative Muscle Strength at Baseline and follow up visits  
6 Other Rehab measures include MMT-28, AMAT, 6 Min walk (or 10 meter run), timed up-go test, forward/ functional reach test will be performed at baseline and every follow-up visit. Jebsen 
hand test to be performed only at baseline, 12, and 24 months. 
7 Muscle biopsy at Baseline and at 3 months 
8 Collect blood for PK analysis. See Appendix D  
9 Collect blood for PD.  See Appendix D. 
10 Patient-Reported Outcomes to include Global Rate of Change, HAP, IBMFRS, PROMIS and ABC scale. 
11 Performed at NIH clinical center, or home physician office or local lab; only safety blood draws to be performed. 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
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54 
APPENDIX D. BLOOD/URINE SAMPLING SCHEDULE   
Baseline and Pharmacokinetic Phase 
Sample 
Timepoints 
Sample 
Blood 
Volume 
(mL) 
Lab 
Baseline 
PK Phase 
Safety 
Phase 
Day 1 
(hours post-dose) 
Day 
2-6 
Day 7 
(hours after last dose) 
Day  
8-10 
 
Pre2 
0.5 
1 
2 
3 
4 
6 
8 
10 
122 
Pre2 
Pre2 
0.5 
1 
2 
3 
4 
6 
8 
10 
12 
 
 
 
 
Blood 
PK1 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Blood 
3 
Alliance 
Clinical 
labs3 
X 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
X 
Blood/ 
Urine 
14.5 
NIH 
DLM 
PD4 
X 
 
 
 
 
 
 
X 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
X 
Blood 
20 
Alliance 
Research 
labs5 
X 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
X 
Blood/ 
Urine 
10-30 
Gahl/ 
TRND 
Urine 
PK6 
 
X 
 
X 
 
X 
 
X 
 
 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
1Blood for plasma PK analysis will be collected on Day 1 at pre-dose and at 0.5, 1, 2, 3, 4, 6, 8, 10, 12 hours after the first administration of study drug. Note that 12-hour timepoint should be 
collected immediately before administering the evening dose of study drug (trough level).  
On Days 2-6 (weekdays only), samples will be collected immediately before administering the morning dose of the study drug.  
On Day 7, blood will be collected before the morning dose and at 0.5, 1, 2, 3, 4, 6, 8, 10 and 12 hours after morning administration of study drug. Note that 12-hour timepoint should be collected 
immediately before administering the evening dose of study drug (trough level) (Section 5.2.3) 
2Collection of trough blood samples (immediately before drug administration). 
3Clinical laboratory test will be collected to perform safety evaluation at baseline, on Day 2, 5 and 8 (±1). Subjects in Cohort A will have an additional test on Day 10 (±1). Clinical laboratory tests 
will include CBC with differential, platelet count, reticulocyte count, ESR, C-reactive protein, PT, and PTT, acute care panel (sodium, potassium, chloride, carbon dioxide, glucose, creatinine, 
blood urea nitrogen (BUN)), mineral panel (albumin, calcium, magnesium, phosphorus), hepatic panel (alkaline phosphatase, alanine aminotransferase (ALT), aspartate aminotransferase (AST), 
direct bilirubin), GGT, lipid panel, creatine kinase, and cystatin-C, urinalysis, and pregnancy test (Section 5.2.2) 
4Blood for PD to include plasma and white blood cell pellets and will be collected at baseline, on Day 1 at pre-dose and at 6, 10 and 12 hours after administration of the first dose, and on Day 3 (±1) 
and Day 7. Subjects in Cohort A will have an additional test on Day 9 (±1).  
5Research labs to include DNA/RNA, blood plasma, serum, red blood cells, and urine (first morning void) will be collected at baseline and on Day 3 (±2) and Day 7. Subjects in Cohort A will have 
an additional test on Day 9 (±1) (Section 5.3.2). 
6 Collect urine on Day 1 at Pre-dose (first morning void), 0-1 h, 1-3h, 3-6h, 6-12h and 12-24h. On Days 2-7 (weekdays only) collect first morning void. 
Blood volume collected shall not exceed 10.5 mL/kg or 550 mL whichever is smaller, over any eight-week period. 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
55 
 
Safety/Efficacy Phase and Final Pharmacokinetic Phase 
Sampl
e 
Timepoints 
Sample 
Blood 
Volume (mL) 
Lab 
Safety/Efficac
y Phase 
Terminal PK  
Safety/Efficacy Phase 
 
 
 
Day 
45  
(±5 
days
) 
Day 85  
(±5 
days) 
Day 90 (-5 days) 
Day 
180  
(±5 
days) 
Day 
365 
(±5 
days) 
Day 
450 
(±30 
days) 
Day 
548, 
730 
(±30 
days) 
Day 
638, 
820 
(±30 
days) 
Day 
912 
(±30 
days) 
 
 
 
 
 
Pre2 
0.
5 
1 
2 
3 
4 
6 
8 
1
0 
1
2 
2
4 
4
8 
7
2 
 
 
 
 
 
 
 
 
 
Blood 
PK1 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
Blood 
3 
Alliance 
Clinical 
labs3 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
X 
X 
X 
X 
X 
X 
Blood/ 
Urine 
14.5 
Various 
Researc
h labs4 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
X 
X 
 
X 
 
 
Blood/ 
Urine 
10-30 
Gahl 
PD5 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
X 
 
X 
X 
 
X 
 
 
Blood 
20 
Various 
1Blood for plasma PK analysis will be collected on Day 45, 85, 180, 365, 548 and 730 (±5 days) immediately before administering the morning dose of the study drug (though levels).  On Day 
90 (-5 days), blood will be collected for terminal PK at pre-dose and at 0.5, 1, 2, 3, 4, 6, 8, 10, 12, 24, 48 and 72 hours after administration of study drug. Drug will be withheld for 72 hours 
(Section 5.2.3). On Day 912, PK will be collected at 2, 4, 6, 8, 24 and 48 hours after the first study drug administration on TID dosing. Plasma will be collected right before ManNAc dose 
(trough) at the 8, 24 and 48 hour timepoints. Patient will avoid ingestion of ManNAc for 5-7 days prior to pre-dose PK draw on TID dosing. 
2Collection of trough blood samples (immediately before drug administration) 
3Clinical laboratory evaluations will be collected at baseline and on Days 45, 85, 90, 180 , 365, 548, 730, 820, 912 (±5 days), and 24-48 hours after last administration of study drug and will 
include CBC with differential, platelet count, reticulocyte count, ESR, C-reactive protein, PT, and PTT, acute care panel (sodium, potassium, chloride, carbon dioxide, glucose, creatinine, 
blood urea nitrogen (BUN), mineral panel (albumin, calcium, magnesium, phosphorus), hepatic panel (alkaline phosphatase, alanine aminotransferase (ALT), aspartate aminotransferase 
(AST), direct bilirubin), lipid panel, creatine kinase, and cystatin-C, urinalysis, and pregnancy test (Section 5.2.2). Day 450 and 638 will include all clinical labs except pregnancy test and lipid 
profile. 
4Research labs to include plasma, serum, red blood cells, and urine (first morning void) and will be collected on Days 45, 85, 180, 365, 548, 730 (±5 days), and 48 hours during terminal PK 
evaluation. (See Section 5.3.2).  
5 Blood for PD will be collected on Days 45, 85, 90, 180 and 365 and 548, 730 and 912  (±5 days), and post-48 hours during terminal PK evaluation.  
Blood volume collected shall not exceed 10.5 mL/kg or 550 mL whichever is smaller, over any eight-week period. 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
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56 
APPENDIX E. INVESTIGATIONAL AGENT(S) INFORMATION FOR 
PHARMACY 
 
Investigational Agent 
 
Active compound: ManNAc/ManNAc  
(N-acetyl-D-mannosamine monohydrate; ManNAc) 
Storage requirements:  
Store refrigerated at 2 to 8°C. 
Stability:  
Shelf life of 5 years when ManNAc powder is stored at 2 
to 8°C. 
Inpatient Administration 
Product description:  
 
ManNAc will be provided as powder-in-bottle at doses of 
3,000 mg, 4,000 mg and 6,000 mg. 
Solution preparation: 
 
ManNAc will be reconstituted as follows: 
Add 200 mL of sterile water for irrigation 
Shake to dissolve the drug 
Re-label the bottles appropriately for delivery to the 
subjects. 
Route of administration:  
ManNAc will be administered as a liquid for ORAL 
administration.  
Subjects will drink the dose directly from the prescription 
bottle. 
After ingestion, the bottle will be rinsed with 100 mL 
water for irrigation that will also be ingested by the 
subjects. 
Attach an appropriate investigational label including the 
Food and Drug Administration (FDA) caution statement 
"New drug- Limited by Federal Law to Investigational 
Use." 
Self-Administration 
Product description:  
 
ManNAc will be provided as bulk powder in a canister 
(300 g/container) to be measured by subjects with 
calibrated Spatula Balance™. 
Self-administration: 
 
Measure ManNAc using a Spatula Balance™. Add exact 
amount to a glass of water. Stir to dissolve the drug and 
drink all contents immediately. Rinse glass with water, 
stir to dissolve leftover drug and drink all contents.  
 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
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57 
APPENDIX F. 90-DAY TOXICOLOGY STUDIES 
The doses to be investigated (3,000, 4,500 and 6,000 mg ManNAc twice daily for a total daily 
dose of 6,000, 9,000 and 12,000 mg, respectively) are based on the safety and PK data collected 
in NIH Study 12-HG-0207 (See Section 3.5.3). 
Effects on the gastrointestinal tract were the most prominent in the 90-day toxicology studies 
performed in rats and dogs, and included loose and discolored feces, mild liver enlargement and 
mucosal hypertrophy of the colon. Given these findings, the No Observed Adverse Effect Level 
NOAEL was determined to be 12,000 mg/kg/day in rats and 6,000 mg/kg/day in dogs as 
described in the table below. It was determined that the human equivalent dose (HED) is 1,714 
mg/kg/day, or approximately 12,000 mg/day for a 70 kg subject based on the NOAEL observed 
in rats, the most sensitive species, with a 10-fold safety factor.  
Findings on Toxicology studies: 90-Day Rat Study 
Doses 
(mg/kg/day) 
Type of 
Observation 
Dose 
(mg/kg/day) 
Findings and Comments 
Monitoring in 
Current protocol 
0, 400, 1200, 
4000, 12000 
Gastrointestinal 
effects 
>4,000* 
- Discolored feces (Days 63 and 77) 
- Minimal to mild mucosal hyperplasia in 
the cecum and/or colon in males and 
females at all doses  
Clinical Evaluation 
 
12,000 
- Discolored, loose feces (daily from Day 
42 to the end of dosing)  
 
Liver effect 
12,000 
- Mild increase in mean ALT in males 
(60.5 U/L) compared to controls (34.4 
U/L).   
- Increased liver weight in males at 4,000 
and 12,000 mg/kg/day  
- Minimal to mild hepatocellular 
hypertrophy in 6 of 10 males.   
Liver function tests 
 
Kidney effects 
12,000 
- Increased kidney weight in males and 
females.  
- Blood in the urine 6 of 10 males and 2 
of 10 females at 1, mpkd compared with 1 
of 10 males and no females in the control 
group at the end of the dosing period. 
- Turbid urine in 5 of 10 males and 2 of 
10 females. 
- No correlative kidney-related clinical 
chemistry or histopathological changes. 
Cystatin C 
Urinalysis 
Recovery: complete or trend towards recovery observed for all changes 
*Monitorable and reversible effects 
References: 90-day study in rats – IND 78091 vol08 11.2.4.3A 2012 06 27.pdf and 90-day study in rats 
bionalytical– IND 78091 vol09 11.2.4.3B 2012 06 27.pdf 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
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58 
 
Findings on 90-Day Dog Toxicology Study 
Doses 
(mg/kg/day) 
Type of Observation 
Dose 
(mg/kg/day) 
Findings and Comments 
Monitoring in 
current protocol 
0, 200, 600, 
2,000, 6,000 
GI effects 
600 
Loose discolored feces (Days 
21-70) 
 
2,000 
Loose discolored feces (Days 
11 onward)  
 
6,000 
Loose discolored feces almost 
daily for all males and females. 
 
Hematology 
>2,000* 
Minimally decreased mean 
RBC/HGB/HCT in females at 
2,000 mg/kg/day and in males 
and females at 
6,000 mg/kg/day.  
Complete blood 
count 
Liver effects 
>2,000* 
- Minimally reduced mean 
albumin concentrations 
- Mild diffuse vacuolations of 
panlobular hepatocytes  (all 
doses but at less severity) 
Serum albumin 
Liver function 
tests 
 
Kidney effects 
>,2000* 
Minimally elevated mean BUN. 
BUN 
*Monitorable and reversible effects 
References: 90-day study in dogs – IND 78091 vol11 11.2.4.6A 2012 06 27.pdf and 90-day study in dogs 
bioanalytical - IND 78091 vol 12 11.2.4.6B 2012 06 27.pdf 
 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
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59 
APPENDIX G. LONG-TERM TOXICOLOGY STUDIES 
Table 9. Summary table of findings from 26-Week Rat oral toxicity studies of ManNAc. 
Type of 
Observations 
Noteworthy Test Article-Related Observations 
Dose 
(mg/kg/day) 
Findings and Comments 
Mortality 
> 2,400 
2 females and one male from Gr-4 and one male from Gr-3 dose groups 
died prematurely during week 20-26 of treatment but there were no 
consistent or adverse macroscopic or microscopic abnormalities that were 
considered to have had a contributing factor to these deaths 
GI effects 
12,000 
Caecum distended at 26 weeks: 5 males and 2 females in Gr-4.  
Minimal mucosal hyperplasia 26 weeks:  13 males and 7 females in Gr-4.   
Liver effects 
12,000 
Alkaline phosphatase levels were slightly elevated (1.45X) at weeks 13 
and 26 in Gr-4, however they seem comparable to historical control 
range. No treatment-related liver weight abnormalities noticed.  
Minimal centrilobular hypertrophy was seen in 12 males and 10 females 
in Gr-4. 
Adrenal 
effects 
≥ 400 
Analysis of urine: Weeks 13 and 26 revealed test article-related effects 
(predominantly at 12000 mg/kg/dayGr-4) including abnormalities in 
urinary volume, slightly high specific gravity and slightly low total 
sodium (0.62X) and potassium (0.38X) in Weeks 13 and 26 in both sexes 
in Gr-4.  
Histopathological changes included minimal hypertrophy of the zona 
glomerulosa in 10 males and 6 females in Gr-4;,1 male and 3 females in 
Gr-3 and 1 male and 2 females in Gr-2. 
No treatment related adrenal weight changes noticed. 
Kidney effects 
≥ 2,400 
Slightly high plasma urea concentration (1.46X) in weeks 13 and 26 in 
Gr-4.  
A higher than control incidence of trace amounts of blood pigment were 
detected in the urine in Weeks 13 and 26 in males in Gr-4 and, to a lesser 
extent, in males at Gr-3, but this finding showed complete recovery.  
No correlative kidney-related histopathological changes. 
No treatment related kidney weight changes noticed. 
Dose Groups: Gr-1: 0 mg/kg TID, Gr-2: 133.3 mg/kg TID (400 mg/kg/day); Gr-3: 800 mg/kg TID (2,400 mg/kg/day), 
Gr-4: 4000 mg/kg TID (12,000 mg/kg/day). 
Recovery: complete or trend towards recovery observed for all changes. 
Abbreviations. TID: three times daily 
Reference: BEQ0005 Final Toxicology Report (09 Dec 14).pdf 
 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
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60 
 
 
Table 10. Summary table of findings from 39-Week Dog oral toxicity study of ManNAc 
Type of 
Observations 
Noteworthy Test Article-Related Observations 
Dose 
(mg/kg/day) 
Findings and Comments 
GI effects 
≥ 1,080 
Liquid feces for all males and females on Gr-4 and within the first 4 
weeks of treatment for a few animals on Gr-3. 
On Gr-4, the fecal disturbances occasionally consisted of mucoid or 
abnormal colored faces (red or green) during the early stages of the 
study. 
No correlative GI related histopathological changes noticed. 
Liver effects 
≥ 1,080 
Week 26 Males: Higher ALT (40-41 U/L, Gr 4 and 3), cholesterol 
(3.86 mmol/L, Gr 4) and triglyceride concentrations (0.42-0.44 
mmol/L, non-statistically higher in Gr 3 and 4). 
Week 39 Males: Higher ALT (42 U/L, Gr 4), cholesterol (3.86 
mmol/L, Gr 4) and Triglycerides (0.41 mol/L, non-statistically 
higher in Gr 4). 
No accompanying liver histopathology changes noticed. 
No treatment-related liver weight changes noticed. 
Kidney effects 
4,500 
Urinalysis : Wk 13- three females in Gr 4 with higher proteins and 
urinary blood.  
Histopath changes, Wk 40: one Gr 4 female with Kidney Infiltration, 
Inflammatory Cells, Interstitial, minimal; one Gr 3 female with 
urinary bladder mineralization.  
No treatment related kidney weight changes noticed. 
Dose Groups: Gr-1: 0 mg/kg TID, Gr-2: 60 mg/kg TID (180 mg/kg/day); Gr-3: 365 mg/kg TID (1,080 
mg/kg/day), Gr-4: 1,500 mg/kg TID (4,500 mg/kg/day). 
Recovery: complete or trend towards recovery observed for all changes. 
Abbreviations. TID: three times daily 
Reference: BEQ0001 Final Report 17 Oct 2014.pdf 
 

15-HG-0068: Open-Label Phase 2 Study of ManNAc in Subjects with GNE Myopathy  
December 7, 2017 
 
61 
APPENDIX H. SIGNATURE OF INVESTIGATOR 
 
Title:  
An Open-Label Phase 2 Study to Evaluate the Pharmacokinetics, Safety 
and Efficacy of ManNAc in Subjects with GNE Myopathy 
Protocol number:  
15-HG-0068 
Date:  
 
December 7, 2017 
 
By signing this page I attest that I have read and understand the contents of Clinical Protocol 
15-HG-0068 and any subsequent amendments. I agree to adhere to the design, conduct, and 
reporting requirements of the study as stated in the clinical protocol and to my obligations to the 
Sponsor as described in the protocol and executed contracts between myself, my Institution, and 
the Sponsor. 
 
Investigator's Signature:  
_____________________________________________ 
 
Investigator's Name:  
_____________________________________________ 
 
Institution:  
 
 
_____________________________________________ 
 
Date:  
 
 
_____________________________________________