A Randomized, Double-blind, Two Treatment, Two Period, Chronic Dosing (4 Weeks), Crossover, Multi-center Pilot Study to Evaluate the Effects of Budesonide/Glycopyrronium/Formoterol Fumarate and Glycopyrronium/Formoterol Fumarate on Specific Image Based Airway Volumes and Resistance in Subjects With Moderate to Severe COPD
Phase: PHASE3
Conditions: Chronic Obstructive Pulmonary Disease (COPD)
Sponsor: AstraZeneca

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Clinical Study Protocol 
Drug Substance
Budesonide/Glycopyrronium/Formote
rol Fumarate (BGF)
Study Code
D5980C00019
Version
3.0
Date
05 July 2019
A Randomized, Double-blind, Two Treatment, Two Period, 
Chronic dosing (4 weeks), Cross-over, Multi-center Pilot study to 
evaluate the effects of Budesonide/Glycopyrronium/Formoterol 
Fumarate and Glycopyrronium/Formoterol Fumarate on Specific 
Image based Airway Volumes and Resistance in Subjects with 
Moderate to Severe Chronic Obstructive Pulmonary Disease
Sponsor: AstraZeneca AB, 151 85 Södertälje, Sweden
Regulatory Agency Identifying Number(s):
IND Number: 118313
EudraCT Number: 2018-001704-10

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VERSION HISTORY
Version 3.0, 05 July 2019 -Protocol Amendment 02
Section 1.1 Schedule of Assessments (SoA):

Moved and revised footnote “n” from “Adverse Event” to “Demography and 
Medical/Surgical History” since COPD exacerbation history will be collected as 
respiratory disease history per revised footnote. 
Updated footnote “f” and added separate row to clarify Visit 1 through Visit 3 
prohibited medication washouts and use of maintenance and rescue medications per 
Table 6, and Section 6.2.2.2.
Section 1.2 Synopsis and Section 3 Objectives and Endpoints: 

Objectives and Endpoints: secondary endpoint variable updated to include the 
timepoint for “Forced expiratory volume in one second (Post-dose FEV1)", so as to 
clarify whether the pre-dose or post-dose FEV1 was to be used as the secondary 
endpoint
Section 6.2.2.2 Atrovent HFA (Ipratropium Bromide) and Section 8.1.7 Subject Diary Data 
Collection:

Added the following text to Section 6.2.2.2 to clarify Atrovent dispensation and start 
date, “Atrovent is expected to be dispensed at Visit 1; the first dose should be taken 
in the morning of Visit 2, before the visit procedures will be performed.”

Added “starting at Visit 2” to Section 8.1.7 to ensure collection of Atrovent HFA 
four times daily in diary
Section 6.5.1 Prohibited COPD Medications: 

add clarification regarding the discontinuation of all prohibited medications as noted 
in this section and specifications on the start of Atrovent and rescue medication at 
visit 2 to align with section 6.2.2.2.
Section 7.4 Study and Site Closure: 

Additional information for the study and site closure has been added. The rationale 
for this change is to specify the conditions for closure of sites during and after study 
completion

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Section 8.1.5 Inhalation Profile with Body Plethysmography:

Title revised to “Inhalation Profile” to align with the Fluidda Manual   
Section 8.1.11 COPD Exacerbations: 

section has been revised to record those exacerbations that are required for safety 
reporting
Section 8.1.2.2 Stability Criteria:

Clarified wording based on Section 8.1.2 revisions for pre-dose spirometry 
timepoints at Visit 3 and Visit 5.
Section 8.3.2 Time Period and Frequency for collecting AE and SAE information

Collection of SAE time period included
Appendix D Actions required in cases of increases in liver biochemistry and evaluation of 
Hy’s law:

The appendix has been updated including addition of section E6 in conjunction with 
sponsor's routine pharmacovigilance activities/processes.
Other administrative changes to correct and/or clarify protocol language were also 
addressed. These changes included edits for consistency, grammar, and typographical 
errors, which are not summarized in this table
Version 2.0, 26 October 2018-Protocol Amendment 01
Section 1.1 and 8.1.1: HRCT scans revised to include 7 scans -2 predose (TLC(PRE) and 
FRC(PRE)) at Visit 3 and 2 post dose (TLC(POST) and FRC(POST)) at the end of each treatment 
period. During visit 3 an additional scan of the upper airway (UA) will be taken. 
Section 9.1 (Statistical hypotheses): The section was updated to provide additional detail 
and clarity regarding the statistical hypotheses for the two primary endpoints of this study.
Section 9.2 (Sample size determination): The section was updated to provide an indication 
of the effect size which could be detected with the 20 planned subjects.
Section 9.3 (Populations for analyses): The terminology for two of the listed populations 
was updated to be aligned with terminology used in the previous FRI studies. The “Full 
analysis set” was changed to the “Intent-to-Treat (ITT) analysis set” and the “Evaluable 

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analysis set” was changed to the “Modified Intent-to-Treat (mITT) analysis set”. Also 
clarified the definition for the mITT analysis set and included how the various analysis sets 
would be utilized to summarize the data.
Section 9.4.1 (General principles): Section was added for clarity.
Section 9.4.2 (Efficacy analyses): The section was updated to provide additional detail and 
clarity regarding the planned efficacy analyses. In addition, the methodology has been 
updated to reflect the change in collection of the HRCT scans for the efficacy endpoints.
Section 9.4.4 (Methods for multiplicity control): Section added to clarify how the analysis 
of the two primary endpoints for this study would be addressed.
Version 1.0, 26 June 2018 -Original Protocol
This Clinical Study Protocol has been subject to a peer review according to AstraZeneca 
Standard procedures. The Clinical Study Protocol is publicly registered and the results are 
disclosed and/or published according to the AstraZeneca Global Policy on Bioethics and in 
compliance with prevailing laws and regulations.

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TABLE OF CONTENTS
TITLE PAGE........................................................................................................................ 1
VERSION HISTORY........................................................................................................... 2
TABLE OF CONTENTS...................................................................................................... 5
1
PROTOCOL SUMMARY.................................................................................. 9
1.1
Schedule of Activities (SoA)............................................................................... 9
1.2
Synopsis ........................................................................................................... 13
1.3
Schema............................................................................................................. 17
2
INTRODUCTION............................................................................................ 19
2.1
Study rationale.................................................................................................. 19
2.2
Background ...................................................................................................... 19
2.3
Benefit/risk assessment..................................................................................... 20
3
OBJECTIVES AND ENDPOINTS................................................................... 20
4
STUDY DESIGN ............................................................................................. 22
4.1
Overall design................................................................................................... 22
4.2
Scientific rationale for study design .................................................................. 22
4.3
Justification for dose......................................................................................... 22
4.4
End of study definition...................................................................................... 22
5
STUDY POPULATION ................................................................................... 23
5.1
Inclusion criteria............................................................................................... 23
5.2
Exclusion criteria.............................................................................................. 25
5.3
Lifestyle restrictions ......................................................................................... 29
5.3.1
Meals and dietary restrictions............................................................................ 29
5.3.2
Illicit Drug and or Drugs of Abuse.................................................................... 29
5.3.3
Smoking Status................................................................................................. 29
5.4
Screen failures .................................................................................................. 30
6
STUDY TREATMENTS.................................................................................. 31
6.1
Treatments administered................................................................................... 31
6.1.1
Investigational products.................................................................................... 31
6.1.2
Medical devices................................................................................................ 32
6.1.3
Primary Packaging and Labelling Information .................................................. 32
6.1.4
Secondary Packaging and Labelling Information (Box) .................................... 33
6.2
Preparation/handling/storage/accountability...................................................... 33
6.2.1
Storage Requirements....................................................................................... 34
6.2.2
Instructions for Preparation of Treatments for Administration and Dispensing.. 34
6.2.2.1
BGF MDI and GFF MDI .................................................................................. 34
6.2.2.2
Atrovent HFA (Ipratropium Bromide)............................................................... 35
6.2.2.3
Ventolin HFA (Albuterol Sulfate)..................................................................... 35

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6.2.2.4
Placebo MDI..................................................................................................... 35
6.2.3
Drug Accountability/Return of Clinical Supplies .............................................. 35
6.3
Measures to minimise bias: randomisation and blinding.................................... 36
6.4
Treatment compliance....................................................................................... 36
6.5
Concomitant therapy......................................................................................... 37
6.5.1
Prohibited COPD Medications.......................................................................... 37
6.5.2
Other concomitant treatment............................................................................. 40
6.5.3
Rescue medication............................................................................................ 40
6.6
Dose modification............................................................................................. 40
6.7
Treatment after the end of the study.................................................................. 40
7
DISCONTINUATION OF TREATMENT AND SUBJECT WITHDRAWAL . 41
7.1
Discontinuation of study treatment.................................................................... 41
7.1.1
Procedures for discontinuation of study treatment............................................. 41
7.2
Lost to follow-up .............................................................................................. 41
7.3
Withdrawal from the study................................................................................ 42
7.4
Study and Site Closure...................................................................................... 42
8
STUDY ASSESSMENTS AND PROCEDURES ............................................. 43
8.1
Efficacy assessments......................................................................................... 44
8.1.1
HRCT scans...................................................................................................... 44
8.1.2
Spirometry........................................................................................................ 44
8.1.2.1
Characterization of Reversibility....................................................................... 45
8.1.2.2
Stability Criteria ............................................................................................... 45
8.1.2.3
Inspiratory Capacity.......................................................................................... 46
8.1.2.4
Standardization of IC and Spirometry Collections............................................. 46
8.1.3
Body plethysmography ..................................................................................... 46
8.1.4
Diffusion capacity............................................................................................. 47
8.1.5
Inhalation Profile .............................................................................................. 47
8.1.6
Inhalation Profile during administration............................................................ 47
8.1.7
Subject Diary Data Collection........................................................................... 47
8.1.8
Rescue Ventolin HFA Use................................................................................ 48
8.1.9
Recording of Dose Indicator Reading ............................................................... 48
8.1.10
Subject Questionnaires...................................................................................... 49
8.1.10.1
COPD Assessment Test .................................................................................... 49
8.1.10.2
Modified Medical Research Council Dyspnea Scale ......................................... 49
8.1.11
COPD Exacerbations ........................................................................................ 50
8.2
Safety assessments............................................................................................ 50
8.2.1
Clinical safety laboratory assessments............................................................... 50
8.2.2
Medical/Surgical History and Physical Examination......................................... 51
8.2.3
Vital Sign Measurements.................................................................................. 52
8.2.4
Electrocardiograms........................................................................................... 52
8.3
Collection of adverse events ............................................................................. 52
8.3.1
Method of detecting AEs and SAEs .................................................................. 52
8.3.2
Time period and frequency for collecting AE and SAE information.................. 53

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8.3.3
Follow-up of AEs and SAEs ............................................................................. 53
8.3.4
Adverse event data collection............................................................................ 53
8.3.5
Causality collection........................................................................................... 54
8.3.6
Adverse events based on signs and symptoms................................................... 54
8.3.7
Adverse events based on examinations and tests ............................................... 55
8.3.8
Hy’s law ........................................................................................................... 55
8.3.9
Disease-under study (DUS)............................................................................... 55
8.4
Safety reporting and medical management........................................................ 55
8.4.1
Reporting of serious adverse events .................................................................. 55
8.4.2
Pregnancy......................................................................................................... 56
8.4.2.1
Maternal exposure ............................................................................................ 57
8.4.2.2
Paternal exposure.............................................................................................. 57
8.4.3
Overdose .......................................................................................................... 57
8.4.4
Medical device incidents (including malfunctions)............................................ 58
8.4.4.1
Time period for detecting medical device incidents........................................... 58
8.4.4.2
Follow-up of medical device incidents.............................................................. 58
8.4.4.3
Reporting of medical device incidents to sponsor.............................................. 59
8.4.4.4
Regulatory reporting requirements for medical device incidents........................ 59
8.4.5
Medication error ............................................................................................... 59
8.5
Pharmacokinetics.............................................................................................. 59
8.6
Pharmacodynamics........................................................................................... 59
8.7
Genetics............................................................................................................ 59
8.8
Biomarkers ....................................................................................................... 59
8.9
Medical Resource Utilization and Health Economics........................................ 60
9
STATISTICAL CONSIDERATIONS............................................................... 61
9.1
Statistical hypotheses........................................................................................ 61
9.2
Sample size determination ................................................................................ 61
9.3
Populations for analyses.................................................................................... 61
9.4
Statistical analyses............................................................................................ 62
9.4.1
General principles............................................................................................. 62
9.4.2
Efficacy analyses .............................................................................................. 62
9.4.3
Safety analyses ................................................................................................. 63
9.4.4
Methods for multiplicity control ....................................................................... 63
9.5
Interim analyses................................................................................................ 63
10
REFERENCES................................................................................................. 64
11
SUPPORTING DOCUMENTATION AND OPERATIONAL 
CONSIDERATIONS........................................................................................ 65
REFERENCES ................................................................................................................... 79

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LIST OF TABLES
Table 1
Study Assessments .................................................................................... 9
Table 2
Study Medication and Products................................................................ 16
Table 3
Study objectives....................................................................................... 20
Table 4
Investigational Products........................................................................... 31
Table 5
Description of Boxes ............................................................................... 33
Table 6
Prohibited COPD Medications and Required Washout Periods Prior to 
Visit 1 and Visit 3.................................................................................... 38
Table 7
Other Respiratory/Nasal Medications: Required Washout Periods ........... 39
Table 8
Rescue medication................................................................................... 40
Table 9
MMRC Dyspnea Scale ............................................................................ 50
Table 10
Laboratory safety variables...................................................................... 51
LIST OF FIGURES
Figure 1
Study design............................................................................................ 18
LIST OF APPENDICES
Appendix A
Regulatory, ethical and study oversight considerations............................. 65
Appendix B
Adverse event definitions and additional safety information .................... 69
Appendix C
Handling of Human Biological Samples .................................................. 73
Appendix D
Actions required in cases of increases in liver biochemistry and 
evaluation of Hy’s Law............................................................................ 75
Appendix E
Medical device incidents: definition and procedures for recording, 
evaluating, follow-up, and reporting ........................................................ 80
Appendix F
Abbreviations .......................................................................................... 82

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1
PROTOCOL SUMMARY
1.1
Schedule of Activities (SoA)
Table 1
Study Assessments
Screening 
Treatment Period 1 k
Treatment Period 2 k
Follow-up
Visit
1
2
3k
Telephone 
Callq
4 k
5 k
Telephone 
Callq
6 k
Discontinuation
Telephone 
Call
UNS
Details in CSP 
section or 
Appendix
Day
-21
-14 or -7a
1 a
28
29
53
79
80
87-90
N/A
Visit window
±3
-3
0
±3
±3
±3
±3
±3
N/A
Informed consent 
X
Section 5.1
Review of Inclusion 
/Exclusion criteria
X
X
X
Section 5.1 and 5.2
Chest X-raye
X
Section 5.1 and 5.2
Routine Safety Measurements 
Demography and 
Medical/Surgical 
Historyn
X
Section 8.2.2
Physical 
examinationd
X
X
Section 8.2.2
Vital signs
X
X
X
X
X
Section 8.2.3
Smoking Status 
X
X
X
X
X
X
X
X
X
Section 5.3.3
Prior/Concomitant 
medicationb
X
X
X
X
X
X
X
X
X
Section 6.5
COPD Washout 
Medicationsf
X
X
X
X
Section 6.5.1
COPD Maintenance 
medicationsf
X
X
X
X
X
X
X
Adverse events
X
X
X
X
X
X
X
X
X
X
Section 8.3
12-lead ECG 
X

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Screening 
Treatment Period 1 k
Treatment Period 2 k
Follow-up
Visit
1
2
3k
Telephone 
Callq
4 k
5 k
Telephone 
Callq
6 k
Discontinuation
Telephone 
Call
UNS
Details in CSP 
section or 
Appendix
Day
-21
-14 or -7a
1 a
28
29
53
79
80
87-90
N/A
Visit window
±3
-3
0
±3
±3
±3
±3
±3
N/A
Pregnancy testm
X
X
X
X
Section 8.4.2
Clinical Laboratory 
Testing 
X
Section 8.2.1
Efficacy Assessments 
Recording of 
Inhalation Profile 
with Respiration 
Beltl
X
X
Section 8.1.5
HRCT scano
X
X
X
Section 8.1.1
Spirometryc
X
X
X
X
X
X
Section 8.1.2
Reversibility
X
Section 8.1.2.1
COPD Assessment 
Test (CAT)
X
Section 8.1.10.1
MMRC
X 
Section 8.1.10.2
Diffusion Capacity
X
Section 8.1.4
Body 
Plethysmography
X
X
X
X
Section 8.1.3
Study Treatment Administration 
Randomisation
X
Section 6.3
Study Drug 
Dispensing/Collectio
nh
X
X
X
X
X
Section 6
Study Drug 
Administrationi
X
X
X
X
Section 6.1

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Screening 
Treatment Period 1 k
Treatment Period 2 k
Follow-up
Visit
1
2
3k
Telephone 
Callq
4 k
5 k
Telephone 
Callq
6 k
Discontinuation
Telephone 
Call
UNS
Details in CSP 
section or 
Appendix
Day
-21
-14 or -7a
1 a
28
29
53
79
80
87-90
N/A
Visit window
±3
-3
0
±3
±3
±3
±3
±3
N/A
Review/Record 
Study Drug Dose 
Indicator Readingj
X
X
X
X
Section 8.1.9
Review/Record 
Ventolin Dose 
Indicator Reading
X
X
X
X
X
X
Section 8.1.8
Inhalation Device 
Trainingg
X
Section 6.2
Inhalation Profile
X
X
Section 8.8
Diary Training
X
X
Section 8.1.7
Compliance Diary 
X
X
X
X
X
Section 8.1.7
Review of Diary
Xp
X
X
X
Section 8.1.7
Telephone Contact 
X
X
X
Abbreviations: CAT=COPD assessment test; MMRC= Modified Medical Research Council; ECG=electrocardiogram; COPD=Chronic obstructive pulmonary 
disease; HRCT=High-resolution computed tomography; ICS=inhaled corticosteroids; MDI=metered dose inhaler; FRC= functional residual capacity; 
TLC=total lung capacity; UNS=unscheduled visit
a
Scheduling visits: If subject is on a BID COPD maintenance medication(s) return in ~7 days (day -14) and QD COPD maintenance medication(s) return in 
~14 days (day -7). 
b
At all visits beyond Visit 2 (Screening), note the time of last dose of COPD medications, including rescue medication (if <6 hours, visit should be 
rescheduled)
c
Refer to Section 8.1.2 for spirometry assessments and specific timepoints to be performed at each treatment visit.
d
Includes evaluation of height and weight at Visit 1.
e
Obtain a new chest x-ray if the chest x-ray or CT scan performed within 6 months of Visit 1 (Screening) is not available.

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f
After informed consent is obtained, COPD maintenance and rescue medications will be withheld 6 hours before study visits. Prohibited COPD medications 
will be stopped prior to Visit 1 for ICS and ICS/LABA containing medications and all other prohibited medications will be stopped prior to Visit 3 per 
Table 6 to be able to start study provided Atrovent HFA QID at Visit 2 as COPD maintenance medication per protocol section 6.2.2.2. At the end of Visit 6, 
return subject to pre-study or other appropriate inhaled maintenance COPD medications. Additionally, check and instruct on inclusion criteria #8 for no ICS 
use and exclusion criteria #3m, #3n and #10 through #15 for prohibited medications. 
g
Site should use the sponsor provided placebo MDI to train subjects on the use of MDIs. Additional inhalation training tools (e.g. AIM device) may be used 
to help ensure the subjects are able to use the MDI device correctly
h
Sponsor provided Atrovent HFA or Ventolin HFA should be dispensed only after a subject is determined to be eligible to proceed to Visit 3 (Day 1) (i.e., 
only if a subject meets the definition of COPD following spirometry assessments at Screening).
i
In-clinic dosing time is recorded as time of the second puff/inhalation.
j
Refer to Section 8.1.9 for details and instructions on recording dose indicator readings.
k
Visit windows during each Treatment Period are relative to Day 1 of that Treatment Period. Washout period between Visit 4 and Visits 5 is a minimum of 
21 days to a maximum of 28 days.
l
The inhalation profile with the use of the respiration belt will be measured simultaneously with the drug administration.
m
Only in female of childbearing potential.
n
The number of COPD exacerbations requiring oral steroids and/or oral antibiotics, or hospitalization within 12 months of Visit 1 (Screening) will be 
collected as respiratory disease history.
o
At Visit 3 two breathing levels: TLC(PRE) and FRC(PRE). During Visit 3 an additional scan of the UA will be taken. At Visit 4 (post dose) and 6 (post dose) 
two breathing level: TLC(POST) and FRC(POST).
p
Subjects who are unable to meet the compliance requirement (>70% subject completion of diary assessments) in the last 7 days preceding the 
Randomization Visit (Visit 3) must be retrained. When retraining is required due to noncompliance the Randomization Visit (Visit 3) must be rescheduled.
q
Prior to Visit 4 and Visit 6 site staff should call the subject to remind them to take the last dose of study medication the day before their following visit. 

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1.2
Synopsis
Protocol Title:
A randomized, double-blind, two treatment, two period, chronic dosing (4 weeks), cross-over, 
multi-center study to evaluate the effects of Budesonide/Glycopyrronium/Formoterol 
Fumarate (BGF) and Glycopyrronium/Formoterol Fumarate (GFF) on specific image based 
airway volumes and resistance in subjects with moderate to severe Chronic Obstructive 
Pulmonary Disease (D5980C00019)
Short Title: Phase IIIB mechanistic study using FRI
Rationale: 
This imaging methodology will allow an assessment of the extent of airway changes using a 
triple combination of BGF and the dual combination GFF. Previous studies demonstrated that 
looking directly at airway volumes and resistance is a more sensitive measure than FEV1 to 
evaluate the acute bronchodilating effect of inhaled LABA and/or LAMA (De Backer et al 
2011; De Backer et al 2012; Vos et al 2013).
The study hypothesis states that ICS may change airway caliber via its effect on airway 
inflammation, edema, and secretions. ICS may also enhance the LABA/LAMA effect and 
could create beneficial synergies leading to a better regional exposure, a larger 
bronchodilation, and a reduced inflammation in more peripheral lung regions.
It is believed that the additional effect of ICS on top of LABA/LAMA will reduce 
hyperinflation and air trapping, resulting in lower lung and lobar volumes. At the same time, 
the specific airway volume (i.e. airway volumes that are corrected for lung volumes) are 
expected to increase. The primary goal of this study is to describe the effect on airway volume 
with the addition of ICS. This goal builds on the results of a lung function study (KRONOS), 
where we studied the effect on FEV1 when ICS was added to LAMA/LABA and was recently 
published [Ferguson, 2018]. As illustrated in Figure 2 of this publication, the addition of 
budesonide to glycopyrrolate/formoterol, resulted in clinically meaningful improvements of 
trough FEV1, and of FEV1 AUC 0-4 hours post-dose, in COPD patients. 
However, while FEV1 is a well-established lung function parameter, it is still rather crude and 
does not make a good representation of the function of smaller airways. Thus, the purpose of 
the present study is to further characterize the lung function benefit by a more sensitive 
method. FRI is a well-established method to achieve a more regional characterization of the 
respiratory system. By simultaneously looking at the airway resistance and internal airflow 
distribution, functional respiratory imaging will be able to infer physiological changes in the 
peripheral lung regions.
.

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Objectives and Endpoints
Primary objective:
Endpoint/variable:
To assess the effects of BGF and GFF on 
specific image-based airway volumes and 
resistance in subjects with moderate to severe 
COPD following chronic twice-daily (BID) 
dosing after approximately four weeks of 
treatment

Specific airway volume (siVaw) 

Specific airway resistance (siRaw)
Secondary objective:
Endpoint/variable:
To assess the effects of BGF and GFF on 
various Functional Respiratory Imaging (FRI) 
parameters

Airway volume (iVaw)

Airway resistance (iRaw)
To assess the effects of BGF and GFF on lung 
function parameters
Forced expiratory volume in one second (Post-
dose FEV1)
To assess the effects of BGF and GFF on body 
plethysmography parameters
Functional Residual Capacity (FRC)
Safety objective:
Endpoint/variable:
To assess the safety of BGF and GFF
Adverse events (AEs), serious adverse events 
(SAEs), adverse events leading to treatment 
discontinuation (DAEs)
Exploratory
Endpoint/variable:
To assess the effects of BGF and GFF on other 
FRI parameters

Lobe volumes (iVlobes) 

Air Trapping (AT)

Internal lobar airflow distribution (IAD)

Low attenuation or emphysema score (LAS)

Blood Vessel density or fibrosis score (iVby)

Airway Wall Thickness (iVaww)

Mass of deposited particles per defined 
airway section
To assess the effects of BGF and GFF on other 
lung function parameters

Forced vital capacity (FVC)

Tiffeneau index (FEV1/FVC ratio)

Forced expiratory flow 25%-75% (FEF25-75)

Inspiratory capacity (IC)

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Objectives and Endpoints
To assess the effects of BGF and GFF on other 
body plethysmography parameters

Residual volume (RV)

Total Lung Capacity (TLC)

Airway resistance (Raw)

Specific airway resistance (sRaw)

Specific airway conductance (sGaw)
Overall design:
This is a phase IIIb randomised, controlled, two period cross-over, 4 weeks chronic dosing, 
study to evaluate the effects of Budesonide/Glycopyrronium/Formoterol Fumarate 
(BGF), 320/14.4/9.6 µg (160/7.2/4.8 µg per actuation), MDI 2 oral inhalations BID, morning* 
and evening and Glycopyrronium/Formoterol Fumarate (GFF), 14.4/9.6 µg (7.2/4.8 µg per 
actuation), MDI 2 oral inhalations BID, morning* and evening on specific image based airway 
volumes and resistance in subjects with moderate to severe Chronic Obstructive Pulmonary 
Disease. In this study, airway dimension parameters will be calculated for each of the active 
compounds. 
Computed Tomography (CT)-scans during study: On Day 1 of Treatment Period 1(Visit 3) 
pre-dose baseline measurement inspiratory scans (total lung capacity [TLC(PRE)] scan) and 
expiratory scan (functional residual capacity [FRC(PRE)] scan) will be conducted. During Visit 
3 an additional scan of the upper airway (UA) will be taken. Post dose measurement 
inspiratory scan (total lung capacity [TLC(POST)] scan) and expiratory scan (functional residual 
capacity [FRC(POST)] scan) will be taken after approximately 4 weeks of each treatment with 
BGF MDI or GFF MDI on Day 29 ±3 days (Visit 4 and Visit 6). Post dose activities should be 
started 1 hour after dosing on Visit 4 and Visit 6 and should be concluded within 2.5 hours 
after dosing. Between the Treatment Periods there will be a washout period of approximately 
21-28 days with treatment of Atrovent HFA.
Study is planned to be conducted in one country, approximately three centres.
Study Period:
Estimated date of first patient enrolled 21 December 2018
Estimated date of last patient completed 17 September 2019
Number of Subjects:
A total of approximately 20 patients with moderate to severe COPD will be randomized in a 
1:1 scheme of BGF:GFF treatment sequences. 
Treatments and treatment duration: 
2 cross-over treatments of approximately 28 days each with:

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BGF: Budesonide/Glycopyrronium/Formoterol Fumarate, 320/14.4/9.6 µg (160/7.2/4.8 µg per 
actuation), MDI (current phase III device) 2 oral inhalations in the morning* and 2 oral 
inhalations in the evening.
GFF: Glycopyrronium/Formoterol Fumarate, 14.4/9.6 µg (7.2/4.8 µg per actuation), MDI 
(current phase III device) 2 oral inhalations in the morning* and 2 oral inhalations in the 
evening.
Each treatment will be separated by a washout period of approximately 21-28 days where 
treatment with Atrovent HFA will be administered.
*Dosing of IP in the clinic should be planned to occur at approximately the same time the 
patient prefers to administer IP in the mornings between the visits. The patient should then be 
advised that subsequent morning IP administration should happen at approximately this time, 
and that evening dosing should occur as close as possible to +12 hours from the morning time. 
It is recommended that dosing in the clinic occurs before approximately 10:00 AM. If it is 
unavoidable that IP administration in the clinic is at a later time of day than the patient 
normally administers IP at home (for example due to the travelling time to site), then patients 
should be strongly advised that on the day prior to the next clinic visit, the time of IP 
administration should be adjusted to be approximately 24 hours and 12 hours prior to the 
planned dosing at the clinic. Sites should make every effort to ensure that dosing in the clinic 
occurs as close as possible to 24 and 12 hours after the patient’s IP intake the previous day.
Table 2
Study Medication and Products
Product Name and 
Total Dose
Product Strength
Dose Form/Fill 
Count
Administration 
route
Blinded Study Medications
BGF MDI 320/14.4/9.6 µg 
ex-actuator
BGF MDI 160/7.2/4.8 µg 
per actuation
1 MDI
120 inhalations
Taken BID as two oral 
inhalations in the 
morning and two oral 
inhalations in the evening
GFF MDI 14.4/9.6 µg ex-
actuator
GFF MDI 7.2/4.8 µg per 
actuation
1 MDI
120 inhalations
Taken BID as two oral 
inhalations in the 
morning and two oral 
inhalations in the evening
Open-label Products
Ventolin (albuterol sulfate) 
HFA inhalation aerosol
90 µg ex-actuator
Ventolin (albuterol sulfate) 
HFA inhalation aerosol will 
be the supplied product
Each inhalation contains 
108 μg corresponding to 
90 µg albuterol base per 
actuation
1 MDI
60 or 200 actuations
Taken as needed (PRN)

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Figure 1
Study design
R Randomisation; TC Telephone contact

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2
INTRODUCTION
2.1
Study rationale
This imaging methodology will allow an assessment of the extent of airway changes using a 
triple combination of BGF and the dual combination GFF. Previous studies demonstrated that 
looking directly at airway volumes and resistance is a more sensitive measure than FEV1 to 
evaluate the acute bronchodilating effect of inhaled LABA and/or LAMA (De Backer et al 
2011; De Backer et al 2012; Vos et al 2013).
The study hypothesis states that ICS may change airway caliber via its effect on airway 
inflammation, edema, and secretions. ICS may also enhance the LABA/LAMA effect and 
could create beneficial synergies leading to a better regional exposure, a larger 
bronchodilation, and a reduced inflammation in more peripheral lung regions.
It is believed that the additional effect of ICS on top of LABA/LAMA will reduce 
hyperinflation and air trapping, resulting in lower lung and lobar volumes. At the same time, 
the specific airway volume (i.e. airway volumes that are corrected for lung volumes) are 
expected to increase. The primary goal of this study is to describe the effect on airway volume 
with the addition of ICS. This goal builds on the results of a lung function study (KRONOS), 
where we studied the effect on FEV1 when ICS was added to LAMA/LABA and was recently 
published [Ferguson, 2018]. As illustrated in Figure 2 of this publication, the addition of 
budesonide to glycopyrrolate/formoterol, resulted in clinically meaningful improvements of 
trough FEV1, and of FEV1 AUC 0-4 hours post-dose, in COPD patients.
However, while FEV1 is a well-established lung function parameter, it is still rather crude and 
does not make a good representation of the function of smaller airways. Thus, the purpose of 
the present study is to further characterize the lung function benefit by a more sensitive 
method. FRI is a well-established method to achieve a more regional characterization of the 
respiratory system. By simultaneously looking at the airway resistance and internal airflow 
distribution, functional respiratory imaging will be able to infer physiological changes in the 
peripheral lung regions 
2.2
Background
A detailed description of the chemistry, pharmacology, efficacy, and safety of BGF is 
provided in the Investigator’s Brochure for BGF MDI, BFF MDI and GFF is provided in the 
Investigator’s Brochure for GFF MDI.

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2.3
Benefit/risk assessment
More detailed information about the known and expected benefits and risks and reasonably 
expected adverse events of BGF and GFF may be found in the respective Investigator 
Brochures.
3
OBJECTIVES AND ENDPOINTS
Table 3
Study objectives
Primary objective:
Endpoint/variable:
To assess the effects of BGF and GFF on 
specific image-based airway volumes and 
resistance in subjects with moderate to severe 
COPD following chronic twice-daily (BID) 
dosing after approximately four weeks of 
treatment

Specific airway volume (siVaw) 

Specific airway resistance (siRaw)
Secondary objective:
Endpoint/variable:
To assess the effects of BGF and GFF on 
various Functional Respiratory Imaging (FRI) 
parameters

Airway volume (iVaw)

Airway resistance (iRaw)
To assess the effects of BGF and GFF on lung 
function parameters
Forced expiratory volume in one second (Post-
dose FEV1)
To assess the effects of BGF and GFF on body 
plethysmography parameters
Functional Residual Capacity (FRC)
Safety objective:
Endpoint/variable:
To assess the safety of BGF and GFF
Adverse events (AEs), serious adverse events 
(SAEs), adverse events leading to treatment 
discontinuation (DAEs)
Exploratory
Endpoint/variable:
To assess the effects of BGF and GFF on other 
FRI parameters

Lobe volumes (iVlobes) 

Air Trapping (AT)

Internal lobar airflow distribution (IAD)

Low attenuation or emphysema score (LAS)

Blood Vessel density or fibrosis score (iVby)

Airway Wall Thickness (iVaww)

Mass of deposited particles per defined 
airway section

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To assess the effects of BGF and GFF on other 
lung function parameters

Forced vital capacity (FVC)

Tiffeneau index (FEV1/FVC ratio)

Forced expiratory flow 25%-75% (FEF25-75)

Inspiratory capacity (IC)
To assess the effects of BGF and GFF on other 
body plethysmography parameters

Residual volume (RV)

Total Lung Capacity (TLC)

Airway resistance (Raw)

Specific airway resistance (sRaw)

Specific airway conductance (sGaw)

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4
STUDY DESIGN
4.1
Overall design
For an overview of the study design see Figure 1, Section 1.3. For details on treatments given 
during the study, see Section 6.1 Treatments administered.  
For details on what is included in the efficacy and safety endpoints, see Section 3 Objectives 
and Endpoints.  
4.2
Scientific rationale for study design
This study will recruit patients with moderate to severe COPD; therefore, spirometry entry 
requirements are set according to the thresholds defined by GOLD guidelines (GOLD 2018).
These requirements are in line with the inclusion criteria used in the pivotal study programmes 
of both GFF and BGF. In patients meeting these criteria, with severe or persistent 
breathlessness, treatment with at least dual bronchodilator therapy is recommended (GOLD 
2018).
Randomisation and blinding will minimise any potential for selection bias, or bias in the 
assessment of study endpoints or the management of patients. Patients will also continue to 
use short-acting rescue medication when necessary (albuterol/salbutamol MDI inhaler). 
4.3
Justification for dose
GFF is an approved therapy for COPD in the USA and Canada currently. GFF treatment will 
be given in accordance with the labelled dosing regimens. BGF treatment is currently in phase 
III development and a pivotal study has been completed using the 320mcg BID regimen 
[Ferguson, 2018].
4.4
End of study definition
The end of study is defined as the last expected visit/contact of the last subject undergoing the 
study.
A subject is considered to have completed the study when he/she has completed the follow-up 
telephone contact post last treatment 
See Appendix A 5 for guidelines for the dissemination of study results. 

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5
STUDY POPULATION
Prospective approval of protocol deviations to recruitment and enrolment criteria, also known 
as protocol waivers or exemptions, is not permitted.
Each subject should meet all of the inclusion criteria and none of the exclusion criteria for this 
study in order to assigned/randomised to a study intervention.  Under no circumstances can 
there be exceptions to this rule. Subjects who do not meet the entry requirements are screen 
failures, refer to section 5.4
For procedures for withdrawal of incorrectly enrolled subjects see Section 7.3.
5.1
Inclusion criteria
Subjects are eligible to be included in the study only if all of the following inclusion criteria 
and none of the exclusion criteria apply:
Informed consent
1. Give their signed written informed consent to participate.

Capable of giving signed informed consent which includes compliance with the 
requirements and restrictions listed in the informed consent form (ICF) and in this 
protocol.

Provision of signed and dated, written informed consent form prior to any mandatory 
study specific procedures, sampling, and analyses. 
The ICF process is described in Appendix A 3.
Age
2
Subject must be 40 years to ≤80 years of age inclusive, at the time of signing the 
informed consent form at Visit 1.
Type of subject and disease characteristics
3
Subjects with an established clinical history of COPD as defined by the American 
Thoracic Society (ATS)/European Respiratory Society (ERS) (Celli, 2004) or by locally 
applicable guidelines e.g., JRS Guidelines (JRS, 2013) characterized by:

Airflow limitation that is not fully reversible. Progressive airflow limitation 
associated with an abnormal inflammatory response of the lungs to noxious 
particles or gases, primarily caused by cigarette smoking.
4
Tobacco Use: Current or former smokers with a history of at least 10 pack-years of 
smoking. (Number of pack-years = [number of cigarettes per day/20] x number of years 
smoked [e.g., 20 cigarettes per day for 10 years, or 10 cigarettes per day for 20 years 
represent 10 pack-years]).

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5
Severity of Disease: Subjects with an established clinical history of COPD and severity 
defined as:

At Visit 1 pre-bronchodilator FEV1 must be >30% and <80% predicted normal 
value, calculated using The Third National Health and Nutrition Examination 
Survey (NHANES III) reference equations.

At Visit 2 post-bronchodilator FEV1/FVC ratio of <0.70.

At Visit 2 post-bronchodilator FEV1 must be >30% and <80% predicted normal 
value, calculated using The Third National Health and Nutrition Examination 
Survey (NHANES III) reference equations.
6
Stability criteria: At Visit 5 if the pre-dose -60 minute FEV1 value is outside of the ±20% 
range compared to the average (-30 and -60 minute) pre-dose FEV1 value of Visit 3, the 
visit may be rescheduled at the Investigator’s discretion, or the subject may be 
discontinued.
7
Blood eosinophil count > 150 cells per µL at Visit 1
8
Patients should be on scheduled maintenance treatment with one or more inhaled 
bronchodilator therapies, since at least 1 month prior to visit 1. LAMA, LABA, or regular 
scheduled maintenance with SAMA or SABA would qualify. Note: Inhaled 
corticosteroids are not allowed for 3 months prior to Visit 1.
9
Chest x-ray or computed tomography (CT) scan of the chest/lungs within 12 months prior 
to Visit 1 must be acceptable to the Investigator. Subjects who have a chest x-ray that 
reveals clinically significant abnormalities not believed to be due to the presence of 
COPD should not be included.
10 Screening clinical laboratory tests must be acceptable to the Investigator.
11 Screening ECG must be acceptable to the Investigator.
12 Individual is willing and, in the opinion of the Investigator, able to adjust current COPD 
therapy as required by the protocol.
13 Compliance: Subjects must be willing to remain at the study center as required per 
protocol to complete all visit assessments.
Sex
14 Male or female
Reproduction
15 Negative pregnancy test (urine or serum) for female subjects of childbearing potential.
16 Female subjects must be 1 year post-menopausal, surgically sterile, or using an acceptable 
method of contraception (an acceptable method of contraception is defined as a barrier 
method in conjunction with a spermicide) for the duration of the study (from the time they 
sign consent) and for 1 month after the last dose of study medication to prevent 
pregnancy. In addition, oral contraceptives, approved contraceptive implant, long-term 

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injectable contraception, intrauterine device, or tubal ligation are allowed. Oral 
contraception alone is not acceptable; additional barrier methods in conjunction with 
spermicide must be used. 
5.2
Exclusion criteria
Medical conditions
1
As judged by the investigator, any evidence of significant diseases other than COPD, i.e., 
disease or condition which, in the investigator’s opinion makes it undesirable for the 
subject to participate in the trial.
2
Respiratory:
a.
Asthma: Subjects, who in the opinion of the Investigator, have a current or 
recent (i.e., within the past 10 years) diagnosis of asthma.
b. Alpha-1 Antitrypsin Deficiency: Subjects who have alpha-1 antitrypsin 
deficiency as the cause of COPD.
c.
Other Respiratory Disorders: Subjects who have other active pulmonary 
disease such as active tuberculosis, lung cancer, bronchiectasis (High 
Resolution Computed Tomography (HRCT) evidence of bronchiectasis that 
causes repeated acute exacerbations), sarcoidosis, idiopathic interstitial 
pulmonary fibrosis (IPF), WHO group 1 or primary pulmonary 
hypertension, or uncontrolled sleep apnea (i.e., in the opinion of the 
Investigator severity of the disorder would impact the conduct of the 
study).
Note: Allergic rhinitis is not exclusionary.
d. Lung Volume Reduction: Subjects who have undergone lung volume 
reduction surgery, lobectomy or bronchoscopic lung volume reduction 
(endobronchial blockers, airway bypass, endobronchial valves, thermal 
vapor ablation, biological sealants, and airway implants) within 1 year of 
Visit 1.
e.
Hospitalization: Subjects who have been hospitalized due to poorly 
controlled COPD within 3 months prior to Visit 1 (Screening) or during the 
run-in period (Visit 1 to Visit 3).
f.
Poorly Controlled COPD: Subjects who have poorly controlled COPD, 
defined as acute worsening of COPD that requires treatment with oral 
corticosteroids or antibiotics within 3 months prior to Visit 1 (Screening) or 
during the run-in period (Visit 1 to Visit 3).
g. Lower Respiratory Tract Infection: Subjects who had lower respiratory 
tract infections that required antibiotics and/or oral steroids within 6 weeks 
prior to Visit 1 (Screening) or during the run-in period (Visit 1 to Visit 3).

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h. Spirometry Performance:
1) Acceptability: Subjects who cannot perform acceptable spirometry, i.e., 
meet ATS/ERS acceptability criteria.
2) Repeatability: Subjects who cannot perform technically acceptable 
spirometry with at least three acceptable flow-volume curves with two or 
more meeting ATS repeatability criteria for FEV1 during the pre-
bronchodilator assessments at Visit 1 and at the post-bronchodilator 
assessment at Visit 1.
i.
Oxygen: Subjects receiving long-term-oxygen therapy (LTOT).
Note: PRN oxygen use is not exclusionary.
j.
Subject use of any non-invasive positive pressure ventilation device 
(NIPPV).
Note: Subjects using continuous positive airway pressure (CPAP) or bilevel 
positive airway pressure (BiPAP) for Sleep Apnea Syndrome are allowed in 
the study.
k. Change in smoking status (i.e., start or stop smoking,) or initiation of a 
smoking cessation program within 6 weeks of Visit 1 and throughout the 
run-in period (Visit 1 to Visit 3).
l.
Pulmonary Rehabilitation: Subjects who have participated in the acute 
phase of a pulmonary rehabilitation program within 4 weeks prior to Visit 1 
(Screening) or who will enter the acute phase of a pulmonary rehabilitation 
program during the study. Subjects who are in the maintenance phase of a 
pulmonary rehabilitation program are not to be excluded.
m. Subjects who are steroid dependent and maintained on inhaled 
corticosteroids, either as mono products or as part of fixed combination 
products, or on oral /systemic corticosteroids, are not eligible. 
n. Subjects who have initiated or altered the dose regimen of intranasal 
corticosteroids, intranasal antihistamines, or a combination thereof within 7 
days prior to Visit 1 or during the run-in period (Visit 1 to Visit 3) 
o. Risk factors for pneumonia: immune suppression (HIV) severe 
neurological disorders affecting control of the upper airway or other risk 
factors that in the opinion of the Investigator would put the subject at 
substantial risk of pneumonia 
p. Pneumonia not clinically resolved within 1 month of Visit 1. 
3
Cancer: Subjects who have cancer that has not been in complete remission for at least five 
years.
Note: Subjects with squamous cell carcinoma of the skin, basal cell carcinoma of the skin, 
or localized prostate cancer are eligible, if in the opinion of the Investigator, the condition 

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has been adequately evaluated, is clinically controlled and the subject’s participation in 
the study would not represent a safety concern.
4
Glaucoma: Subjects with a diagnosis of narrow-angle glaucoma that, in the opinion of the 
Investigator, has not been adequately treated. All medications approved for control of 
intraocular pressures are allowed including topical ophthalmic non-selective beta-
blockers (such as betaxolol, carteolol, levobunolol, metipranolol, timolol) and 
prostaglandin analogues. 
5
Substance Abuse: Subjects, who in the opinion of the Investigator, significantly abuse 
alcohol or drugs (refer to Exclusion Criterion 1).
6
Liver: Subjects with abnormal liver function tests defined as Alanine aminotransferase 
(ALT), Aspartate aminotransferase (AST), or total bilirubin ≥1.5 times upper limit of 
normal at Visit 1.
7
Renal
a.
Subjects with symptomatic prostatic hypertrophy that is clinically significant in 
the opinion of the Investigator. Subjects with a trans-urethral resection of 
prostate (TURP) or full resection of the prostate within 6 months prior to Visit 1 
are excluded from the study.
b. Subjects with bladder neck obstruction or urinary retention that is clinically 
significant in the opinion of the Investigator.
c.
Subjects with a calculated creatinine clearance ≤30 mL/minute using Chronic 
Kidney Disease Epidemiology Collaboration. (CKD-EPI) formula (Levey et al 
2009) at Visit 1 and on repeat testing prior to Visit 3.
Note: Subjects with overactive bladder syndrome treated with oral 
anticholinergics that have been on treatment for at least one month are allowed 
in the Study. 
8
Cardiac disease
a.
Subjects who have unstable ischemic heart disease, left ventricular failure, or 
documented myocardial infarction within 12 months of Screening (Visit 1). 
Subjects with a recent history of acute coronary syndrome, or who have 
undergone percutaneous coronary intervention or coronary artery bypass graft 
within the past 3 months are to be excluded.
b. Subjects with congestive heart failure (CHF) The New York Heart Association 
(NYHA) Class III/IV).
c.
Clinically significant abnormal ECG: A clinically significant abnormal ECG is 
defined as (but not limited to) any of the following:

Clinically significant conduction abnormalities [e.g., left bundle branch 
block, Wolff-Parkinson-White syndrome or evidence of second degree 
(Mobitz Type II) or third degree atrioventricular block (unless 
pacemaker or defibrillator has been inserted)].

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
QT interval corrected for heart rate (using Fridericia’s formula; QTcF) 
≥500 milliseconds (msec) in patients with QRS <120 msec and QTcF 
≥530 msec in patients with QRS ≥120 msec.
9
Clinically Uncontrolled Hypertension: Subjects who have clinically significant 
uncontrolled hypertension.
Prior/concomitant therapy
10 Any concomitant medications known to be associated with Torsades de Pointes or potent 
inducers of cytochrome P450 3A4 (CYP3A4).
11 Medication prior to spirometry: Subjects who are medically unable to withhold their 
short-acting bronchodilators for the 6-hour period required prior to spirometry testing at 
each study visit will be excluded.
12 Prohibited Medications: Subjects who, in the opinion of the Investigator, would be unable 
to abstain from protocol-defined prohibited medications during the Screening Period and 
treatment phases of this study.
13 Subjects using any herbal inhalation and nebulizer products within 2 weeks prior to Visit 
1 (Screening) and do not agree to stop using them during the study drug treatment.
Note: Nebulized albuterol is acceptable, but requires a minimum 6 hours washout prior to 
Visit 1 and must be discontinued at Visit 1 and throughout the study. 
Prior/concurrent clinical study experience
14 Participation in another clinical study with an investigational product administered in the 
last 30 days or five half-lives prior to Visit 1 (Screening), whichever is longer.
Note: Subject participation in observational studies (i.e., studies that do not require 
change to medication or an additional intervention) is not exclusionary.
15 Drug Allergy: Subjects who have a history of hypersensitivity to β2 agonists, budesonide 
or any other corticosteroid components, glycopyrronium or other muscarinic 
anticholinergics, or any component of the MDI. 
Other exclusions
16 Involvement in the planning and/or conduct of the study (applies to both AstraZeneca 
staff and/or staff at the study site).
17 Affiliations with Investigator site: Study Investigators, sub-Investigators, study 
coordinators, employees of a participating Investigator or immediate family members of 
the aforementioned are excluded from participation in this study.
18 Questionable Validity of Consent: Subjects with a history of psychiatric disease, 
intellectual deficiency, poor motivation, substance abuse (including drug and alcohol), or 
other conditions that will limit the validity of informed consent to participate in the study.

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19 Hand-to-Breath Coordination: Subjects who requires the use of a spacer device to 
compensate for poor hand-to-breath coordination with a MDI.
Note: Use of a nebulizer to deliver COPD medications is prohibited throughout the trial.
20 Judgment by the investigator that the subject should not participate in the study if the 
subject is unlikely to comply with study procedures, restrictions and requirements.
21 Previous enrolment in the present study. 
22 For women only - currently pregnant (confirmed with positive pregnancy test) or breast-
feeding.  
5.3
Lifestyle restrictions
5.3.1
Meals and dietary restrictions
Subjects are encouraged to refrain from consuming grapefruits or grapefruit juice throughout 
the study. Subjects must not ingest xanthine (i.e., caffeine)-containing foods and beverages for 
at least 6 hours prior to each study visit and for the duration of each study visit. Examples of 
such products include coffee, tea, chocolate, and cola. Decaffeinated beverages are acceptable.
5.3.2
Illicit Drug and or Drugs of Abuse 
Illicit drugs or drugs of abuse will not be allowed from the start of Screening (Visit 1) to the 
end of Visit 5 or to whenever the subject discontinues the study. If any illicit drugs or drugs of 
abuse are used by the subject during the study, the dates of use and the amount will be 
documented, and the subject will be discontinued.  Medical marijuana is not an exclusionary 
drug if used for medical purposes, and there is no change in the dose or frequency of 
consumption.
5.3.3
Smoking Status
Changes in a subject’s smoking status (i.e., stopping or re-starting smoking) may have an 
impact on the efficacy outcome measures. At all visits the subject will be asked about any 
recent change in their smoking status (i.e., whether a subject’s status has changed from 
smoker to non-smoker or vice versa). Any change in smoking status during the run-in period 
(Visit 1 to Visit 2) will result in a screen failure. Smoking status changes during the 4-week 
treatment periods will be captured in the eCRF, but the subject will be permitted to continue in 
the study. Subjects will be required to refrain from smoking (including medical marijuana and 
electronic cigarettes) for at least 4 hours prior to each study visit and throughout the duration 
of each study visit. Study participants may utilize various nicotine replacement treatments 
such as chewing gum, inhaler and patches (PRN), in accordance with recommendations from 
the Investigator during the entire study visit.
Note:  For this study, the use of electronic cigarettes will be treated in the same manner as 
cigarette smoking except for the calculation of pack-years to determine cigarette smoking 
history.

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5.4
Screen failures
Screen failures are defined as subjects who signed the informed consent form to participate in 
the clinical study but are not subsequently randomized. A minimal set of screen failure 
information is required to ensure transparent reporting of screen failure subjects to meet the 
Consolidated Standards of Reporting Trials (CONSORT) publishing requirements and to 
respond to queries from regulatory authorities. Minimal information includes demography, 
screen failure details, eligibility criteria, and any serious adverse event (SAE).
Individuals who do not meet the criteria for participation in this study (screen failure) may be 
rescreened.  
These subjects should have the reason for study withdrawal recorded in eCRF.

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6
STUDY TREATMENTS
Study treatment is defined as any investigational product(s) (including marketed product 
comparator and placebo) or medical device(s) intended to be administered to a study 
participant according to the study protocol. Study treatment in this study refers to blinded 
treatment and open label products (Ventolin and Atrovent).
6.1
Treatments administered
6.1.1
Investigational products
Table 4
Investigational Products
Product Name and 
Dosage
Product Strength
Dose Form/Fill 
Count
Administration 
Route
Blinded Study Medications
BGF MDI 320/14.4/9.6 µg 
ex-actuator
BGF MDI 160/7.2/4.8 µg 
per actuation
1 MDI
120 inhalations
Taken BID as two oral 
inhalations in the 
morning and two oral 
inhalations in the 
evening*
GFF MDI 14.4/9.6 µg ex-
actuator
GFF MDI 7.2/4.8 µg per 
actuation
1 MDI
120 inhalations
Taken BID as two oral 
inhalations in the 
morning and two oral 
inhalations in the 
evening*
Open-label Products
Ventolin (albuterol sulfate) 
HFA inhalation aerosol
90 µg ex-actuator
Ventolin (albuterol sulfate) 
HFA inhalation aerosol will 
be the supplied product
Each inhalation contains 
108 μg corresponding to
90 µg albuterol base per 
actuation
1 MDI
60 or 200 actuations
Taken as needed (PRN)
Atrovent (ipratropium 
bromide) HFA inhalation 
aerosol 34 μg ex-actuator
Atrovent (ipratropium 
bromide) HFA will be the 
supplied product
Each inhalation contains 
17 μg ex-actuator per 
actuation
1 MDI
200 actuations
Taken as two inhalations 
QID during run-in period 
and washout period
Abbreviations: BGF MDI=Budesonide/Glycopyrronium/Formoterol Fumarate Inhalation Aerosol; GFF MDI= 
Glycopyrronium/Formoterol Fumarate Inhalation Aerosol; MDI=Metered Dose Inhaler; PRN=as needed; 
BID= two times daily; QID=four times daily
* approximately 12 hours apart
Note:  All study drugs will be administered by oral inhalations.  

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6.1.2
Medical devices
The sponsor manufactured medical devices provided for use in this study are BGF MDI and 
GFF MDI.
Other medical devices (not manufactured by or for sponsor) provided for use in this study are 
Ventolin HFA, and Atrovent HFA.
Instructions for medical device use are provided in Section 6.2.2.
Medical device incidents, including those resulting from malfunctions of the device, must be 
detected, documented, and reported by the investigator throughout the study (see Section 
8.4.4)
6.1.3
Primary Packaging and Labelling Information
Investigational materials will be packaged by the sponsor/designee.  Atrovent HFA and 
Ventolin HFA supplies will be supplied as open-label MDIs.
Blinded Supplies: Each MDI will be labeled with a single label.  The MDI actuator will be 
labeled with a single label. The foil pouch will be labeled with a single label. 
Open-label Supplies: Open-label Atrovent HFA and Ventolin HFA will be provided as 
individually labeled MDIs. Each MDI will contain a single label.  The MDI actuator will be 
labeled with a single label. The foil pouch will be labeled with a single label.
Both single and two-part labels will be printed with black ink and may include the following 
text:
Packaging Lot Trace ID #
Space for entry of screening #
Component ID #
Space for entry of randomization #
Fill Count & Dosage Form
Space for entry of Interval ID (Visit # only)
Re-evaluation/Expiration date (if applicable)
Dosing Instructions
Storage Conditions
Compound ID - Protocol #
Country regulatory requirements
Sponsor address (If applicable)
Translation Key (If applicable)
Abbreviation:  ID=identification

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6.1.4
Secondary Packaging and Labelling Information (Box)
Blinded investigational drug and open-label (Atrovent HFA and Ventolin HFA) supplies will 
be packaged in individual boxes as outlined in Table 5. Box configuration is subject to change 
as a result of packaging constraints.
Table 5
Description of Boxes 
Drug supplies
Individual box contents
Blinded
Atrovent HFA
Ventolin HFA 
1 MDI
1 MDI
1 MDI
Each box will be labeled with a two-part label printed with black ink and may include the 
following text:
Packaging Lot ID #
Space for entry of screening #
Component ID #
Space for entry of randomization #
Kit Contents (1 MDI)
Space for entry of Interval ID
Re-evaluation/Expiration date (if applicable)
Dosing Instructions (if applicable)
Storage Conditions
Compound ID - Protocol #
Country regulatory requirements
Sponsor address (If applicable)
Translation Key (If applicable)
Abbreviation:  ID=identification
6.2
Preparation/handling/storage/accountability
The investigator or designee must confirm appropriate temperature conditions have been 
maintained during transit for all study treatment received and any discrepancies are reported 
and resolved before use of the study treatment.
Only subjects enrolled in the study may receive study treatment and only authorised site staff 
may supply or administer study treatment.  All study treatments must be stored in a secure, 
environmentally controlled, and monitored (manual or automated) area in accordance with the 
labelled storage conditions with access limited to the investigator and authorised site staff.
The investigator, institution, or the head of the medical institution (where applicable) is 
responsible for study treatment accountability, reconciliation, and record maintenance (i.e., 
receipt, reconciliation, and final disposition records).

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stored upright at room temperature by the subject, avoiding temperature extremes, and storage 
in direct sunlight.
6.2.2.2
Atrovent HFA (Ipratropium Bromide) 
Open-label Atrovent HFA will be provided by Sponsor and stored in a secured location within 
the clinic or pharmacy facilities. 
Atrovent HFA is a solution aerosol that does not require shaking. However, as with any other 
MDI, some coordination is required between actuating the canister and inhaling the 
medication. Atrovent HFA should be primed per manufacturer’s instructions prior to 
dispensing to subject (i.e., "prime" or actuate Atrovent HFA before using for the first time by
releasing 2 test sprays into the air away from the face). In cases where the inhaler has not been 
used for more than 3 days, prime the inhaler again by releasing 2 test sprays into the air away 
from the face. Subjects should avoid spraying Atrovent HFA into their eyes.
Subjects will be dispensed the Atrovent HFA for COPD maintenance therapy during the run-
in period (between Visit 2 and 3) and during the washout period (between Visit 4 and 5) per 
the manufacturer’s instruction, 2 puffs with each administration four times a day, divided over 
the daytime. Atrovent is expected to be dispensed at Visit 1; the first dose should be taken 
starting at Visit 2, after the visit 2 procedures are performed after ensuring the washout of 
prohibited medications prior to Visit 3 have been achieved per Table 6 in section 6.5.1. The 
MDI should be stored at room temperature by the subject, avoiding temperature extremes and 
storage in direct sunlight.
6.2.2.3
Ventolin HFA (Albuterol Sulfate)
Open-label Ventolin HFA will be provided by Sponsor and stored in a secured location within 
the clinic or pharmacy facilities. Ventolin HFA should be stored at room temperature by the 
subject. Ventolin HFA should be primed per manufacturer’s instructions prior to dispensing to 
subject. Study personnel will record number on the dose counter at the time of dispensing 
(following priming and characterization of reversibility) and upon return.
6.2.2.4
Placebo MDI 
At screening, on admission to each Treatment Period (as needed), subjects will be instructed 
by site staff on how to use the MDI device correctly using placebo MDIs. In addition, MDI 
training will be supplemented using the Vitalograph AIM Aerosol Inhalation Monitor or an 
equivalent device.
6.2.3
Drug Accountability/Return of Clinical Supplies
Under no circumstances will the Investigator(s) allow the study drug to be used other 
than as directed by this protocol.

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Investigational clinical supplies must be received by a designated person at the study site, 
handled and stored safely and properly, and kept in a secure location to which only the 
Investigator and designated assistants have access. Storage conditions for the clinical supplies 
should be observed, monitored and documented. Clinical supplies are to be dispensed only in 
accordance with the protocol. The Investigator is responsible for keeping accurate records of 
the clinical supplies received from Sponsor, the amount dispensed to and returned by the 
subject, and the amount remaining at the conclusion of the study. The Clinical Monitor should 
be contacted with any questions concerning investigational products where special or 
protective handling is indicated. At the end of the study, all clinical supplies including partial 
and empty containers must be returned as directed by Sponsor.
Sites should check with the Sponsor representative for appropriate documentation that needs 
to be completed for drug accountability.
The Investigator or designated assistant should not open individual clinical supply containers 
until all pre-dose assessments have been completed and the subject is eligible to be 
randomized/continue with the study. Any deviation from this must be discussed with the 
Clinical Monitor.
For each subject, all used study drug materials will be collected.  Used subject supplies will be 
kept at room temperature in a secure and locked cabinet until returned to Sponsor or designee.  
Note: Used study drug will be stored separately from unused study drug.
All product complaints (including device malfunctions) must be reported to the Sponsor or 
designee using the Product Complaints Form provided in each site’s investigator file. Sponsor 
or designee will contact the site to evaluate the nature of the complaint and determine what 
further action is needed.
6.3
Measures to minimise bias: randomisation and blinding
Subjects will be randomized to receive one of the treatment sequences BGF-GFF and GFF-
BGF in the proportion 1:1 using a fixed block size. Separate randomization lists will be 
created for each centre. Interactive Voice/Web Response System (IVRS/IWRS) will not be 
used.
If a subject withdraws from the study, then his/her enrolment/randomisation code cannot be 
reused. Withdrawn subjects may be replaced.
6.4
Treatment compliance
Any change from the dosing schedule, does interruptions, dose reductions, dose 
discontinuations should be recorded in eCRF.

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The Investigational Product Storage Manager is responsible for managing the IMP from 
receipt by the study site until the destruction or return of all unused IMP. The Investigator(s) 
is responsible for ensuring that the subject has returned all unused IMP.
6.5
Concomitant therapy
Any medication or vaccine including over-the-counter or prescription medicines, vitamins, 
and/or herbal supplements that the subject is receiving at the time of enrolment within 
30 days before Visit 1 (Screening) or receives during the study including any additions, 
deletions, or changes in the dose of these medications while in the study must be recorded 
along with:

Dose and dose regimen

Reason for use

Dates of administration including start and end dates

Dosage information including dose and frequency
6.5.1
Prohibited COPD Medications
The following medications used for the treatment of COPD are not permitted during this 
study. These medications must be discontinued 6 hours to 24 hours prior to Visit 1 (Screening)
and are not permitted during the run-in period. The minimum washout period before Visit 1 
and between Visit 1 and Visit 3 are shown in Table 6. The only COPD medications permitted 
during the study are sponsor-provided Atrovent HFA® for COPD maintenance during the run-
in and wash-out period and sponsor-provided Ventolin HFA® for rescue of COPD symptoms 
during the study.

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Table 6
Prohibited COPD Medications and Required Washout Periods Prior to 
Visit 1 and Visit 3
Minimum Washout Period Prior to:
Class of Medication
Visit 1
Visit 3
LAMAs
24 hours
Tiotropium: 14 days
Aclidinium: 7 days
Glycopyrronium: 7 days
Umeclidinium: 7 days 
Short-acting muscarinic antagonists 
(SAMA)a
6 hours
6 hours
LABAs (inhaled)
24 hours
48 hours (Indacaterol: 15 days) 
Fixed-combinations of LABA/LAMA
24 hours
7 days 
(14 days for 
indacaterol/glycopyrronium 
and olodaterol/tiotropium)
Fixed-combinations of LABA/ICS
3 months
Fixed-combinations of SABAs and SAMAs 
6 hours
6 hours
SABAsb
6 hours
6 hours
Oral β-agonists
2 days 
Theophylline (total daily dose 
>400 mg/day)c
7 days
ICS (alone or in combination)
3 months
Abbreviations:  COPD=chronic obstructive pulmonary disease; HFA=hydrofluoroalkane; ICS=inhaled 
corticosteroid; LABA=long-acting β2-agonist; LAMA=long-acting muscarinic antagonist; SABA=short-acting 
β2-agonist
Note: Subjects taking roflumilast are allowed provided they have been on stable dose of therapy for at least 
2 months prior to Randomization.
a. Discontinue and use only sponsor-provided Atrovent HFA during run-in and washout period 
b. Discontinue and use only sponsor-provided rescue Ventolin HFA throughout the study
c. Theophylline (<400 mg/day) is permitted provided the subject has been on a stable dose of therapy for at 
least 4 weeks prior to Randomization.
Subjects that have received depot corticosteroids including, intra-articular or intraocular 
corticosteroids require a 3 month washout prior to Visit 1. Subjects that have received oral, 
intravenous or intramuscular corticosteroids for any reason require a 6 week washout prior 

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to Visit 1. Any subject that requires use of systemic corticosteroids during the run-in period 
(Visit 1 to Visit 3) will be screen failed.
Note:

During the TP 1 and 2 (Visit 3 to Visit 4 and Visit 5 to Visit 6), subjects treated with oral 
corticosteroids and/ or antibiotics for exacerbation should be discontinued from the study.
Subjects who meet all entry criteria but are using one or more of the prohibited COPD 
medications (previously listed) will have their maintenance therapy for COPD adjusted as 
follows: 

Subjects taking prohibited inhaled COPD medications (listed in this section) will 
discontinue these medications as noted above. At Visit 2 after study procedures subjects will 
be switched to sponsor-provided Atrovent HFA MDI administered QID (during the run-in 
and wash-out periods only) and sponsor-provided Ventolin HFA to be administered as 
needed (PRN) throughout the study for control of COPD symptoms.

Sponsor-provided Atrovent HFA MDI administered QID (during the run-in and wash-out 
periods only), and sponsor-provided Ventolin HFA to be administered as needed (PRN) 
throughout the study for control of COPD symptoms.

All subjects treated with either a LABA (salmeterol, formoterol, indacaterol) or currently 
marketed LAMA (tiotropium, aclidinium, glycopyrronium, [eg, Seebri]) administered 
alone or as a loose combination will have these medications discontinued and replaced 
with sponsor-provided Atrovent HFA MDI administered QID (during the run-in and wash-
out periods only), and sponsor-provided Ventolin HFA to be administered as needed 
(PRN) throughout the study for control of COPD symptoms.
The following respiratory medications are not permitted during this study (Table 7)
Table 7
Other Respiratory/Nasal Medications: Required Washout Periods
Required washout periods prior to Visit 3:
Class of medication
Minimum cessation period prior to Visit 3 
Leukotriene antagonists (eg, zafirlukast, 
montelukast) 
7 days
Cromoglycate
7 days
Nedocromil
7 days
Ketotifen *
7 days

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*Ketotifen eye drops are allowed
6.5.2
Other concomitant treatment
Other medication other than that described above, which is considered necessary for the 
subject’s safety and wellbeing, may be given at the discretion of the Investigator and recorded 
in the appropriate sections of the Case Report Form.
6.5.3
Rescue medication
The study site will supply Ventolin HFA® rescue medication that will be provided by the 
sponsor.  
Although the use of rescue medications is allowable at any time during the study, the use of 
rescue medications should be delayed, if possible, for at least 6 hours following the 
administration of Study treatment.  The date and time of rescue medication administration as 
well as the name and dosage regimen of the rescue medication must be recorded.
Table 8
Rescue medication
Rescue/Supportive medication/class of drug:
Usage:
Ventolin HFA®
For rescue of COPD symptoms
6.6
Dose modification
N/A
6.7
Treatment after the end of the study 
N/A

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7
DISCONTINUATION OF TREATMENT AND SUBJECT
WITHDRAWAL 
7.1
Discontinuation of study treatment 
Subjects may be discontinued from investigational product (IP) in the following situations. 
Note that discontinuation from study treatment is NOT the same thing as a complete 
withdrawal from the study.

Subject decision. The subject is at any time free to discontinue treatment, without 
prejudice to further treatment

Adverse Event

Severe non-compliance with the Clinical Study Protocol 

Subjects who require treatment for their COPD symptoms, other than the study or rescue 
medication during the treatment period will be discontinued from the study. 

If a female subject becomes pregnant during the course of the study, the subject will be 
discontinued and the pregnancy will be followed full-term through delivery or final 
outcome (refer to Section 8.4.2).
See the SoA for data to be collected at the time of treatment discontinuation and follow-up 
and for any further evaluations that need to be completed.
7.1.1
Procedures for discontinuation of study treatment
The investigator should instruct the subject to contact the site before or at the time if study 
treatment is stopped.  A subject that decides to discontinue study treatment will always be 
asked about the reason(s) and the presence of any AEs.  The date of last intake of study 
treatment should be documented in the electronic CRF.  All study treatment should be 
returned by the subject at their next on-site study visit or unscheduled visit.  Subjects 
permanently discontinuing study treatment should be given locally available standard of care 
therapy, at the discretion of the Investigator.
7.2
Lost to follow-up
A subject will be considered potentially lost to follow-up if he or she fails to return for 
scheduled visits and is unable to be contacted by the study site.  
The following actions must be taken if a subject fails to return to the clinic for a required 
study visit:

The site must attempt to contact the subject and reschedule the missed visit as soon as 
possible and counsel the subject on the importance of maintaining the assigned visit 
schedule.

Before a subject is deemed lost to follow up, the investigator or designee must make 
every effort to regain contact with the subject or next of kin by e.g. repeat telephone 
calls, certified letter to the subject´s last known mailing address or local equivalent 

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methods. These contact attempts should be documented in the subject’s medical 
record. 

Efforts to reach the subject should continue until the end of the study. Should the 
subject be unreachable at the end of the study the subject should be considered to be 
lost to follow up with unknown vital status at end of study and censored at latest 
follow up contact.
7.3
Withdrawal from the study
A subject may withdraw from the study (eg, withdraw consent), at any time (investigational 
product and assessments) at his/her own request, without prejudice to further treatment.
A subject who considers withdrawing from the study must be informed by the Investigator 
about modified follow-up options (eg, telephone contact, a contact with a relative or treating 
physician, or information from medical records).
If the subject withdraws consent for disclosure of future information, the sponsor may retain 
and continue to use any data collected before such a withdrawal of consent.
If a subject withdraws from the study, he/she may request destruction of any samples taken, 
and the investigator must document this in the site study records.  
A subject who withdraws consent will always be asked about the reason(s) and the presence of 
any adverse events (AE).  The Investigator will follow up subjects as medically indicated. 
See SoA, Table 1, for data to be collected at the time of study discontinuation and follow-up 
and for any further evaluations that need to be completed. All Study treatment should be 
returned by the subject.
7.4
Study and Site Closure
The sponsor designee reserves the right to close the study site or terminate the study at any 
time for any reason at the sole discretion of the sponsor. The study may be stopped if, in the 
judgment of AstraZeneca, trial subjects are placed at undue risk because of clinically 
significant findings that:

meet individual stopping criteria or are otherwise considered significant 

are assessed as causally related to study drug, 

are not considered to be consistent with continuation of the study
Regardless of the reason for termination, all data available for the subject at the time of 
discontinuation or follow-up must be recorded in the CRF. All reasons for discontinuation of 
treatment must be documented.

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In terminating the study, the Sponsor will ensure that adequate consideration is given to the 
protection of the subjects’ interests
Study sites will be closed upon study completion. A study site is considered closed when all 
required documents and study supplies have been collected and a study-site closure visit has 
been performed.
The investigator may initiate study-site closure at any time, provided there is reasonable cause 
and sufficient notice is given in advance of the intended termination.
Reasons for the early closure of a study site by the sponsor or investigator may include but are 
not limited to:

Failure of the investigator to comply with the protocol, the requirements of the 
IRB/IEC or local health authorities, the sponsor's procedures, or GCP guidelines

Inadequate recruitment of participants by the investigator
Discontinuation of further study intervention development
8
STUDY ASSESSMENTS AND PROCEDURES
Study procedures and their timing are summarised in the SoA.
The investigator will ensure that data are recorded on the electronic Case Report Forms.   
The investigator ensures the accuracy, completeness, for electronic CRFs include: legibility 
and timeliness of the data recorded and of the provision of answers to data queries according 
to the Clinical Study Agreement.  The investigator will sign the completed electronic Case 
Report Forms.  A copy of the completed electronic Case Report Forms will be archived at the 
study site.
Immediate safety concerns should be discussed with the sponsor immediately upon occurrence 
or awareness to determine if the subject should continue or discontinue Study treatment.
Adherence to the study design requirements, including those specified in the SoA, is essential 
and required for study conduct.
All screening evaluations must be completed and reviewed to confirm that potential subjects 
meet all eligibility criteria.  The investigator will maintain a screening log to record details of 
all subjects screened and to confirm eligibility or record reasons for screening failure, as 
applicable.
Procedures conducted as part of the subject’s routine clinical management (e.g., blood count)
and obtained before signing of the ICF may be utilised for screening or baseline purposes 

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provided the procedures met the protocol-specified criteria and were performed within the 
time frame defined in the SoA.
The maximum amount of blood collected from each subject over the duration of the study, 
including any extra assessments that may be required, will not exceed 10 mL. Repeat or 
unscheduled samples may be taken for safety reasons or for technical issues with the samples.
8.1
Efficacy assessments 
8.1.1
HRCT scans
Subjects will receive a total of seven HRCT scans. The first will be conducted at baseline, the 
beginning of treatment period 1 at Visit 3. The pre-dose CT-scan of the thorax will be taken on 
two breathing levels, TLC(PRE) and FRC(PRE). During Visit 3 an additional scan of the UA will 
be taken. The post-dose measurement will be performed on two breathing level, TLC(POST) and 
FRC(POST). The Post dose scans will be taken after approximately 4 weeks of each treatment 
(treatment 1 and treatment 2) of BGF MDI and GFF MDI on Day 29 (±3 days) (Visit 4 and 
Visit 6). 
On Day 1 of the first TP (Visit 3) the HRCT scans (TLC(PRE) and FRC(PRE)) and the UA scan 
will be taken at least 30 minutes prior to dosing.
Post dose HRCT scans (TLC(POST) and FRC(POST)) on Day 29 (±3 days) of each TP (Visit 4 and 
Visit 6) should be started 90 minutes ± 30 minutes after dosing. 
Spirometry followed by body plethysmography will be performed after the HRCT scans but 
within 150 minutes after dosing.
Between the two TPs there will be a washout period of a minimum of 21 days up to a maximum 
of 28 days.
Whenever possible the same scanner should be used at all the study visits.
HRCT scan is performed with a low radiation protocol (average exposure of 1.806 mSv * 6 + 
1mSV (UA scan) = 11.836 mSv). These images are made to perform Computational fluid 
dynamics (CFD) in order to obtain more information on regional lung function characteristics.
8.1.2
Spirometry
Forced expiratory spirometry maneuvers for derivation of FEV1, FVC, FEF25-75, FEV1/FVC 
ratio and IC will be assessed using a spirometer that meets or exceeds minimum performance 
recommendations of the ATS.

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Spirometry will be conducted at all visits. At Visit 1, Spirometry will be conducted 
approximately 60 minutes and 30 minutes prior to bronchodilator administration and 
approximately 30-60 minutes post-bronchodilator (refer to Section 8.1.2.1).
Note: Spirometry must meet the severity and both acceptability and repeatability criteria.
At Visit 3 and Visit 5, spirometry will be obtained at the beginning of the visit. A second 
spirometry will be obtained before the study drug administration after the pre-dose CT-scans
are taken (at Visit 3 only). The -60 minute FEV1 value obtained at Visit 5 prior to study drug
administration will be used to check the stability criteria. At Visit 4 and Visit 6, spirometry
will be obtained before the study drug administration, and post-dosing of study drug. Post-
dose spirometry assessments will not be conducted before the CT-scan is taken. At Visit 4 and
6 none of the post dose assessments will start before 1 hour after the administration of the
study drug. All assessments should be completed within 2.5 hours after dosing.
8.1.2.1
Characterization of Reversibility
Reversibility to Ventolin HFA (SABA) will be evaluated at Visit 1.
The procedure will be, as follows: Reversibility testing to Ventolin HFA:

Perform pre-bronchodilator PFTs (approximately -60 minutes and -30 minutes) prior to 
administration of Ventolin HFA (albuterol).

Administer 4 puffs of Ventolin HFA (albuterol).

Perform post-bronchodilator PFT 30-60 minutes after the administration of Ventolin HFA.
Reversibility will be a comparison of the average best FEV1 effort obtained at 
approximately -60 minutes and -30 minutes pre-bronchodilator to the best FEV1 effort 
obtained at approximately 30-60 minutes post-bronchodilator. A subject is determined to be 
reversible to Ventolin HFA if the improvement in FEV1 approximately 30-60 minutes 
following administration of 4 puffs of Ventolin HFA, respectively, is ≥12% and ≥200 ml. 
Reversibility to Ventolin HFA (obtained at Visit 1) will be used to characterize the population.
8.1.2.2
Stability Criteria
It is important to ensure that the baseline FEV1 is stable and reflective of the subject’s COPD 
severity prior to continuation in the second TP.
At Visit 3, spirometry will be obtained at the beginning of the visit. A second spirometry will 
be obtained before the study drug administration after the pre-dose CT scans are taken (at 
Visit 3 only). The average of the FEV1 values obtained prior to study drug administration (- 60 
min and - 30 min) at Visit 3 will be the baseline value used to compare with the -60 minute 
FEV1 value obtained at Visit 5 to check baseline stability. 

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At Visit 5, if the pre-dose FEV1 is outside of the ±20% or 200 mL range compared to the 
average (-30 and -60 minute) pre-dose FEV1 value of Visit 3, at the investigator's discretion, 
the visit may be rescheduled or the subject may be discontinued.
8.1.2.3
Inspiratory Capacity
Visit 2 to Visit 6: IC assessments will be conducted with every spirometry. All subjects will 
be instructed on the performance of the IC manoeuvre. Subjects must be tested in the seated 
position wearing a nose clip with no air leaks between the mouth and mouthpiece. Subjects 
should be relaxed with shoulders down and asked to breathe regularly for several breaths until 
the end-expiratory lung volume is stable (this usually requires at least five tidal manoeuvres). 
They are then urged to take a deep breath to TLC with no hesitation. From at least three 
acceptable trials, the two largest IC measurements should agree within 5% or 150 ml, both of 
these IC values will be captured and analysed. 
8.1.2.4
Standardization of IC and Spirometry Collections
All pulmonary function tests including FEV1, FVC, FEF25-75, FEV1/FVC ratio, as well as all 
IC assessments, as defined in ATS/ERS guidelines will be performed in accordance with ATS 
criteria (Miller et al 2005).
The volume accuracy of the spirometer is to be checked daily using a 3 L syringe across 
3 flow ranges (i.e., low, medium and high flows), with temperature and barometric pressure 
correction. The calibration syringe must meet ATS specifications and must not be used 
beyond the expiry date. Required accuracy is ± 3% (i.e., 3,09 L to 2,91 L) (ATS/ERS).  
The results of the calibration factor will be maintained on site, which will be available if the 
sponsor wants to check for compliance or an audit.
8.1.3
Body plethysmography
Visit 3 to Visit 6: RV, TLC, FRC, Raw, sRaw, sGaw will be measured using body 
plethysmography.
On Day 1 of each treatment period (Visit 3 and Visit 5) the body plethysmography measurement 
will be performed after the CT-scan (at Visit 3 only) however, before the IP administration.
On Day 29 (±3 days) of each treatment period (Visit 4 and Visit 6) the body plethysmography 
measurement will be performed after the CT-scan and after the post-dose spirometry 
measurement.
Post dose activities on Day 29 (±3 days) of each treatment period (Visit 4 and Visit 6) will be 
started 1 hour after dosing on and will be concluded within 2.5 hours after dosing. 

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8.1.4
Diffusion capacity
The single-breath diffusing capacity of the lungs for carbon monoxide (TCO), alveolar volume 
(VA) and TCO/VA will be measured at Visit 1. TCO measurement will be used to characterize 
the subjects enrolled in the trial and will not be used to determine subject eligibility to participate 
in the study.
8.1.5
Inhalation Profile 
Visit 3 and Visit 5: In order to draw an airflow versus time curve, the subject’s inhalation 
profile will be measured. The subject will be asked to inhale and exhale maximally through a 
mouthpiece without a nose clip. This measurement is performed by a (mobile) 
pneumotachograph with extraction of all flow data collected during the inhalation profile. At 
the moment of this measurement the signal from the respiration belt, used for the measurement 
of the inhalation profile during the study drug administration, will also be logged. The thorax 
and abdomen expansion will be measured with the Alice PDx diagnostic device.
8.1.6
Inhalation Profile during administration
Visit 3 and Visit 5: During IP administration on Day 1 of both active compounds, the inhalation 
profile will be recorded while the subject inhales through the device to generate a subject 
specific inhalation profile by using a respiration belt. The thorax and abdomen expansion will 
be measured with the Alice PDx diagnostic device. 
Sensor cables transmit the appropriate signals to the Alice PDx. The signals are stored on the 
removable memory card, or if configured to do so, the signals can be displayed from the Alice 
PDx on a computer running the appropriated software application. 
8.1.7
Subject Diary Data Collection
At Visit 1, subjects will be provided with a Diary to be completed twice daily (morning and 
evening).  Study personnel will train subjects on Diary completion and will instruct subjects to 
return Diary responses to the clinic for all in-clinic study visits.  

At Visit 1, subjects will be instructed to record in the Diary Atrovent HFA four-times 
daily use (starting at Visit 2) and rescue Ventolin HFA use during the Run-in Period prior to
Visit 3. 

At Visit 3, subjects will be instructed to record in the Diary study medication 
administration during the treatment phase. 

At Visit 4, subjects will be instructed to record in the Diary Atrovent HFA four times daily 
use and rescue Ventolin HFA) use during the Wash-out Period between Visit 4 and Visit 5.  

At Visit 5, subjects will be instructed to record in the Diary study medication use 
administration during the treatment phase. 

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Diary Compliance Requirement: Subject participation may be terminated at any time during 
the study for the following reason:
Chronic failure, in the judgment of the Investigator, to comply with diary completion, despite 
documentation at the site of repeated efforts to reinforce compliance. As defined for this study, 
compliance requires >70% subject completion of diary assessments.  The Sponsor may also 
instruct a site to discontinue a subject based on consistent noncompliance.
Subjects who are unable to meet the compliance requirement (>70% subject completion of diary 
assessments) in the last 7 days preceding the Randomization Visit (Visit 3) must be retrained. 
When retraining is required due to non-compliance the Randomization Visit (Visit 3) must be 
rescheduled.
In-clinic dosing times and dose indicator readings will be documented in the eCRF by the site 
staff and will not be entered by the subject into their Diary.
During the treatment periods, the subject will record study medication usage.
8.1.8
Rescue Ventolin HFA Use 
Subjects requiring more than 8 puffs per day on 3 consecutive days with worsening symptoms 
should contact the site. The number of “puffs” of rescue Ventolin HFA is the number of 
actuations of the canister. For example, when rescue Ventolin HFA is required and 
2 actuations are inhaled, this should be counted as 2 “puffs.” In the event the subject requires 
4 actuations, this should be counted as 4 “puffs”.  
At all study visits the subject will be asked to bring the rescue Ventolin HFA and the site 
personnel will review the number of actuations of the canister to ensure compliance and 
subject safety.
8.1.9
Recording of Dose Indicator Reading
The BGF MDI and GFF MDI are fitted with a dose indicator to track use of the MDI.
All MDIs must be primed before the first use. Priming involves releasing a certain number of 
sprays (4) into the air before the first use of the inhaler.  Shaking and priming the inhaler fills 
a chamber inside the canister with the correct dose and mix of medication so that the inhaler is 
ready to use.
Site personnel will be instructed to record the dose indicator reading from the MDI after 
priming (prior to the first dosing Day 1) and after the first dosing Day 1 of both the TPs (Visit 
3 and Visit 5). 

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Prior to dosing at Day 29 (±3 days) of each TP Visit (Visit 4 and Visit 6) or at a Premature 
Discontinuation Visit, site personnel will observe the dose indicator reading on the study drug 
returned by the subject and record the dose indicator reading in the source. 
Note: The dose indicator reading recorded by the site staff on Day 29 (±3 days) of each TP 
(Visit 4 and Visit 6) will be the dose indicator reading observed prior to subject dosing.  
At Visit 4 and 6, the site staff will compare the dose indicator reading from the prior entered 
reading of Day 1 (Visit 3 and Visit 5 respectively) of that TP. For major discrepancies (i.e., 
>20 puff difference), the site staff will review the major discrepancy with the subject and 
document reason for the major discrepancy in the appropriate study source and eCRF. If 
appropriate, site staff will retrain the subject on the proper use of the MDI.
8.1.10
Subject Questionnaires
The following subject questionnaires will be completed by subjects at Visit 1: CAT, and 
MMRC.
8.1.10.1 COPD Assessment Test
The CAT is a self-administered questionnaire designed to assess the condition of subjects and 
overall impact of COPD. Since the CAT is designed to assess the impact of COPD on the 
subject by measuring overall impairment, it has moderate correlations with other instruments, 
such as the MMRC Dyspnea Scale.
Subjects will complete the CAT at Visit 1. 
The CAT score will describe the burden and symptomatic impact of COPD in subjects 
enrolled in the trial and will not be used to determine subject eligibility to participate in the 
study.
8.1.10.2 Modified Medical Research Council Dyspnea Scale
The MMRC Dyspnea Scale uses a simple grading system to assess a subject's level of 
dyspnea, shortness of breath.

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Table 9
MMRC Dyspnea Scale
Grade
Description of Breathlessness
0
I only get breathless with strenuous exercise.
1
I get short of breath when hurrying on level ground or walking up a slight hill.
2
On level ground, I walk slower than people of the same age because of breathlessness, or have to 
stop for breath when walking at my own pace.
3
I stop for breath after walking about 100 meters or after a few minutes on level ground.
4
I am too breathless to leave the house or I am breathless when dressing.
The MMRC scale is a five-point scale published in 1959 that considers certain activities, such 
as walking or climbing stairs, which provoke breathlessness (Fletcher et al 1959). 
In one minute, the subject selects a grade on the MMRC scale that most closely matches 
his/her severity of dyspnea. The MMRC scale is considered a discriminative instrument that 
can categorize subjects with COPD in terms of their disability. The MMRC scale is not 
satisfactory as an evaluative instrument to measure changes in dyspnea, and its broad grades 
are generally unresponsive to interventions such as pharmacotherapy. 
Subjects will complete the MMRC scale at Visit 1, as a description of the symptomatic burden 
in study subjects. The MMRC scale will not be used to determine subject eligibility to 
participate in the study.
8.1.11
COPD Exacerbations
COPD exacerbations will only be recorded and summarized if they meet the criteria of being 
an SAE or if they lead to discontinuation of study drug.
8.2
Safety assessments 
Planned time points for all safety assessments are provided in the SoA.
8.2.1
Clinical safety laboratory assessments
See Table 10 for the list of clinical safety laboratory tests to be performed and to the SoA for 
the timing and frequency.  All protocol-required laboratory assessments, as defined in the 
table, must be conducted in accordance with the laboratory manual and the SoA.
The Investigator should make an assessment of the available results with regard to clinically 
relevant abnormalities.  The laboratory results should be signed and dated and retained at 
centre as source data for laboratory variables.  

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For information on how AEs based on laboratory tests should be recorded and reported, see 
Section 8.3.7.
Additional safety samples may be collected if clinically indicated at the discretion of the 
Investigator.  The clinically abnormal results (values, units and reference ranges) will be 
recorded on the appropriate CRF (Medical History if prior to randomization or Adverse Event 
if after randomization unless serious that may require documentation on the SAE eCRF).
The clinical chemistry, haematology and urinalysis will be performed at a local laboratory at 
or near to the Investigator site.  Sample tubes and sample sizes may vary depending on 
laboratory method used and routine practice at the site.
Table 10
Laboratory safety variables
Haematology/Haemostasis (whole blood)
Clinical Chemistry (serum or plasma)
B-Haemoglobin (Hb)
S/P-Creatinine
B-Leukocyte count
S/P-Bilirubin, total
B-Leukocyte differential count (absolute count)
S/P-Alkaline phosphatase (ALP)
B-Platelet count
S/P-Aspartate transaminase (AST)
Hematocrit
S/P-Alanine transaminase (ALT)
Red Blood Cell Count
S/P-Albumin
B-Glucose
S/P-Potassium
B-Urea Nitrogen (BUN)
S/P-Calcium, total
S/P-Sodium
NB. In case a subject shows an AST or ALT ≥3xULN together with total bilirubin ≥2xULN 
please refer to Appendix D ‘Actions required in cases of increases in liver biochemistry and 
evaluation of Hy’s Law’, for further instructions.
8.2.2
Medical/Surgical History and Physical Examination
Medical history, including smoking history details, will be collected at timelines as specified 
in the SoA. The number of COPD exacerbations requiring oral steroids and/or oral antibiotics, 
or hospitalization within 12 months of Visit 1 (Screening) will be collected.
A complete physical examination will be performed and include evaluation of relevant body 
parts, general appearance, skin, head, eyes, ears, nose, throat, neck (including thyroid), lymph 
nodes, chest, heart, abdomen, extremities, and nervous system. Weight, assessed in ordinary 
indoor clothing with shoes removed and height will be recorded at Visit 1 (Screening). 

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At all visits (including the follow-up telephone call [TC]) the subject will be asked about any 
recent change in their smoking status (i.e., whether a subject’s status has changed from 
smoker to non-smoker or vice versa). 
Physical examination will be performed at timelines as specified in the SoA, Investigators 
should pay special attention to clinical signs related to previous serious illnesses, new or 
worsening abnormalities may qualify as adverse events, see Section 8.3.7 for details.
8.2.3
Vital Sign Measurements
Heart rate, systolic and diastolic blood pressure, (‘vital signs’) will be assessed at timelines as 
specified in the SoA; assessments may be obtained in either the supine or seated position 
obtained after the subject has been in the supine or seated position for 5 minutes. 
If, in the opinion of the Investigator, a clinically significant vital sign change occurs, then the 
measurement will be repeated at medically appropriate intervals until the value returns to 
within an acceptable range. Temperature will be collected at Screening (Visit 1) and at pre-
dose at all visits and will not be repeated post-dose.
8.2.4
Electrocardiograms 
12-lead ECG will be collected for screening purposes only.
Electrocardiogram parameter assessments include: heart rate, QRS duration, QT interval, and 
QTcF ECG values will be checked by the investigator or designee.
8.3
Collection of adverse events
The Principal Investigator is responsible for ensuring that all staff involved in the study are 
familiar with the content of this section
The definitions of an AE or SAE can be found in Appendix B.
AE will be reported by the subject (or, when appropriate, by a caregiver, surrogate, or the 
subject's legally authorized representative).  
The investigator and any designees are responsible for detecting, documenting, and recording 
events that meet the definition of an AE or SAE. For information on how to follow/up AEs 
see section 8.3.3.  
8.3.1
Method of detecting AEs and SAEs
Care will be taken not to introduce bias when detecting AEs and/or SAEs. Open-ended and 
non-leading verbal questioning of the subject is the preferred method to inquire about 
AE occurrences.  

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8.3.2
Time period and frequency for collecting AE and SAE information 
Adverse Events will be collected from visit 2 throughout the treatment period and including 
the follow-up period telephone call.
SAEs will be reported from when the subject has signed informed consent and will continue 
throughout the clinical study until the end of any follow-up period. All SAEs will be recorded 
and reported to the sponsor or designee within 24 hours, as indicated in Appendix B.  The 
investigator will submit any updated SAE data to the sponsor within 24 hours of it being 
available.
Investigators are not obligated to actively seek AE or SAE in former study subjects. However, 
if the investigator learns of any SAE, including a death, at any time after a subject’s last visit 
and he/she considers the event to be reasonably related to the Study treatment or study 
participation, the investigator may notify the sponsor.
The method of recording, evaluating, and assessing causality of AE and SAE and the 
procedures for completing and transmitting SAE reports are provided in Appendix B.
8.3.3
Follow-up of AEs and SAEs
After the initial AE/SAE report, the investigator is required to proactively follow each subject 
at subsequent visits/contacts.  All SAEs will be followed until resolution, stabilization, the 
event is otherwise explained, or the subject is lost to follow-up 
Any AEs that are unresolved at the subject’s last AE assessment in the study are followed up 
by the Investigator for as long as medically indicated, but without further recording in the 
CRF.  AstraZeneca retains the right to request additional information for any subject with 
ongoing AE(s)/SAE(s) at the end of the study, if judged necessary.
8.3.4
Adverse event data collection
'The following variables will be collect for each AE;

AE (verbatim)

The date when the AE started and stopped

Maximum intensity

Whether the AE is serious or not

Investigator causality rating against the Investigational Product(s) (yes or no)

Action taken with regard to Investigational Product(s)

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
Outcome.
In addition, the following variables will be collected for SAEs:

Date AE met criteria for serious AE

Date Investigator became aware of serious AE

AE is serious due to

Date of hospitalisation

Date of discharge

Probable cause of death

Date of death

Autopsy performed

Causality assessment in relation to Study procedure(s)

Causality assessment to other medication'
8.3.5
Causality collection
The Investigator will assess causal relationship between Investigational Product and each 
Adverse Event, and answer ‘yes’ or ‘no’ to the question ‘Do you consider that there is a 
reasonable possibility that the event may have been caused by the investigational product?’
For SAEs, causal relationship will also be assessed for other medication and study procedures 
and AZ Medical device. Note that for SAEs that could be associated with any study procedure 
the causal relationship is implied as ‘yes’.
A guide to the interpretation of the causality question is found in Appendix B to the Clinical 
Study Protocol.
8.3.6
Adverse events based on signs and symptoms
All AEs spontaneously reported by the subject or reported in response to the open question 
from the study site staff: ‘Have you had any health problems since the previous visit/you were 
last asked?’, or revealed by observation will be collected and recorded in the CRF.  When 
collecting AEs, the recording of diagnoses is preferred (when possible) to recording a list of 
signs and symptoms.  However, if a diagnosis is known and there are other signs or symptoms 
that are not generally part of the diagnosis, the diagnosis and each sign or symptom will be 
recorded separately.

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8.3.7
Adverse events based on examinations and tests
The results from the Clinical Study Protocol mandated laboratory tests and vital signs will be 
summarised in the CSR.  Deterioration as compared to baseline in protocol-mandated vital 
signs should therefore only be reported as AEs if they fulfil any of the SAE criteria or are the 
reason for discontinuation of treatment with the investigational product.
If deterioration in a laboratory value/vital sign is associated with clinical signs and symptoms, 
the sign or symptom will be reported as an AE and the associated laboratory result/vital sign 
will be considered as additional information.  Wherever possible the reporting Investigator 
uses the clinical, rather than the laboratory term (e.g., anaemia versus low haemoglobin 
value).  In the absence of clinical signs or symptoms, clinically relevant deteriorations in non-
mandated parameters should be reported as AE(s).
Any new or aggravated clinically relevant abnormal medical finding at a physical examination 
as compared with the baseline assessment will be reported as an AE unless unequivocally 
related to the disease under study, see sections 8.3.9 and 8.310.
8.3.8
Hy’s law
Cases where subject shows elevations in liver biochemistry may require further evaluation and 
occurrences of AST or ALT ≥ 3xULN together with total bilirubin ≥ 2xULN may need to be 
reported as SAEs. Please refer to Appendix D for further instruction on cases of increases in 
liver biochemistry and evaluation of Hy’s Law
8.3.9
Disease-under study (DUS)
Symptoms of DUS are those which might be expected to occur as a direct result of COPD. 
Events which are unequivocally due to disease under study should not be reported as an AE 
during the study unless they meet SAE criteria or lead to discontinuation of the investigational 
product.
8.4
Safety reporting and medical management
8.4.1
Reporting of serious adverse events
All SAEs have to be reported, whether or not considered causally related to the investigational 
product, or to the study procedure(s).  All SAEs will be recorded in the CRF.
If any SAE occurs in the course of the study, then Investigators or other site personnel inform 
the appropriate AstraZeneca representatives within one day i.e., immediately but no later 
than 24 hours of when he or she becomes aware of it.
The designated AstraZeneca representative works with the Investigator to ensure that all the 
necessary information is provided to the AstraZeneca Patient Safety data entry site within 1

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calendar day of initial receipt for fatal and life-threatening events and within 5 calendar
days of initial receipt for all other SAEs.
For fatal or life-threatening adverse events where important or relevant information is missing, 
active follow-up is undertaken immediately.  Investigators or other site personnel inform 
AstraZeneca representatives of any follow-up information on a previously reported SAE 
within one calendar day i.e., immediately but no later than 24 hours of when he or she 
becomes aware of it.
Once the Investigators or other site personnel indicate an AE is serious in the EDC system, an 
automated email alert is sent to the designated AstraZeneca representative.
If the EDC system is not available, then the Investigator or other study site staff reports a SAE 
to the appropriate AstraZeneca representative by telephone.
The AstraZeneca representative will advise the Investigator/study site staff how to proceed.
Prompt notification by the investigator to the sponsor of a SAE is essential so that legal 
obligations and ethical responsibilities towards the safety of participants and the safety of a 
study intervention under clinical investigation are met.
The sponsor has a legal responsibility to notify both local authority and other regulatory 
agencies about the safety of a study intervention under clinical investigation. 
The sponsor will comply with country-specific regulatory requirements relating to safety 
reporting to the regulatory authority. Institutional Review Boards (IRB)/Independent Ethics 
Committees (IEC) and investigators.
Investigator safety reports must be prepared for suspected unexpected serious adverse 
reactions (SUSAR) according to local regulatory requirements and sponsor policy and 
forwarded to investigators as necessary.
An investigator who receive safety report describing a SAE or other safety information (e.g. 
summary of listing of SAEs) from the sponsor will review and then file it along with the 
Investigator’s Brochure and will notify the IRB/IEC if appropriate according to local 
requirements.
For further guidance on the definition of a SAE, see Appendix B of the Clinical Study 
Protocol.
8.4.2
Pregnancy
All pregnancies and outcomes of pregnancy should be reported to AstraZeneca except for:

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
If the pregnancy is discovered before the study subject has received any study drug
If a pregnancy is reported, the investigator should inform the sponsor within 24 hours of 
learning of the pregnancy.
Abnormal pregnancy outcomes (eg, spontaneous abortion, foetal death, stillbirth, 
congenital anomalies, ectopic pregnancy) are considered SAEs.
A urine pregnancy test will be performed in women of childbearing potential only, at 
timelines as specified in the SoA.
If any of these tests are positive, the subject must be discontinued from the study. The 
pregnancy test should be performed at the beginning of the visit.
8.4.2.1
Maternal exposure
If a subject becomes pregnant during the course of the study, investigational product should be 
discontinued immediately.
Pregnancy itself is not regarded as an adverse event unless there is a suspicion that the 
investigational product under study may have interfered with the effectiveness of a 
contraceptive medication.  Congenital abnormalities/birth defects and spontaneous 
miscarriages should be reported and handled as SAEs.  Elective abortions without 
complications should not be handled as AEs.  The outcome of all pregnancies (spontaneous 
miscarriage, elective termination, ectopic pregnancy, normal birth or congenital abnormality) 
should be followed up and documented even if the subject was discontinued from the study.
If any pregnancy occurs in the course of the study, then the Investigator or other site personnel 
informs the appropriate AstraZeneca representatives within 1day i.e., immediately but no 
later than 24 hours of when he or she becomes aware of it.
The designated AstraZeneca representative works with the Investigator to ensure that all 
relevant information is provided to the AstraZeneca Patient Safety data entry site within 1 or 5 
calendar days for SAEs (see Section 9.2.5) and within 30 days for all other pregnancies.
The same timelines apply when outcome information is available.
8.4.2.2
Paternal exposure 
There is no restriction on fathering children or donating sperm during the study.
8.4.3
Overdose
For this study, any dose of study medication greater than the high dose level evaluated in this 
study as described in Section 6.1 will be considered an overdose.
Sponsor does not recommend specific treatment for an overdose.

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
An overdose with associated AEs is recorded as the AE diagnosis/symptoms on the 
relevant AE modules in the CRF and on the Overdose CRF module.

An overdose without associated symptoms is only reported on the Overdose CRF module
If an overdose on an AstraZeneca study drug occurs in the course of the study, then the 
Investigator or other site personnel inform appropriate AstraZeneca representatives 
immediately, or no later than 24 hours of when he or she becomes aware of it.
The designated AstraZeneca representative works with the Investigator to ensure that all 
relevant information is provided to the AstraZeneca Patient Safety data entry site.

For overdoses associated with a SAE, the standard reporting timelines apply, see Section 
Time period and frequency for collecting AE and SAE information8.3.2. For other 
overdoses, reporting must occur within 30 days.
8.4.4
Medical device incidents (including malfunctions)
Medical devices are being provided for use in this study in order to dispense the dose to the 
patient.  In order to fulfil regulatory reporting obligations worldwide, the investigator is 
responsible for the detection and documentation of events meeting the definitions of incident 
or malfunction that occur during the study with such devices.
The definition of a Medical Device Incident can be found in Appendix E
NOTE: Incidents fulfilling the definition of an AE/SAE will also follow the processes outlined 
in Section 8.3 and Appendix B of the protocol.
8.4.4.1
Time period for detecting medical device incidents

Medical device incidents or malfunctions of the device that result in an incident will be 
detected, documented, and reported during all periods of the study in which the medical 
device is used.  

If the investigator learns of any incident at any time after a subject has been discharged 
from the study, and such incident is considered reasonably related to a medical device 
provided for the study, the investigator will promptly notify the sponsor.
The method of documenting Medical Device Incidents is provided in Appendix E.
8.4.4.2
Follow-up of medical device incidents

All medical device incidents involving an AE will be followed and reported in the same 
manner as other AEs (see Section 8.3.2). This applies to all subjects, including those who 
discontinue Study treatment.

The investigator is responsible for ensuring that follow-up includes any supplemental 
investigations as indicated to elucidate the nature and/or causality of the incident.

New or updated information will be recorded on the originally completed form with all 
changes signed and dated by the investigator.

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8.4.4.3
Reporting of medical device incidents to sponsor

Medical device incidents will be reported to the sponsor within 24 hours after the 
investigator determines that the event meets the protocol definition of a medical device 
incident.

The Medical Device CRF module will be completed in RAVE.

The same individual will be the contact for the receipt of medical device reports and SAE.

If an investigational medical device is used, the Study Representative will send the SAE 
report to AZ DES within one calendar day.
8.4.4.4
Regulatory reporting requirements for medical device incidents

The investigator will promptly report all incidents occurring with any medical device 
provided for use in the study in order for the sponsor to fulfil the legal responsibility to 
notify appropriate regulatory authorities and other entities about certain safety 
information relating to medical devices being used in clinical studies.

The investigator, or responsible person according to local requirements (e.g., the head of 
the medical institution), will comply with the applicable local regulatory requirements 
relating to the reporting of incidents to the IRB/IEC.
8.4.5
Medication error
If a medication error occurs in the course of the study, then the Investigator or other site 
personnel informs the appropriate AstraZeneca representatives within 1 day i.e., immediately 
but no later than 24 hours of when he or she becomes aware of it.
The designated AstraZeneca representative works with the Investigator to ensure that all 
relevant information is completed within 1 (Initial Fatal/Life-Threatening or follow up 
Fatal/Life-Threatening) or 5 (other serious initial and follow up) calendar days if there is an 
SAE associated with the medication error (see Section 8.3.2) and within 30 days for all other 
medication errors.
The definition of a Medication Error can be found in Appendix B.
8.5
Pharmacokinetics
PK parameters are not evaluated in this study.
8.6
Pharmacodynamics
Pharmacodynamic parameters are not evaluated in this study.
8.7
Genetics
Genetic testing is not evaluated in this study.
8.8
Biomarkers
Biomarkers are not evaluated in this study.

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8.9
Medical Resource Utilization and Health Economics
Medical Resource Utilization and Health Economics parameters are not evaluated in this 
study.

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9
STATISTICAL CONSIDERATIONS 
9.1
Statistical hypotheses
The purpose of this study is to assess the extent of airway changes with each of two treatments 
(BGF and GFF) over 4 weeks. The first day of treatment in each treatment period is Day 1. 
Each treatment period is planned to contain 29 (±3 days) calendar days. Therefore, the 
assessments collected on Day 29 (Visits 4 and 6) will occur following 28 days of treatment.
Denote the FRI value at baseline by FRI(PRE) and the post-treatment FRI value at Day 29 by 
FRI(POST). The change from baseline for each subject will then be calculated as FRI(CHG) = 
FRI(POST) – FRI(PRE) and analysed for each treatment. The hypotheses for the respective 
“within-treatment” comparisons are: 
H0: FRI(CHG) = 0, for BGF (no effect of treatment)
H1: FRI(CHG) ≠ 0, for BGF
H0: FRI(CHG) = 0, for GFF (no effect of treatment)
H1: FRI(CHG) ≠ 0, for GFF
9.2
Sample size determination 
A total of approximately 20 subjects will be randomized. No formal sample size calculation 
has been done. The proposed sample size for this pilot study is based on previous experience, 
which included two previously conducted FRI studies with FLUIDDA (PT003018 and 
PT003019). Each of these studies included approximately 20 subjects. 
In PT003019, the change (ratio) from baseline observed with glycopyrronium treatment was 
1.13 (SD=0.22); leading to an effect size of 0.59. Assuming similar improvements from 
baseline in airway volume parameters with active treatments in this study, a change of 13% 
can be observed when 20 subjects are included (power goal 80%, alpha=0.05).
9.3
Populations for analyses
For purposes of analysis, the following populations are defined:
Population
Description
Enrolled 
All subjects who sign the ICF.
Intent-to-Treat (ITT) analysis set 
All subjects who were randomized to study treatment.
Modified ITT (mITT) analysis set
All subjects in the ITT analysis set who completed both treatment 
periods and have FRI data at baseline and after approximately four 
weeks of treatment. Data judged to be impacted by major protocol 
deviations will be determined prior to unblinding and excluded.

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Safety analysis set
All subjects who were randomized to study treatment and who took at 
least 1 dose of IMP and for whom any post-dose data are available. 
Demographics and subject characteristics will be summarized for the ITT analysis set. Extent 
of exposure and safety data will be summarized for the safety analysis set. The ITT analysis 
set will be considered the primary analysis population for efficacy. The mITT analysis set is a 
subset of the ITT analysis set. If the data contributing to the mITT analyses differs from the 
data contributing to the ITT analyses, then the mITT analysis set may be used to conduct 
sensitivity analyses for the two primary endpoints.
9.4
Statistical analyses
All personnel involved with the analysis of the study will remain blinded until database lock 
and Clinical Study Protocol deviations identified.
Analyses will be performed by AstraZeneca or its representatives. A comprehensive statistical 
analysis plan will be developed and finalised before database lock and will describe the 
subject populations to be included in the analyses, and procedures for accounting for missing, 
unused, and spurious data. This section is a summary of the planned statistical analyses of the 
primary and secondary endpoints. Any deviations from this plan will be reported in the
clinical study report.
9.4.1
General principles
Continuous efficacy variables will be summarized with descriptive statistics (n, mean, 
standard deviation, median, minimum and maximum). Categorical variables will be 
summarized with frequency counts and percentages.
It is anticipated that logarithmic transformations may be required for most FRI and body 
plethysmography endpoints. If this is the case, estimates for the treatment effect will be 
presented as a ratio.
No imputation for missing values is planned.
9.4.2
Efficacy analyses
The focus of this study is on estimation of the individual effects of treatment with BGF and 
GFF. For the primary analyses, the individual (“within-treatment”) effects of both BGF and 
GFF will be assessed. This effect is defined as the change from baseline to Day 29 for BGF 
treatment and the change from baseline to Day 29 for GFF treatment. Baseline for both 
treatment groups will be defined as the pre-dose FRI value taken at Visit 3.

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10
REFERENCES
De Backer et al 2012
De Backer L, Vos W, De Backer J, Van Holsbeke C, Vinchurkar S, De Backer W. The acute 
effect of budesonide/formoterol in COPD: a multi-slice computed tomography and lung 
function study. Eur Respir J. 2012 Aug 1;40(2):298–305.
De Backer et al 2011
De Backer L, Vos W, Salgado R, De Backer J, Devolder A, Verhulst S, et al. Functional 
imaging using computer methods to compare the effect of salbutamol and ipratropium 
bromide in subject-specific airway models of COPD. Int J Chron Obstruct Pulmon Dis. 
2011;6:637–46.
Fletcher et al 1959
Fletcher CM, Elmes PC, Fairbairn MB, et al. The significance of respiratory symptoms and 
the diagnosis of chronic bronchitis in a working population. Br Med J. 1959; 2:257-266.
GOLD 2018
GOLD (Global Initiative for Chronic Obstructive Lung Disease). Global strategy for the 
diagnosis, management, and prevention of chronic obstructive pulmonary disease. National 
Institutes of Health, updated 2018 (www.goldcopd.com).
Ferguson et al 2018
Gary T Ferguson, Klaus F Rabe, Fernando J Martinez, Leonardo M Fabbri, Chen Wang, 
Masakazu Ichinose, Eric Bourne, Shaila Ballal, Patrick Darken, Kiernan DeAngelis, Magnus 
Aurivillius, Paul Dorinsky, Colin Reisner “Triple therapy with 
budesonide/glycopyrrolate/formoterol fumarate with co-suspension delivery technology 
versus dual therapies in chronic obstructive pulmonary disease (KRONOS): a double-blind, 
parallel-group, multicentre, phase 3 randomised controlled trial;” Lancet Respir Med 2018, 
Published Online September 16, 2018 http://dx.doi.org/10.1016/S2213-2600(18)30327-8
Levey et al 2009
Levey AS, Stevens LA, Schmid CH et al. A new equation to estimate glomerular filtration 
rate. Annals of Internal Medicine. 2009; 150 (9): 604–12.
Miller et al 2005
Miller MR, Crapo R, Hankinson J, et al. ATS/ERS Task Force. General considerations for
lung function testing. Eur Respir J. 2005; 26:153-61 Eur Respir J. 2005; 26:153-61.
Vos et al 2013
Vos W, De Backer J, Poli G, De Volder A, Ghys L, Van Holsbeke C, et al. Novel functional 
imaging of changes in small airways of subjects treated with extrafine 
beclomethasone/formoterol. Respiration. 2013; 86(5):393–401.

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11
SUPPORTING DOCUMENTATION AND OPERATIONAL
CONSIDERATIONS
Appendix A
Regulatory, ethical and study oversight considerations
A 1
Regulatory and ethical considerations
This study will be conducted in accordance with the protocol and with the following:

Consensus ethical principles derived from international guidelines including the 
Declaration of Helsinki and Council for International Organizations of Medical Sciences 
(CIOMS) International Ethical Guidelines

Applicable ICH Good Clinical Practice (GCP) Guidelines

Applicable laws and regulations
The protocol, protocol amendments, ICF, Investigator Brochure, and other relevant documents 
(eg, advertisements) must be submitted to an IRB/IEC by the investigator and reviewed and 
approved by the IRB/IEC before the study is initiated.  
Any amendments to the protocol will require IRB/IEC approval before implementation of 
changes made to the study design, except for changes necessary to eliminate an immediate 
hazard to study subjects.  
The investigator will be responsible for the following:

Providing written summaries of the status of the study to the IRB/IEC annually or more 
frequently in accordance with the requirements, policies, and procedures established by 
the IRB/IEC

Notifying the IRB/IEC of SAEs or other significant safety findings as required by 
IRB/IEC procedures

Providing oversight of the conduct of the study at the site and adherence to requirements 
of 21 CFR, ICH guidelines, the IRB/IEC, European regulation 536/2014 for clinical 
studies (if applicable), and all other applicable local regulations
The study will be performed in accordance with the AstraZeneca policy on Bioethics and 
Human Biological Samples.
AstraZeneca will provide Regulatory Authorities, Ethics Committees and Principal 
Investigators with safety updates/reports according to local requirements.
A 2
Financial disclosure
Investigators and sub-investigators will provide the sponsor with sufficient, accurate financial 
information as requested to allow the sponsor to submit complete and accurate financial 
certification or disclosure statements to the appropriate regulatory authorities.  Investigators 

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are responsible for providing information on financial interests during the course of the study 
and for 1 year after completion of the study.
A 3
Informed consent process
The investigator or his/her representative will explain the nature of the study to the subject or 
his/her legally authorised representative and answer all questions regarding the study.  
Subjects must be informed that their participation is voluntary.  Subjects or their legally 
authorised representative will be required to sign a statement of informed consent that meets 
the requirements of 21 CFR 50, local regulations, ICH guidelines, Health Insurance Portability 
and Accountability Act (HIPAA) requirements, where applicable, and the IRB/IEC or study 
centre.  
The medical record must include a statement that written informed consent was obtained 
before the subject was enrolled in the study and the date the written consent was obtained.  
The authorised person obtaining the informed consent must also sign the ICF.
Subjects must be re-consented to the most current version of the ICF(s) during their 
participation in the study.  
A copy of the ICF(s) must be provided to the subject or the subject’s legally authorised 
representative.  
Subjects who are rescreened are required to sign a new ICF.
A 4
Data protection
Each subject will be assigned a unique identifier by the sponsor.  Any subject records or data 
sets transferred to the sponsor will contain only the identifier; subject names or any 
information which would make the subject identifiable will not be transferred.  
The subject must be informed that his/her personal study-related data will be used by the 
sponsor in accordance with local data protection law.  The level of disclosure must also be 
explained to the subject.  
The subject must be informed that his/her medical records may be examined by Clinical 
Quality Assurance auditors or other authorised personnel appointed by the sponsor, by 
appropriate IRB/IEC members, and by inspectors from regulatory authorities.
The safety of all AstraZeneca clinical studies is closely monitored on an on-going basis by 
AstraZeneca representatives in consultation with Patient Safety.  Issues identified will be 

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addressed; for instance, this could involve amendments to the Clinical Study Protocol and 
letters to Investigators.
A 5
Dissemination of clinical study data
A description of this clinical trial will be available on http://astrazenecaclinicaltrials.com and 
http://www.clinicaltrials.gov as will the summary of the study results when they are available. 
The clinical trial and/or summary of study results may also be available on other websites 
according to the regulations of the countries in which the study is conducted.
A 6
Data quality assurance
All subject data relating to the study will be recorded on printed or electronic CRF unless 
transmitted to the sponsor or designee electronically (eg, laboratory data).  The investigator is 
responsible for verifying that data entries are accurate and correct by physically or 
electronically signing the CRF.  
The investigator must maintain accurate documentation (source data) that supports the 
information entered in the CRF.  
The investigator must permit study-related monitoring, audits, IRB/IEC review, and 
regulatory agency inspections and provide direct access to source data documents.  
The sponsor or designee is responsible for the data management of this study including quality 
checking of the data.  
Study monitors will perform ongoing source data verification to confirm that data entered into 
the CRF by authorised site personnel are accurate, complete, and verifiable from source 
documents; that the safety and rights of subjects are being protected; and that the study is 
being conducted in accordance with the currently approved protocol and any other study 
agreements, ICH GCP, and all applicable regulatory requirements.  
Records and documents, including signed ICFs, pertaining to the conduct of this study must 
be retained by the investigator for 15 years after study completion unless local regulations or 
institutional policies require a longer retention period.  No records may be destroyed during 
the retention period without the written approval of the sponsor.  No records may be 
transferred to another location or party without written notification to the sponsor. 
A 7
Source documents
Source documents provide evidence for the existence of the subject and substantiate the 
integrity of the data collected.  Source documents are filed at the investigator’s site.

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Data reported on the CRF that are transcribed from source documents must be consistent with 
the source documents or the discrepancies must be explained.  The investigator may need to 
request previous medical records or transfer records, depending on the study.  Also, current 
medical records must be available.
A 8
Publication policy
The results of this study may be published or presented at scientific meetings.  If this is 
foreseen, the investigator agrees to submit all manuscripts or abstracts to the sponsor before 
submission.  This allows the sponsor to protect proprietary information and to provide 
comments.  
The sponsor will comply with the requirements for publication of study results.  In accordance 
with standard editorial and ethical practice, the sponsor will generally support publication of 
multicentre studies only in their entirety and not as individual site data.  In this case, a 
coordinating investigator will be designated by mutual agreement.
Authorship will be determined by mutual agreement and in line with International Committee 
of Medical Journal Editors authorship requirements.

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Appendix B
Adverse event definitions and additional safety information
B 1
Definition of adverse events
An adverse event is the development of any untoward medical occurrence in a subject or 
clinical study subject administered a medicinal product and which does not necessarily have a 
causal relationship with this treatment.   An AE can therefore be any unfavourable and 
unintended sign (e.g.  an abnormal laboratory finding), symptom (for example nausea, chest 
pain), or disease temporally associated with the use of a medicinal product, whether or not 
considered related to the medicinal product.  
The term AE is used to include both serious and non-serious AEs and can include a 
deterioration of a pre-existing medical occurrence.  An AE may occur at any time, including 
run-in or washout periods, even if no Study treatment has been administered.
B 2
Definitions of serious adverse event
A serious adverse event is an AE occurring during any study phase (i.e., run-in, treatment, 
washout, follow-up), that fulfils one or more of the following criteria:

Results in death

Is immediately life-threatening

Requires in-subject hospitalisation or prolongation of existing hospitalisation 

Results in persistent or significant disability or incapacity.  

Is a congenital abnormality or birth defect

Is an important medical event that may jeopardise the subject or may require medical 
treatment to prevent one of the outcomes listed above.
B 3
Life threatening
‘Life-threatening’ means that the subject was at immediate risk of death from the AE as it 
occurred or it is suspected that use or continued use of the product would result in the 
subject’s death.  ‘Life-threatening’ does not mean that had an AE occurred in a more severe 
form it might have caused death (e.g., hepatitis that resolved without hepatic failure).
B 4
Hospitalisation
Outpatient treatment in an emergency room is not in itself a serious AE, although the reasons 
for it may be (e.g., bronchospasm, laryngeal oedema).  Hospital admissions and/or surgical 
operations planned before or during a study are not considered AEs if the illness or disease 
existed before the subject was enrolled in the study, provided that it did not deteriorate in an 
unexpected way during the study.

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B 5
Important medical event or medical treatment
Medical and scientific judgement should be exercised in deciding whether a case is serious in 
situations where important medical events may not be immediately life threatening or result in 
death, hospitalisation, disability or incapacity but may jeopardize the subject or may require 
medical treatment to prevent one or more outcomes listed in the definition of serious.  These 
should usually be considered as serious.
Simply stopping the suspect drug does not mean that it is an important medical event; medical 
judgement must be used.

Angioedema not severe enough to require intubation but requiring iv hydrocortisone 
treatment

Hepatotoxicity caused by paracetamol (acetaminophen) overdose requiring treatment with 
N-acetylcysteine

Intensive treatment in an emergency room or at home for allergic bronchospasm

Blood dyscrasias (e.g., neutropenia or anaemia requiring blood transfusion, etc.) or 
convulsions that do not result in hospitalisation

Development of drug dependency or drug abuse
B 6
Intensity rating scale:
1
mild (awareness of sign or symptom, but easily tolerated)
2
moderate (discomfort sufficient to cause interference with normal activities)
3
severe (incapacitating, with inability to perform normal activities)
It is important to distinguish between serious and severe AEs.  Severity is a measure of 
intensity whereas seriousness is defined by the criteria in Appendix B 2.  An AE of severe 
intensity need not necessarily be considered serious.  For example, nausea that persists for 
several hours may be considered severe nausea, but not a SAE unless it meets the criteria 
shown in Appendix B 2. On the other hand, a stroke that results in only a limited degree of 
disability may be considered a mild stroke but would be a SAE when it satisfies the criteria 
shown in Appendix B 2.
B 7
A Guide to Interpreting the Causality Question
When making an assessment of causality consider the following factors when deciding if there 
is a ‘reasonable possibility’ that an AE may have been caused by the drug.

Time Course.  Exposure to suspect drug.  Has the subject actually received the suspect 
drug?  Did the AE occur in a reasonable temporal relationship to the administration of the 
suspect drug?

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
Consistency with known drug profile.  Was the AE consistent with the previous 
knowledge of the suspect drug (pharmacology and toxicology) or drugs of the same 
pharmacological class? Or could the AE be anticipated from its pharmacological 
properties?

De-challenge experience.  Did the AE resolve or improve on stopping or reducing the 
dose of the suspect drug?

No alternative cause.  The AE cannot be reasonably explained by another aetiology such 
as the underlying disease, other drugs, other host or environmental factors.

Re-challenge experience.  Did the AE reoccur if the suspected drug was reintroduced 
after having been stopped? AstraZeneca would not normally recommend or support a re-
challenge.

Laboratory tests.  A specific laboratory investigation (if performed) has confirmed the 
relationship.
In difficult cases, other factors could be considered such as:

Is this a recognized feature of overdose of the drug?

Is there a known mechanism?
Causality of ‘related’ is made if following a review of the relevant data, there is evidence for a 
‘reasonable possibility’ of a causal relationship for the individual case.  The expression 
‘reasonable possibility’ of a causal relationship is meant to convey, in general, that there are 
facts (evidence) or arguments to suggest a causal relationship.
The causality assessment is performed based on the available data including enough 
information to make an informed judgment.  With limited or insufficient information in the 
case, it is likely that the event(s) will be assessed as ‘not related’.
Causal relationship in cases where the disease under study has deteriorated due to lack of 
effect should be classified as no reasonable possibility.
B 8
Medication Error
For the purposes of this clinical study a medication error is an unintended failure or mistake in 
the treatment process for an AstraZeneca study drug that either causes harm to the participant 
or has the potential to cause harm to the participant.  
A medication error is not lack of efficacy of the drug, but rather a human or process related 
failure while the drug is in control of the study site staff or participant.
Medication error includes situations where an error.  

occurred

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
was identified and intercepted before the participant received the drug

did not occur, but circumstances were recognize that could have led to an error
Examples of events to be reported in clinical studies as medication errors:

Drug name confusion

Dispensing error e.g.  medication prepared incorrectly, even if it was not actually given to 
the participant

Drug not administered as indicated, for example, wrong route or wrong site of 
administration

Drug not taken as indicated e.g.  tablet dissolved in water when it should be taken as a 
solid tablet 

Drug not stored as instructed e.g.  kept in the fridge when it should be at room 
temperature 

Wrong participant received the medication 

Wrong drug administered to participant 
Examples of events that do not require reporting as medication errors in clinical studies:

Participant accidentally missed drug dose(s) e.g.  forgot to take medication

Accidental overdose (will be captured as an overdose)

Participant failed to return unused medication or empty packaging

Errors related to background and rescue medication, or standard of care medication in 
open label studies, even if an AZ product 
Medication errors are not regarded as AEs but AEs may occur as a consequence of the 
medication error.

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Appendix C
Handling of Human Biological Samples
C 1
Chain of custody of biological samples
A full chain of custody is maintained for all samples throughout their lifecycle.
The Investigator at each centre keeps full traceability of collected biological samples from the 
subjects while in storage at the centre until shipment or disposal (where appropriate).
The sample receiver keeps full traceability of the samples while in storage and during use until 
used or disposed of or until further shipment and keeps documentation of receipt of arrival.
AstraZeneca will keep oversight of the entire life cycle through internal procedures, 
monitoring of study sites, auditing or process checks, and contractual requirements of external 
laboratory providers
C 2
Withdrawal of Informed Consent for donated biological samples 
If a subject withdraws consent to the use of donated biological samples, the samples will be 
disposed of/destroyed, and the action documented.  If samples are already analysed,
AstraZeneca is not obliged to destroy the results of this research.
As collection of the biological sample(s) is an optional part of the study, then the subject may 
continue in the study.
The Investigator:

Ensures subjects’ withdrawal of informed consent to the use of donated samples is 
notified immediately to AstraZeneca

Ensures that biological samples from that subject, if stored at the study site, are 
immediately identified, disposed of /destroyed, and the action documented

Ensures the organization(s) holding the samples is/are informed about the withdrawn 
consent immediately and that samples are disposed of/destroyed, the action documented 
and the signed document returned to the study site

Ensures that the subject and AstraZeneca are informed about the sample disposal.
AstraZeneca ensures the organizations holding the samples is/are informed about the 
withdrawn consent immediately and that samples are disposed of/destroyed and the action 
documented and returned to the study site.

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C 3
 
Guidance Document
LABELLING AND SHIPMENT OF BIOHAZARD SAMPLES
 classifies biohazardous agents into 3 
categories 
 For 
transport purposes the classification of infectious substances according to risk groups was 
removed from the Dangerous Goods Regulations in 
 Infectious 
substances are now classified either as Category A, Category B or Exempt. There is no direct 
relationship between Risk Groups and Categories A and B.
Category A Infectious Substances are infectious substances in a form that, when exposure to 
it occurs, is capable of causing permanent disability, life-threatening or fatal disease in 
otherwise healthy humans or animals. Category A pathogens are eg, Ebola, Lassa fever virus:

are to be packed and shipped in accordance with 
Category B Infectious Substances are infectious Substances that do not meet the criteria for 
inclusion in Category A. Category B pathogens are eg, Hepatitis A, B, C, D, and E viruses, 
Human immunodeficiency virus types 1 and 2. They are assigned the following UN number 
and proper shipping name:


Exempt - all other materials with minimal risk of containing pathogens

Clinical trial samples will fall into Category B or exempt under 

Clinical trial samples will routinely be packed and transported at ambient

 

Biological samples transported in dry ice require additional dangerous goods 
specification for the dry-ice content

 courier and packaging materials should be used for packing and 
transportation and packing should be done by an 
, as applicable

Samples routinely transported by road or rail are subject to local regulations which 
require that they are also packed and transported in a safe and appropriate way to contain 
any risk of infection or contamination by using approved couriers and 
packaging/containment materials at all times. 
 biological sample 
containment standards are encouraged wherever possible when road or rail transport is 
used.
.

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Appendix D
Actions required in cases of increases in liver biochemistry 
and evaluation of Hy’s Law
D 1
Introduction
This Appendix describes the process to be followed in order to identify and appropriately 
report Potential Hy’s Law (PHL) cases and Hy’s Law (HL) cases. It is not intended to be a 
comprehensive guide to the management of elevated liver biochemistries. 
<<Specific guidance on managing liver abnormalities can be found in Section XX of the 
Clinical Study Protocol >>.
During the course of the study the Investigator will remain vigilant for increases in liver 
biochemistry.  The Investigator is responsible for determining whether a subject meets 
potential PHL criteria at any point during the study.
All sources of laboratory data are appropriate for the determination of PHL and HL events; 
this includes samples taken at scheduled study visits and other visits including central and all 
local laboratory evaluations even if collected outside of the study visits; for example, PHL 
criteria could be met by an elevated ALT from a central laboratory and/or elevated TBL from 
a local laboratory.  
The Investigator will also review Adverse Event data (for example, for AEs that may indicate 
elevations in liver biochemistry) for possible PHL events.
The Investigator participates, together with AstraZeneca clinical project representatives, in 
review and assessment of cases meeting PHL criteria to agree whether Hy’s Law (HL) criteria 
are met.  HL criteria are met if there is no alternative explanation for the elevations in liver 
biochemistry other than Drug Induced Liver Injury (DILI) caused by the Investigational 
Medicinal Product (IMP). 
The Investigator is responsible for recording data pertaining to PHL/HL cases and for 
reporting Serious Adverse Events (SAEs) and Adverse Events (AEs) according to the 
outcome of the review and assessment in line with standard safety reporting processes.
D 2
Definitions
Potential Hy’s Law (PHL)
Aspartate Aminotransferase (AST) or Alanine Aminotransferase (ALT) ≥ 3x Upper Limit of 
Normal (ULN) together with Total Bilirubin (TBL) ≥ 2xULN at any point during the study 

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following the start of study medication irrespective of an increase in Alkaline Phosphatase 
(ALP). 
Hy’s Law (HL)
AST or ALT ≥ 3x ULN together with TBL ≥ 2xULN, where no other reason, other than the 
IMP, can be found to explain the combination of increases, e.g., elevated ALP indicating 
cholestasis, viral hepatitis, another drug.  
For PHL and HL the elevation in transaminases must precede or be coincident with (i.e. on the 
same day) the elevation in TBL, but there is no specified timeframe within which the 
elevations in transaminases and TBL must occur.
D 3
Identification of potential Hy’s Law cases
In order to identify cases of PHL it is important to perform a comprehensive review of 
laboratory data for any subject who meets any of the following identification criteria in 
isolation or in combination:

ALT ≥ 3 × ULN

AST ≥ 3 × ULN

TBL ≥ 2 × ULN
The Investigator will without delay review each new laboratory report and if the identification 
criteria are met will:

Notify the AstraZeneca representative

Determine whether the subject meets PHL criteria (see Appendix D 2 for definition) by 
reviewing laboratory reports from all previous visits

Promptly enter the laboratory data into the laboratory CRF
D 4
Follow-up
D 4.1
Potential Hy’s Law criteria not met
If the subject does not meet PHL criteria the Investigator will:

Inform the AstraZeneca representative that the subject has not met PHL criteria.

Perform follow-up on subsequent laboratory results according to the guidance provided in 
the Clinical Study Protocol.
D 4.2
Potential Hy’s Law Criteria Met
If the subject does meet PHL criteria the Investigator will:

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
Notify the AstraZeneca representative who will then inform the central Study Team

Within 1 day of PHL criteria being met, the Investigator will report the case as an SAE of 
Potential Hy’s Law; serious criteria ‘Important medical event’ and causality assessment 
‘yes/related’ according to CSP process for SAE reporting.

For subjects that met PHL criteria prior to starting IMP, the investigator is not required to 
submit a PHL SAE unless there is a significant change# in the subject’s condition

The Study Physician contacts the Investigator, to provide guidance, discuss and agree an 
approach for the study subjects’ follow-up (including any further laboratory testing) and 
the continuous review of data

Subsequent to this contact the Investigator will:

Monitor the subject until liver biochemistry parameters and appropriate clinical 
symptoms and signs return to normal or baseline levels, or as long as medically 
indicated. Completes follow-up SAE Form as required.

Investigate the aetiology of the event and perform diagnostic investigations as 
discussed with the Study Physician. << For studies using a central laboratory add:
This includes deciding which the tests available in the Hy’s law lab kit should be 
used>> 

Complete the three Liver CRF Modules as information becomes available 
# A ‘significant’ change in the subject’s condition refers to a clinically relevant 
change in any of the individual liver biochemistry parameters (ALT, AST or total 
bilirubin) in isolation or in combination, or a clinically relevant change in associated 
symptoms.  The determination of whether there has been a significant change will be at 
the discretion of the Investigator, this may be in consultation with the Study Physician if 
there is any uncertainty.
D 5
Review and assessment of potential Hy’s Law cases
The instructions in this section should be followed for all cases where PHL criteria are met.
As soon as possible after the biochemistry abnormality was initially detected, the Study 
Physician contacts the Investigator in order to review available data and agree on whether 
there is an alternative explanation for meeting PHL criteria other than DILI caused by the 
IMP, to ensure timely analysis and reporting to health authorities within 15 calendar days 
from date PHL criteria was met.  The AstraZeneca Global Clinical Lead or equivalent and 
Global Safety Physician will also be involved in this review together with other subject matter 
experts as appropriate.  

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According to the outcome of the review and assessment, the Investigator will follow the 
instructions below.
Where there is an agreed alternative explanation for the ALT or AST and TBL elevations, 
a determination of whether the alternative explanation is an AE will be made and 
subsequently whether the AE meets the criteria for a SAE:

If the alternative explanation is not an AE, record the alternative explanation on 
the appropriate CRF

If the alternative explanation is an AE/SAE: update the previously submitted 
Potential Hy’s Law SAE and AE CRFs accordingly with the new information 
(reassessing event term; causality and seriousness criteria) following the AZ 
standard processes.
If it is agreed that there is no explanation that would explain the ALT or AST and TBL 
elevations other than the IMP:

Send updated SAE (report term ‘Hy’s Law’) according to AstraZeneca standard 
processes. 

The ‘Medically Important’ serious criterion should be used if no other serious 
criteria apply

As there is no alternative explanation for the HL case, a causality assessment of 
‘related’ should be assigned.
If, there is an unavoidable delay, of over 15 calendar days in obtaining the information 
necessary to assess whether or not the case meets the criteria for HL, then it is assumed that 
there is no alternative explanation until such time as an informed decision can be made:

Provides any further update to the previously submitted SAE of Potential Hy’s
Law, (report term now ‘Hy’s Law case’) ensuring causality assessment is related 
to IMP and seriousness criteria is medically important, according to CSP process 
for SAE reporting.

Continue follow-up and review according to agreed plan.  Once the necessary 
supplementary information is obtained, repeat the review and assessment to 
determine whether HL criteria are still met.  Update the previously submitted PHL 
SAE report following CSP process for SAE reporting, according to the outcome of 
the review and amending the reported term if an alternative explanation for the 
liver biochemistry elevations is determined.

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D 6
Laboratory tests
Hy’s Law lab kit for laboratories
Additional standard chemistry and 
coagulation tests
GGT
LDH
Prothrombin time
INR
Viral hepatitis
IgM anti-HAV 
IgM and IgG anti-HBc
HBsAg
HBV DNA
IgG anti-HCV
HCV RNA* 
IgM anti-HEV
HEV RNA
Other viral infections
IgM & IgG anti-CMV
IgM & IgG anti-HSV
IgM & IgG anti-EBV
Alcoholic hepatitis
Carbohydrate deficient transferrin (CD-
transferrin)**
Autoimmune hepatitis
Antinuclear antibody (ANA)
Anti-Liver/Kidney Microsomal Ab (Anti-
LKM)
Anti-Smooth Muscle Ab (ASMA)
Metabolic diseases
alpha-1-antitrypsin
Ceruloplasmin
Iron
Ferritin
Transferrin
Transferrin saturation
* HCV RNA is only tested when IgG anti-HCV is positive or inconclusive
References
Aithal et al 2011, Clinical Pharmacology and Therapeutics 89(6):806-815.
FDA Guidance for Industry (issued July 2009) ‘Drug-induced liver injury: Premarketing 
clinical evaluation’

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Appendix E
Medical device incidents: definition and procedures for 
recording, evaluating, follow-up, and reporting 
E 1
Definitions of a Medical Device Incident
The detection and documentation procedures described in this protocol apply to all sponsor 
provided medical devices provided for use in the study (see Section 6.1.2) for the list of 
sponsor provided medical devices).
Medical Device Incident Definition

A medical device incident is any malfunction or deterioration in the characteristics 
and/or performance of a device as well as any inadequacy in the labelling or the 
instructions for use which, directly or indirectly, might lead to or might have led to the 
death of a subject/user/other person or to a serious deterioration in his/her state of health.

Not all incidents lead to death or serious deterioration in health.  The non-occurrence of 
such a result might have been due to other fortunate circumstances or to the treatment of 
health care personnel.
It is sufficient that:

An incident associated with a device happened.
AND

The incident was such that, if it occurred again, might lead to death or a serious 
deterioration in health.
A serious deterioration in state of health can include any of the following:

Life-threatening illness

Permanent impairment of body function or permanent damage to body structure

Condition necessitating medical or surgical treatment to prevent one of the above 

Foetal distress, foetal death, or any congenital abnormality or birth defects
Examples of incidents:

A subject, user, caregiver, or healthcare professional is injured as a result of a medical 
device failure or its misuse.

A subject’s Study treatment is interrupted or compromised by a medical device failure.

A misdiagnosis due to medical device failure leads to inappropriate treatment.
A subject’s health deteriorates due to medical device failure.

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Documenting medical device incidents
Medical device incident documentation
Any medical device incident occurring during the study will be documented in the subject’s 
medical records, in accordance with the investigator’s normal clinical practice, and on the 
appropriate form of the CRF.
For incidents fulfilling the definition of an AE or an SAE, the appropriate AE/SAE CRF page 
will be completed as described in Appendix B.
The CRF will be completed as thoroughly as possible and signed by the investigator before 
transmittal to the sponsor or designee.
It is very important that the investigator provides his/her assessment of causality (relationship 
to the medical device provided by the sponsor) at the time of the initial AE or SAE report and 
describes any corrective or remedial actions taken to prevent recurrence of the incident.
A remedial action is any action other than routine maintenance or servicing of a medical 
device where such action is necessary to prevent recurrence of an incident.  This includes any 
amendment to the device design to prevent recurrence.

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Appendix F
Abbreviations 
Abbreviation or 
special term
Explanation
AE
adverse event
ALP
Alkaline phosphatase
ALT
Alanine aminotransferase
AST
Aspartate aminotransferase
AT
Air Trapping
ATS
American Thoracic Society
BGF
Budesonide/Glycopyrronium/Formoterol Fumarate
BID
twice-daily
BiPAP
bilevel positive airway pressure
CAT
COPD assessment test
CFD
Computational fluid dynamics
CIOMS
Council for International Organizations of Medical Sciences
CKD-EPI
Chronic Kidney Disease Epidemiology Collaboration
CPAP
continuous positive airway pressure
CRF
case report form (electronic/paper)
CONSORT
Consolidated Standards of Reporting Trials
COPD
Chronic obstructive pulmonary disease
CSA
clinical study agreement
CSR
clinical study report
CT
Computed Tomography
CTCAE
Common Terminology Criteria for Adverse Event
DAE
discontinuation of investigational product due to adverse event
DES
data entry site
DILI
drug induced liver injury
DNA
deoxyribonucleic acid 
DUS
Disease-under study
EC
ethics committee, synonymous to institutional review board (IRB) and 
independent ethics committee (IEC)
ECG
Electrocardiogram

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Abbreviation or 
special term
Explanation
EDC
electronic data capture
ERS
European Respiratory Society
FAS
full analysis set
FEV1
Forced expiratory volume in one second
FRI
functional respiratory imaging
FRC
functional residual capacity
FVC
Forced vital capacity
GCP
Good Clinical Practice
GFF
Glycopyrronium/Formoterol Fumarate
GOLD
The Global Initiative for Chronic Obstructive Lung Disease
HFA
Hydrofluoroalkane
HIPAA
Health Insurance Portability and Accountability Act
HL
Hy’s Law
HRCT
High Resolution Computed Tomography
IAD
Internal lobar airflow distribution
IATA
International Airline Transportation Association
IC
Inspiratory capacity
ICF
informed consent form
ICH
International Conference on Harmonisation
ICS
inhaled corticosteroids
IEC
Independent Ethics Committee
IMP
Investigational Medicinal Product
IPF
interstitial pulmonary fibrosis
IRB
Institutional Review Board
IVRS
interactive voice response system
IWRS
interactive web response system
LABA
long-acting β2-agonist
LAMA
long-acting muscarinic antagonist
LAS
Low attenuation or emphysema score
LSLV
last subject last visit

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Abbreviation or 
special term
Explanation
LIMS
laboratory information management system
LTOT
long-term-oxygen therapy
MDI
metered dose inhaler
MMRC
Modified Medical Research Council
NIPPV
non-invasive positive pressure ventilation
OAE
other significant adverse event
PHL
potential Hy’s Law
PI
principal investigator 
PRN
as needed
QID
four times daily
RV
Residual volume
SABA
short-acting β2-agonist
SAE
serious adverse event 
SAMA
Short acting muscarinic antagonist
SAP
statistical analysis plan
SoA
Schedule of Activities
SUSAR
Serious unexpected suspected adverse reaction
TBL
Total Bilirubin Level
TC
telephone call
TCO
transfer factor for carbon monoxide
TLC
total lung capacity
TP
treatment period
TURP
trans-urethral resection of prostate
UA
upper airway
ULN
upper limit of normal
UNS
unscheduled visit
VA
alveolar volume
WBDC
web based data capture

SIGNATURE PAGE
This is a representation of an electronic record that was signed
electronically and this page is the manifestation of the electronic signature
Document Name: d5980c00019-csp-v3
Document Title:
D5980C00019 Clinical Study Protocol version 3
Document ID:
Version Label:
6.0 CURRENT LATEST APPROVED
Server Date
(dd-MMM-yyyy HH:mm ‘UTC’Z)
Signed by
Meaning of Signature
19-Jul-2019 14:33 UTC
18-Jul-2019 12:31 UTC
17-Jul-2019 14:42 UTC
19-Jul-2019 14:10 UTC
Notes: (1) Document details as stored in ANGEL, an AstraZeneca document management system.