Open Label Pilot Trial in Adults With Recent-onset T1D to Evaluate the Safety, Diabetes Status and Immune Response of GAD-antigen (Diamyd®) Therapy Administered Into Lymph Nodes in Combination With an Oral Vitamin D Regimen
Phase: PHASE1
Conditions: Diabetes Mellitus, Type 1
Sponsor: Johnny Ludvigsson

 
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CLINICAL STUDY PROTOCOL 
 
Open Label Pilot Trial in patients with recent-onset T1D to 
evaluate the safety, diabetes status and immune response of 
GAD-antigen (Diamyd®) therapy administered into lymph 
nodes in combination with an oral vitamin D regimen 
 
Acronym: DIAGNODE-1. (Trial to evaluate the safety and diabetes 
status in patients with recent-onset Type 1 diabetes by giving 
GAD-antigen (Diamyd®) therapy into lymph NODEs in combination 
with an oral Vitamin D regimen) 
 
Study No. DIAGNODE-1 
EudraCT Number: 2014-001417-79 
Study Development Phase: I/II 
Version 5.1: 2018-06-11 
 
Sponsor: 
Johnny Ludvigsson 
 
Div of Pediatrics, Linköping university, 
University Hospital, SE-581 85 Linköping, 
Sweden 
Phone: 
+ 46 13 286854 
Fax: 
+ 46 13 148265 
 
Coordinating & Principal Investigator: 
 
 
Professor Johnny Ludvigsson 
Linköping University Hospital,  
Div of Pediatrics, Dept of Clinical and 
Experimental Medicine, 
Faculty of Health Medicine, Linköping 
university 
SE-581 85 Linköping, Sweden 
 
Contract Research Organization: 
Linköping Academic Research Centre 
(LARC) 
Planned start date: 
Q4, 2014 
 
VERSION TABLE 
Version 5.1: 
Version 5, including Non-Substantial Amendment 
#5.1 
Jun 11, 2018 
Version 5: 
Version 3, including Substantial Amendment #5 
Apr 05, 2018 
Version 4: 
Version 3, including Substantial Amendment #4 
Jan 22, 2018  
NEVER IMPLEMENTED 
Version 3: 
Version 2, including Substantial Amendment #3 
Aug 29, 2016 
Version 2: 
Version 1.1, including Substantial Amendment #2 
Jan 15, 2016 
Version 1.1: 
Version 1, including Information Amendment #1.1 
Nov 24, 2014 
Version 1:  
Version 1 
Aug 14, 2014 

 
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STUDY ADMINISTRATION 
 
Name and address 
Telephone and fax numbers, e-mail 
address 
Sponsor 
Professor Johnny Ludvigsson 
Linköping University Hospital 
Div of Pediatrics,  
Dept of Clinical and 
Experimental Medicine, 
Faculty of Health Medicine, 
Linköping university, 
SE-581 85 Linköping, Sweden 
 
Phone: +46 13 286854 
E-mail: Johnny.Ludvigsson@liu.se 
 
Coordinating & 
Principal 
Investigator 
Professor Johnny Ludvigsson 
Linköping University Hospital 
Div of Pediatrics,  
Dept of Clinical and 
Experimental Medicine, 
Faculty of Health Medicine, 
Linköping university, 
SE-581 85 Linköping, Sweden 
 
Phone: +46 13 286854 
E-mail: Johnny.Ludvigsson@liu.se 
 
 
 
 
CONFIDENTIALITY STATEMENT 
This material is confidential and the property of Sponsor. Its contents must not be disclosed or used 
except as authorised in writing by Sponsor. 

 
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Table of Contents 
STUDY INFRASTRUCTURE .............................................................................................................. 5 
SYNOPSIS OF THE PROPOSED PILOT STUDY ............................................................................ 6 
LIST OF ABBREVIATIONS AND DEFINITION OF STUDY SPECIFIC TERMINOLOGY ..... 8 
1 INTRODUCTION ............................................................................................................................... 9 
1.1 BACKGROUND AND RATIONAL ........................................................................................................ 9 
1.1.1 Factors influencing the natural course ................................................................................. 9 
1.1.2 Interventions ........................................................................................................................ 10 
1.1.3 Immune therapy with auto-antigens ................................................................................... 11 
1.1.4 Previous clinical studies with GAD-Alum ........................................................................... 11 
1.1.5 Intra lymph-node immunotherapy ...................................................................................... 12 
1.1.6 Vitamin D and type 1 diabetes ............................................................................................. 13 
1.2 HYPOTHESIS .................................................................................................................................. 13 
2. RISK-BENEFIT ANALYSES ......................................................................................................... 14 
3. AIM OF PRESENT STUDY............................................................................................................ 14 
4. OBJECTIVES AND ENDPOINTS ................................................................................................. 15 
4.1 
OBJECTIVES ........................................................................................................................... 15 
4.2 
ENDPOINTS ............................................................................................................................ 15 
4.2.1 
Primary endpoints ............................................................................................................ 15 
4.2.2 
Secondary endpoints ........................................................................................................ 15 
5. POPULATION ................................................................................................................................. 15 
5.1 INCLUSION CRITERIA ..................................................................................................................... 16 
5.2 EXCLUSION CRITERIA .................................................................................................................... 16 
5.3 RECRUITMENT AND SCREENING .................................................................................................... 17 
5.4 PATIENT WITHDRAWAL ................................................................................................................. 17 
6. TREATMENT PROCEDURES ...................................................................................................... 18 
6.1 STUDY DESIGN AND TREATMENT ................................................................................................. 18 
6.2 ASSESSMENTS AND PROCEDURES .................................................................................................. 19 
6.2.1 All Visits, Visit 1 through 8 .................................................................................................. 19 
6.2.2 Administrations of GAD-Alum, Visits 3, 4 and 5 ................................................................ 20 
6.2.3 Mixed Meal Tolerance Test (MMTT), Visits 2, 6, 7 and 8 ................................................. 20 
6.3 LABORATORY TESTS AND EXAMINATIONS: ................................................................................... 20 
6.4 MEDICAL HISTORY ........................................................................................................................ 21 
6.5 PHYSICAL EXAMINATION INCLUDING NEUROLOGICAL EXAMINATION ......................................... 21 
6.6 ADVERSE EVENTS.......................................................................................................................... 22 
6.7 CONCOMITANT MEDICATION ........................................................................................................ 22 
7. SCHEDULING OF PROCEDURES .............................................................................................. 23 
7.1 VISITS ........................................................................................................................................... 25 
8. STUDY MEDICATION ................................................................................................................... 25 
8.1 STUDY MEDICATION ...................................................................................................................... 25 
8.2 SUPPLY ......................................................................................................................................... 25 
8.3 DOSAGE AND ADMINISTRATION .................................................................................................... 26 
8.4 DURATION OF TREATMENT ............................................................................................................ 26 
8.5 CONCOMITANT MEDICATION ......................................................................................................... 26 
8.6 STUDY MEDICATION ACCOUNTABILITY ......................................................................................... 26 
9. RESPONSE VARIABLES AND OUTCOMES ............................................................................. 26 
9.1 ASSESSMENTS ............................................................................................................................... 26 
9.1.1. Variables .............................................................................................................................. 26 
9.2 ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS ...................................................................... 27 

 
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9.2.1 Definitions of Adverse Events .............................................................................................. 27 
9.2.2.1 Seriousness ........................................................................................................................ 27 
9.2.2.2 Intensity ............................................................................................................................. 28 
9.2.2.3 Relationship to study medication ...................................................................................... 28 
9.2.2.4 Reporting of Adverse Events ............................................................................................. 29 
10. STATISTICAL METHODOLOGY AND DATA MANAGEMENT ......................................... 31 
10.1 STUDY DESIGN ............................................................................................................................ 31 
10.2 ESTIMATION OF SAMPLE SIZE ...................................................................................................... 31 
10.3 STATISTICAL ANALYSIS PLAN ...................................................................................................... 31 
10.4 STUDY POPULATIONS .................................................................................................................. 32 
10.5 DATA COLLECTION / CASE REPORT FORMS .................................................................................. 32 
10.6 DATA MANAGEMENT ................................................................................................................... 32 
11. REGULATORY AND ADMINISTRATIVE PROCEDURES ................................................... 33 
11.1 ETHICS COMMITTEE AND COMPETENT AUTHORITIES .................................................................. 33 
11.2 PATIENT INFORMATION / INFORMED CONSENT ........................................................................... 33 
11.3 PATIENT CONFIDENTIALITY ......................................................................................................... 34 
11.4 PATIENT TREATMENT PLAN ......................................................................................................... 34 
11.5 GCP ............................................................................................................................................ 34 
11.6 RECORD RETENTION .................................................................................................................... 34 
11.7 MONITORING / QUALITY CONTROL ............................................................................................. 34 
11.8 QUALITY ASSURANCE ................................................................................................................. 35 
11.9 INSURANCE ................................................................................................................................. 35 
12. END OF TRIAL ............................................................................................................................. 35 
12.1 STUDY REPORT ............................................................................................................................ 35 
12.2 STUDY STOPPING CRITERIA ........................................................................................................ 35 
12.3 PUBLICATION AND DATA RIGHTS ............................................................................................... 35 
13. REFERENCES ............................................................................................................................... 37 
14. INVESTIGATOR/SPONSOR SIGNATURES ............................................................................ 40 
APPENDIX TO CLINICAL TRIAL PROTOCOL............................................................................41 
 
 

 
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Study infrastructure  
 
Principal Investigator and sponsor: 
- 
Johnny Ludvigsson. Professor of Pediatrics, Linköping university, Sweden 
 
Co-investigators: 
- 
Rosaura Casas, Ass prof, Div of Endocrinology,  Linköping university 
- 
Jeanette Wahlberg, Ass Prof, Div of Pediatrics, Linköping university hospital 
- 
Ulf Samuelsson, Ass. Prof., Div of Pediatrics, Linköping university Hospital 
 
Study nurses: 
- 
Anne-Marie Sandström, diabetes research nurse, Div of Pediatrics, Linköping 
university hospital 
- 
Eva Isacson, diabetes research nurse, Div of Pediatrics, Linköping university 
hospital 
 
Laboratory staff: 
- 
Rosaura Casas, Ass Prof of Pediatric Immunology, Clin Exp Centre, Div of 
Pediatrics, Linköping university 
- 
Ingela Johansson, MSc, Clin Exp Centre, Div of Pediatrics, Linköping 
university 
- 
Gosia Smolinska, Biomedical Assistant, Clin Exp Centre, Div of Pediatrics, 
Linköping university  
 
 
Facilities and Equipment: 
- 
Laboratory: Clinical Experimental Research, Linköping university hospital, has 
localities with all necessary modern equipments. Div of Pediatrics has laboratory 
facilities, with an experienced and skilful staff  
- 
Clinical infrastructure: Participating clinics have experience from previous clinical 
studies, with experienced diabetologists, nurses with knowledge and experience of 
MMTT and collection of samples, how to fill in CRFs etc 
- 
Study Monitors: Clinical Study Monitors, are available at the Linköping Academic 
Research Centre (LARC) 
- 
Computers, information technology: All necessary facilities are available at the 
Faculty of Health Sciences, Linköping university and at the involved hospitals 
- 
Safety Reporting: Contract Research Organization (CRO) to be decided 
 

 
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SYNOPSIS OF THE PROPOSED PILOT STUDY 
 
Name of Sponsor 
Johnny Ludvigsson 
Individual Study Table Referring to 
Part of Dossier in Which the 
Individual Study or Study Table is 
Presented: 
 
 
 
 
Volume: 
Reference: 
 
(For National 
Authority Use Only) 
 
 
Name of Finished Product:  
DIAMYD® 
 
Name of Active Ingredient:  
Recombinant Human Glutamic 
Acid Decarboxylase (rhGAD65) 
 
Title of Study:   
Open Label Pilot Trial in patients with recent-onset T1D to evaluate the safety, diabetes status and 
immune response of GAD-antigen (Diamyd®) therapy administered into lymph nodes in 
combination with an oral and vitamin D regimen 
Protocol Number:   
DIAGNODE-1 
Investigators and Study Centre:   
2 sites including approximately 15 patients  
Phase of Development: Phase I/II 
Objectives:   
• 
Evaluate the safety of giving GAD-Alum (Diamyd) directly into lymph glands in 
combination with an oral and vitamin D regimen 
• 
Evaluate how the above mentioned treatments influence the immune system and 
endogenous insulin secretion. 
Study Design: The study is a double center open-labelled pilot clinical trial. Eligible patients will 
be treated with 4 µg GAD-Alum into an inguinal lymph gland at three occasions, with one month 
intervals in combination with vitamin D (14 000 IE/week) for 4 months, starting 1 month prior to 
first GAD-Alum injection. 
Selection of Subjects: Patients must be 12.00-29.99 years old, and diagnosed with Type 1 
diabetes (T1D) within the previous 6 months at the time of screening. Patients will be eligible for 
enrolment if fasting C-peptide is ≥0.12 nmol/L (0.36 ng/mL) and elevated levels of GAD65 
antibodies are present. 
Number of Subjects Planned: Approximately 15 patients will be enrolled.   
Description of Treatment Groups: 
There is one single treatment group. The patients will be assessed for eligibility at the screening 
visit (Visit 1) 10 to 21 days prior to the start of the treatment. All patients will from Day 1 (Visit 2) 
receive 14 000 I/E vitamin D per os per week during 4 months. In addition, all patients will at 
Month 1 (Visit 3) receive their first GAD-Alum treatment (4 µg) into a lymph node, where after a 2nd 
and 3rd dose of GAD-Alum will be administered at Months 2 and 3 (Visits 4 and 5). The patients 
will be evaluated at 6 months (main study period, 6 visits) and will then be followed for additionally 
24 months (extension study period, 2 visits). The total study period is 30 months.   

 
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Name of Sponsor 
Johnny Ludvigsson 
Individual Study Table Referring to 
Part of Dossier in Which the 
Individual Study or Study Table is 
Presented: 
 
 
 
 
Volume: 
Reference: 
 
(For National 
Authority Use Only) 
 
 
Name of Finished Product:  
DIAMYD® 
 
Name of Active Ingredient:  
Recombinant Human Glutamic 
Acid Decarboxylase (rhGAD65) 
 
Endpoints: 
 
Primary endpoints:  
To evaluate the safety of giving Diamyd directly into lymph glands in combination with an oral 
vitamin D regimen at Month 6 (main study period) and Month 15 and 30 (extension study period).  
 
Variables to evaluate safety: 
• 
Reactions of the injection site 
• 
Occurrence of adverse events (AEs) 
• 
Laboratory measurements (biochemistry and haematology), including Calcium and 
Vitamin D in serum 
• 
Urinalysis (microalbuminuria, creatinine) 
• 
Physical examinations, including neurological assessments 
• 
GAD65AB titer (GADA) 
 
Secondary endpoints: 
To evaluate how the above mentioned treatment influences the immune system and endogenous 
insulin secretion from baseline to Month 6 (main study period) and subsequent visits during the 
extension study period. 
 
Variables to evaluate the influence on the immune system:  
• 
Inflammatory markers, especially TNF-alfa, IL-1 beta, IL-2, IL-17  
• 
Th2-deviation of cell-mediated immune response seen e.g. as increased ratio of IL-5,10, 
13 in comparison with IFN-gamma, TNF-alfa, IL-1 beta and IL-17 
• 
Increase of T-regulatory cells  
 
Variables to evaluate the effect of endogenous insulin secretion: 
• 
C-peptide (90 minute value and AUCmean 0-120 min) during an MMTT)  
• 
Fasting C-peptide 
• 
Hemoglobin A1c (HbA1c) 
• 
Exogenous insulin dose per kg body weight and 24 hours 
 
Sample size:   
No real sample size calculation is done as this is an open-label pilot study to study safety and 
summarize changes in the immune system and beta cell function descriptively. All variables will be 
summarized descriptively. 
 
 

 
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LIST OF ABBREVIATIONS AND DEFINITION OF STUDY SPECIFIC 
TERMINOLOGY 
 
 
 
ADA 
American Diabetes Association 
AE 
Adverse Event 
Alum 
Aluminum hydroxide 
AUC 
Area Under the Curve 
AUCmean 0-120 min 
AUC mean 0-120 minutes 
BMI 
Body Mass Index 
CRF 
Case Report Form 
CRA 
Clinical Research Associate 
CRO 
Contract Research Organization 
DCCT 
Diabetes Control and Complications Trial 
DCF 
Data Clarification Form 
DSMB 
Data Safety Monitoring Board 
IEC 
Independent Ethics Committee 
GAD 
Glutamic acid decarboxylase 
GADA 
Antibodies to GAD with molecular mass 65,000 
GAD65 
GAD with molecular mass 65,000 
GCP 
Good Clinical Practice 
HbA1c 
Hemoglobin A1c  
HLA 
Human Leukocyte Antigen 
IAA 
Insulin Autoantibody 
IA2 
Islet cell Antigen 512 
ICH 
International Conference on Harmonization 
IRB 
Institutional Review Board 
ITT 
Intent-to-Treat 
LADA 
Latent Autoimmune Diabetes in Adults 
MMTT 
Mixed Meal Tolerance Test 
NOD 
Non-obese Diabetic  
PP 
Per-Protocol 
rhGAD65 
Recombinant Human GAD with molecular mass 65,000 
SAE 
Serious Adverse Event 
T1D 
Type 1 Diabetes 
T2D 
Type 2 Diabetes 

 
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1 Introduction 
 
1.1 Background and rational 
The incidence of Type 1 diabetes (T1D) in children is next to Finland highest in 
Sweden in the world, and is increasing rapidly. T1D is by far the most common 
chronic, serious, life-threatening disease among children and adolescents in our 
country, and the incidence of Type 1 diabetes is high also in young adults.  The 
disease tends to become an extremely serious global problem. The disease is 
characterized by lack of insulin. Even though several patients at diagnosis have 
rather impressive residual beta cell function (1) the deficiency becomes soon very 
pronounced and finally complete (2,3). Residual insulin secretion is of crucial 
importance. In rare cases the beta cell function improves so much shortly after 
diagnosis that glucose metabolism normalizes and no insulin is required for some 
time, that is the patient goes into so called complete remission (4). As long as the 
patient is in a complete remission there is no need of active treatment, more than 
perhaps some recommendation of sound life style regarding physical exercise and 
diet. There are no symptoms, no acute complications and if somebody stayed in 
complete remission it is unlikely that such an individual would ever develop late 
complications. Slight abnormality of glucose or lipid metabolism might increase the 
risk of macrovascular complications in the same way as for individuals with chemical 
diabetes or impaired glucose tolerance.  
 
Complete remission is rare, but partial remission it is not (4). During this period the 
patient usually has near normal blood glucose values, not even mild hypoglycemia 
and no episodes of ketoacidosis. The quality of life is very good as the patient feels 
well, children grow normally, few restrictions are needed, if any with regard to food, 
the patients can exercise with great variation without getting hypoglycemia, and 
experiences very good home blood glucose tests. Only some residual insulin 
secretion is enough to diminish the risk of ketoacidosis (5). Furthermore, it has been 
shown in the DCCT trial that even quite modest residual insulin secretion, a response 
to a beta cell stimulation with serum C-peptide >0.20pmol/ml, plays an important role 
for prevention of complications (6). This effect may be due to the fact that residual 
insulin secretion should reasonably make it easier to reach good blood glucose 
balance, but it is also possible that C-peptide per se has a physiological function. It 
has in fact been reported that C-peptide influences vascular permeability, decreases 
leakage in retinal vessel, and not least has a positive effect on nerve function (7) 
although the effect of C-peptide per se still is under debate.  
1.1.1 Factors influencing the natural course 
At diagnosis of T1D it has been claimed that 80-90% of the beta cells in pancreas 
have been destroyed. However, the proof for this is scarce, and it may well be that 
the main problem is deterioration of function. Furthermore there is great difference 
between patients, as some have quite good residual insulin secretion and others 
have not. Shortly after diagnosis, especially when an active insulin treatment is given, 
there is an increase of C-peptide production, and at the same time an improvement 
of insulin sensitivity. Good metabolic control seems to improve the milieu and 
metabolism for the beta cells and the beta cell function is preserved, which in turn 
contributes to better metabolic control, and vice versa. The intensity of the 
autoimmune process plays a role, and it seems evident that children have a more 
aggressive immune process than adults with Type 1 diabetes, but it is still difficult to 
predict the course. Some studies have suggested that high concentrations of auto-
antibodies are followed by a more rapid loss of insulin secretion, while others have 
not found such a relationship, or even the opposite. No special signs of cell-mediated 

 
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immunity have so far been proven to predict beta cell loss but our own studies have 
shown that disease process is related to a T-helper-1 (Th-1) deviation of the immune 
system with increases of certain cytokines such as IFNg and decrease of IL-10, IL-
13. 
 
The effect of insulin treatment on beta cell function. 
Active insulin treatment during the first period of the disease prolonged the partial 
remission long time ago, and this finding could be confirmed and validated by 
improved residual insulin secretion (2). Intensified treatment seems to improve 
residual beta cell function at least for some time (8), but it may also have long-term 
positive effects (9). Active treatment has been shown not only to prevent or postpone 
diabetes in experimental animals, but studies have indicated that such treatment 
could prevent diabetes in high risk individuals (10). However, when tried at a larger 
scale in the Diabetes Prevention Trial, parenteral insulin treatment did not prevent 
diabetes (11). Oral treatment with insulin might have an effect (12) and therefore 
further studies are needed. 
1.1.2 Interventions 
In the 1970ies it became clear that T1D is an autoimmune disease and therefore 
immune interventions were tried. We performed the first immune intervention studies 
in the world on diabetic children when we already 30 years ago used plasmapheresis 
in newly-diagnosed children and adolescents with some positive effects (13). As a 
side effect of that treatment a new protein with the weight 64kD was found in plasma 
(14), which later showed to be Glutamic Acid Decarboxylase (GAD).  The 
breakthrough, taken as a proof for the concept of immune intervention, was 
cyclosporin, which doubtless slowed down the autoimmune destructive process and 
gave improved residual insulin secretion, while other trials with immune suppression 
had minimal effect, especially so in children (15, 16,17), or showed too serious 
adverse events or risks (18, 19). In an effort to modulate the immune system we 
used photopheresis. Although clear effects on the immune system were 
demonstrated in a double blind placebo-controlled trial (20), the clinical effect was 
minimal and almost no improvement of residual beta cell function could be seen (21). 
Thus, with no successful immune intervention, our interest was directed to protective 
agents such as Nicotinamide and Diazoxide, with no or transient effect (22, 23, 24). 
With increasing knowledge of the immune process leading to beta cell destruction, it 
has become possible to direct more precisely the immune intervention to target the 
important T-cells. Promising studies using anti-CD3antibodies in an attempt to block 
the destructive immune process have been performed. Results from both North-
American and French trials with anti-CD3 have shown that it is possible to block the 
destructive autoimmune process and thereby at least postpone the decline of the 
beta cell function (25,26). The decline of residual insulin secretion was significantly 
slowed down, but unfortunately it looks as if the decline was just delayed a year, and 
thereafter the declining C-peptide curve went parallel to the declining curve in the 
placebo group. Furthermore, a majority of the patients experience some Cytokine 
Release Syndrome (CRS), which may be quite serious, and in addition a number of 
side effects were seen in most of the patients. We have participated in one of two 
recent Phase III trials (Protegé  trial), which failed to reach the primary endpoint, 
although the arm with the most intense treatment indeed showed some preservation 
of residual insulin secretion and lower insulin requirement to reach good HbA1c (27; 
Sherry, Hagopian, Ludvigsson et al Lancet 2011). New studies are needed but it is 
difficult to believe that this type of treatment alone will be the accepted solution for 
general clinical use. Even less likely is such a treatment accepted as a preventive 
treatment in otherwise healthy individuals of whom many never would develop 
diabetes. 
 

 
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1.1.3 Immune therapy with auto-antigens 
In the treatment of allergic diseases, immunotherapy with small amount of disease 
specific antigen has been efficiently used during many years.The mechanism for this 
treatment remains unclear, although immune modulation of the immune responses 
and induction of regulatory cells have been suggested. In autoimmune diseases no 
such treatment has been successful, but should be tried (28). Experiments in 
diabetes prone animals have shown that treatment with a heat shock protein could 
delay or postpone development of diabetes. The use of Diapep277 peptide in a study 
in adults showed significant preservation of insulin secretion without almost any 
adverse events (29). Later trials in children and adolescents with T1D (30), however, 
have shown no effect. Studies with Diapep277 treatment in so called LADA (Latent 
Autoimmune Diabetes in the Adult) are ongoing, and preliminary results (report at 
IDF, Dubai Dec 2011 and at ADA June 2012) suggests that treatment with 
Diapep277 may preserve beta cell function in adults with mild Type 1 diabetes. 
However, the results are a bit unclear, as there was a weak C-peptide preservation 
only seen after Glucagon stimulation, but no effect at all after Mixed Meal Tolerance 
Test, and there was no differences whatsoever between the actively treated group 
and placebo in immune markers. 
 
Active treatment with insulin has been shown not only to prevent or postpone 
diabetes in experimental animals but preliminary open studies indicated that such 
treatment could prevent diabetes in high risk individuals (10). Insulin, clearly a beta 
cell specific auto-antigen, has been parentally administrated (DPT) to prevent 
diabetes in high risk individuals with no effect, while oral insulin administration with 
the same purpose may have a slight effect (12). 
 
1.1.4 Previous clinical studies with GAD-Alum 
 
1.1.4.1 GAD-vaccination 
GAD (Glutamic Acid Decarboxylase), can be regarded as an auto-antigen, as it is 
produced in the islets with increased release as response to beta cell stimulation. 
This protein has been shown to deeply influence the autoimmune immune process 
(31,32,33,34). Several studies have shown that indeed GAD can prevent diabetes in 
experimental animals (35-42). The similarity of GAD with viral proteins may be 
important for the therapeutic action. The observed effect, even after the start of the 
immune process, suggests that it might be possible to expect the same effect in 
humans after the start of the immune process. In a phase II study in LADA patients 
the administration of one low dose, Diamyd 20 µg, led to improved beta cell function 
for up to 2 years compared to the placebo treated group, with no side effects. Also 
other doses were tried: 4 µg showed no effect, 100 µg showed a similar effect as 20 
µg, while 500 µg showed no effect. None of the doses showed any adverse events, 
still so after several years follow-up (43). Association with change in the ratio of 
CD4+CD25+/ CD4- CD25- cells was found, indicating a mechanism for the effect. 
With this promising background we started a Phase II study in Type 1 diabetic 
patients 10-18 years with recent onset. Based on the idea that the treatment earlier 
had effect in slowly progressive LADA patients we included patients with up to 18 
months duration of T1D diabetes at intervention. The patients were randomized to 
either 20 µg GAD-Alum (Diamyd) sc at Day 1 and 30, or placebo. The effect still after 
30 months was remarkable, and clearly both statistically and clinically significant (44), 
with about half of the C-peptide decline in the GAD treated group compared with the 
placebo group. Patients with a diabetes duration < 3 months had a remarkably good 
effect with no or minimal decline of beta cell function during the follow-up of the first 
15 months. Almost all effect was seen in patients with < 6 months duration at 
vaccination. Even more, in contrast to other intervention treatments, this effect was 

 
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gained with no adverse events at all, making the treatment very encouraging! Still 
after 48 months the patients treated with < 6 months duration hade significantly 
preserved C-peptide and still no adverse events (45). So far GAD-treatment looked 
very promising. Two Phase III trials were performed, one European with Johnny 
Ludvigsson (JL) as PI, and one in USA with Jerry Palmer as PI and JL as co-
investigator. In the European trial 334 patients were recruited into three arms, one 
arm with GAD-Alum (Diamyd) 20 µg at Day 1,30, 90 and 270, another arm with GAD-
Alum 20 µg at Day 1 and 30, and placebo at Day 90 and 270 and a third arm with 
Placebo at Day 1,30,90 and 270. Primary endpoint, serum C-peptide AUC after a 
Mixed Meal Tolerance Test (MMTT) at 15 months was not met! (C-peptide AUC 
p=0.1; Fasting C-peptide p=0.07) (46). This prompted the company (Diamyd Medical 
+ Johnson&Johnson) to close the phase III trials early. However, the Phase III trial 
did show several positive effects. Thus statistically significant efficacy was seen in 
several pre-specified subgroups. Furthermore, 45 Swedish patients had passed the 
30 month’s visit when the study was stopped, and those 15 patients who had 
received two doses of GAD-Alum (Diamyd) 20 µg showed a significant preservation 
of C-peptide after 30 months compared with placebo! This is especially remarkable 
as the Swedish patients were the ones without efficacy after 15 months, while 
efficacy was found after 15 months in the non-Nordic countries. 
 
1.1.4.2 Possible Reasons to the different results Phase II and Phase III 
In Phase III randomization, patients receiving active drug were more often in the 10-
11 year age group than in the 16-18 year age group whereas placebo was more 
frequent than active drug in the higher age group. This may have influenced the 
result. The Phase II patients were treated in March–April and those patients in Phase 
III who were treated in March-April had also significant effect of GAD-treatment. In 
the Phase II trial no vaccinations were accepted, but in Phase III Influenza-
vaccination was allowed. Unfortunately, an epidemic of H1N1-flu lead to that almost 
all patients were vaccinated, many of them in connection with the GAD-vaccinations. 
In Sweden and Finland the vaccine contained squalen, suspected to influence the 
immune system towards auto-immunity, and in these two countries there was no 
efficacy of GAD-treatment, while the efficacy was significant in other European 
countries. Patients in Sweden who did not get the influenza vaccination close to the 
GAD-treatment, had better efficacy of GAD-treatment (46). 
 
1.1.4.3 Ongoing DIABGAD-1 trial 
Since Jan 2013 the Phase II DIABGAD-1 trial is ongoing in Sweden. This is a trial in 
64 patients, 10-18 years old, with recent-onset Type 1 diabetes, who are treated in a 
double-blind placebo-controlled randomized study with GAD-Alum 20 µg resp 40 µg 
given twice with 30 days interval, in combination with Vitamin D, 2000 units daily for 
450 days, and Ibuprofen 400 mg daily for 90 days. Recruitment is fulfilled and now 
closed. There are so far no Serious Adverse Events judged as related to study 
medication, and very slight adverse events, not related to the treatment except for 
mild transient reactions on the site of injection of GAD-Alum. An interim analysis is 
planned already after 6 months follow-up of all patients while more extended 
analyses will be performed after 15 and 30 months. 
 
1.1.5 Intra lymph-node immunotherapy 
Antigen therapy aims at presenting the antigen to the T-cells in the lymph nodes to 
get a new balance of the immune system and tolerance against the antigen. In the 
treatment of autoimmune diseases so far antigen has been given either orally, intra-
nasally or subcutaneously, in order to present the antigen to antigen 
presenting/dendritic cells which in turn are expected to present the antigen to the T-
cells of the immune system. However, animal studies have shown that intralymphatic 

 
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injections induce a strong and relevant T-cell response (47,48) and in the allergy field 
clinical studies have shown that presentation of the antigen/allergen directly into the 
lymph nodes seems to be more effective than traditional administration (49). Lower 
doses of the allergen can be used, the number of treatments can be radically 
reduced, and there have been no treatment-related adverse events. Inguinal 
lymphnodes are readily accessible in patients and the pain associated with the 
injection is rated as below that of venous puncture (50). With this background it is our 
aim to study whether the same approach can be used in patients with the 
autoimmune form of Type 1 diabetes.   
 
1.1.6 Vitamin D and type 1 diabetes 
 
Experimental evidence indicates that vitamin D may play a role in the defence 
against Type 1 diabetes (T1D) as well as type 2 diabetes (T2D). Epidemiological 
data suggest that there is a link between vitamin D deficiency and an increased 
incidence of Type 1 diabetes. Thus a multinational case-control study and a birth 
cohort follow-up study from Finland with (51,52) have both concluded that vitamin D3 
supplementation at birth protects from type 1 diabetes later in life, and a meta-
analysis supports gives similar conclusions (53). Others report lower serum levels of 
1α,25-dihydroxyvitamin D3 [1,25(OH)2D3, calcitriol] in patients with recently 
diagnosed type 1 diabetes than in healthy control subjects (54) The protective effects 
of vitamin D are mediated through the regulation of several components such as the 
immune system and calcium homeostasis. Thus, mechanistic studies show that 
1,25(OH)2D3 modulates dendritic cell maturation in vitro and in vivo (55-58) and 
facilitates a shift from a Th1 to a Th2 immune response (59). An increasing amount 
of evidence suggests that vitamin D also affects beta cells directly thereby rendering 
them more resistant to cellular stress (60), and there are results indicating that 
Vitamin D may also improve insulin sensitivity (61), which in turn decrease beta cell 
stress. 
 
With this background vitamin D has been used in patients with recent onset Type 1 
diabetes in an effort to preserve residual insulin secretion. However, so far Vitamin D 
alone has not been efficacious enough (62,63). Therefore there is reason to try 
Vitamin D, both in somewhat higher dose, and in combination with other therapy. 
 
1.2 Hypothesis 
 
• 
The encouraging results of the Phase II GAD trial and the partly positive 
results of the Phase III European Trial, support the concept that 
administration of GAD-Alum (Diamyd) may decrease the autoimmune 
process and contribute to preservation of residual insulin secretion 
• 
As previous studies have indicated that the dose should be somewhere 
between 20 and 100 µg Diamyd, a lower dose of 4 µg given three times 
should be adequate when administrated directly into lymph nodes.  
• 
Injection of GAD-Alum (Diamyd) directly into lymph nodes will give no 
serious adverse events, have desired immunological effects and will 
(shown in future studies) improve efficacy 
• 
Addition of rather large doses of Vitamin D may improve the efficacy both 
via effects on the immune system and mechanism directly on the beta 
cells 

 
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2. Risk-Benefit Analyses 
 
The incidence of Type 1 diabetes is next to Finland higher in Sweden than in any 
other country of the world. The incidence is continuously increasing for decades. The 
disease cannot be cured and cannot be prevented. In spite of a very heavy, 
intensive, expensive treatment many patients get life-threatening serious both acute 
and late complications, and the mortality is much increased. At diagnosis many 
patients have some slight residual insulin secretion. As long as this is the case it is 
much easier to keep blood glucose stable, the incidence of hypoglycaemia 
decreases as well as the risk of ketoacidosis. Quality of life for the patient as well as 
for parents of children with diabetes is better as long as there is some residual insulin 
secretion.  
 
 
It is evident that there is a great benefit of preservation of residual insulin secretion, 
and therefore therapies aiming at preservation of this function justify treatments that 
are quite heavy, even dangerous and expensive. Thus it has been regarded as 
justified to treat Type 1 diabetes at onset with drugs like monoclonal antibodies 
against the CD3-receptor, which causes adverse events in principally all patients, 
some even quite serious adverse events and risks. Even pure cytostatics have been 
used. 
 
In our proposed study we use GAD-Alum (Diamyd) 4µg x 3, a treatment which has 
been used in much larger doses given to children and adults with almost no adverse 
events seen during follow-up of thousands of patient years. In our study we plan to 
use a very low dose, which means that the general risk can be expected to be even 
lower, but the administration will be directly into a lymph node which might give local 
reactions. The effect on the immune system may become more pronounced but 
should not lead to any adverse effects. Previous studies in allergy (where Dr. Helene 
Zachrisson has given the intra lymph node injections of alum-formulated allergens) 
have not shown any adverse effect neither generally nor locally).  
 
In DIABGAD-1 we give vitamin D 14000 IU per week for 15 months. This dose given 
to children and adolescents aged 10-18 years can be compared with the dose of 400 
IU per day given to babies as a health recommendation to avoid vitamin D 
insufficiency. 64 patients in DIABGAD-1 have been randomized of whom ¾ should 
have received Vitamin D, and we have noticed no adverse event which can be 
regarded as related to Vitamin D. 
 
When summarizing the pros and cons, there is a clear possibility of therapeutic 
benefit of great importance, both for the participating patients, for patients in future 
studies, whereas the risk is very small. If these studies contribute to the development 
of a good treatment, this will be of enormous value for a great number of patients. 
3. Aim of present study 
Our aim of the present pilot study is to get information on whether GAD-Alum can be 
given into lymph nodes without treatment related serious adverse events, in 
combination with an oral Vitamin D regimen, to allow future Phase II-studies with the 
same technique to improve efficacy in preserving residual insulin secretion in Type 1 
diabetes. Thus we want to see whether this treatment give any adverse events, and 
how treatment regimens influence the immune system, cause the desired Th-2 
deviation, increase of T-regulatory cells, and hopefully indications of preservation of 
residual beta cell function. Based on the short-term results of this pilot study (6 
months main study period) we then may want to design a larger Phase II trial, to get 
more robust information. The main long-term goal is then to find a treatment at onset 

 
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of Type 1 diabetes in young patients which is tolerable for the patients, safe, and 
which can preserve residual insulin secretion and give the patients a better quality of 
life, with less acute complications and in the long run less risk of late complications.  
4. Objectives and Endpoints 
 
4.1 
Objectives 
• 
Evaluate the safety of giving Diamyd directly into lymph glands in combination 
with an oral vitamin D regimen  
• 
Evaluate how the above mentioned treatments influence the immune system 
and endogenous insulin secretion. 
 
4.2 
Endpoints 
 
4.2.1 
Primary endpoints  
To evaluate the safety of giving Diamyd directly into lymph glands in combination with an oral 
vitamin D regimen at Month 6 (main study period) and Month 15 and 30 (extension study 
period).  
 
Variables to evaluate safety: 
• 
Reactions of the injection site 
• 
Occurrence of adverse events (AEs) 
• 
Laboratory measurements (biochemistry and haematology), including Calcium and 
Vitamin D in serum 
• 
Urinalysis (microalbuminuria, creatinine) 
• 
Physical examinations, including neurological assessments 
• 
GAD65AB titer (GADA) 
 
4.2.2 
Secondary endpoints 
To evaluate how the above mentioned treatment influences the immune system and 
endogenous insulin secretion from baseline to Month 6 (main study period) and subsequent 
visits during the extension study period. 
 
Variables to evaluate the influence on the immune system  
 
• 
Inflammatory markers, especially TNF-alfa, IL-1 beta, IL-2, IL-17  
• 
Th2-deviation of cell-mediated immune response seen e.g. as increased ratio of IL-
5,10, 13 in comparison with IFN-gamma, TNF-alfa, IL-1 beta and IL-17 
• 
Increase of T-regulatory cells  
 
 
Variables to evaluate the effect of endogenous insulin secretion: 
• 
C-peptide (90 minute value and AUCmean 0-120 min) during an MMTT)  
• 
Fasting C-peptide 
• 
Hemoglobin A1c (HbA1c) 
• 
Exogenous insulin dose per kg body weight and 24 hours 
5. Population 
 
Patients with recent-onset Type 1 diabetes and guardian(s) (where applicable) at 
Linköping university hospital are given information about the study and they are 
asked to participate in the trial. 

 
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5.1 Inclusion criteria 
 
1. Informed consent given by patients and/or patient’s parent(s) or legal acceptable 
representative(s) (guardian(s)) according to national regulations 
2. Type 1 diabetes according to the ADA classification with < 6 months diabetes 
duration 
3. Age 12.00-29.99 years at diagnosis of Type 1 diabetes  
4. Fasting C-peptide ≥0.12 nmol/L 
5. Pos GADA but < 50 000 random units 
6. Females must agree to avoid pregnancy and have a negative urine pregnancy 
test 
7. Patients of childbearing potential must agree to using adequate contraception, 
until 1 year after the last administration of GAD-Alum. Adequate contraception is 
as follows:  
 
For females of childbearing potential: 
 
a. oral (except low-dose gestagen (lynestrenol and norestisteron)), 
injectable, or implanted hormonal contraceptives 
b. intrauterine device 
c. intrauterine system (for example, progestin-releasing coil) 
d. vasectomized male (with appropriate postvasectomy documentation 
of the absence of sperm in the ejaculate) 
 
For males of childbearing potential: 
 
e. condom (male) 
 
 
5.2 Exclusion criteria 
 
1. Previous or current treatment with immunosuppressant therapy (although topical 
or inhaled steroids are accepted) 
2. Continuous treatment with any inflammatory drug (sporadic treatment e.g. 
because of headache or in connection with fever a few days will be accepted) 
3. Treatment with any oral or injected anti-diabetic medications other than insulin 
4. Treatment with Vitamin D, marketed or not, or unwilling to abstain from such 
medication during the trial 
5. A history of anaemia or significantly abnormal haematology results at screening 
6. A history of epilepsy, head trauma or cerebro-vascular accident, or clinical 
features of continuous motor unit activity in proximal muscles 
7. Clinically significant history of acute reaction to vaccines or other drugs in the 
past 
8. Treatment with any vaccine, including influenza vaccine, within 4 months prior to 
planned first study drug dose or planned treatment with any vaccine up to 4 
months after the last injection with study drug.  
9. Participation in other clinical trials with a new chemical entity within the previous 3 
months 
10. Inability or unwillingness to comply with the provisions of this protocol 
11. A history of alcohol or drug abuse 
12. A significant illness other than diabetes within 2 weeks prior to first dosing 

 
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13. Known human immunodeficiency virus (HIV) or hepatitis 
14. Females who are lactating or pregnant (the possibility of pregnancy must be 
excluded by urine βHCG on-site within 24 hours prior to the GAD-Alum treatment) 
15. Males or females not willing to use adequate contraception until 1 year after the 
last GAD-Alum treatment 
16. Presence of associated serious disease or condition, including active skin 
infections that preclude subcutaneous injection, which in the opinion of the 
investigator makes the patient non-eligible for the study 
17. Deemed by the investigator not being able to follow instructions and/or follow the 
study protocol 
 
5.3 Recruitment and screening 
 
Potential study patients and guardian(s) (where applicable) will have the study 
explained to them, and will receive the written patient information. After having had 
the time to review the nature of the study, the patient/guardian(s) will have the 
opportunity to ask questions to the investigational team. If, after this, the subjects 
agree to participate, patient and/or guardian(s) will personally sign and date the 
written informed consent form. 
 
The patients and/or guardian(s) will then receive a copy of the signed and dated 
patient information/informed consent form. 
 
5.4 Patient withdrawal 
 
In accordance with the Declaration of Helsinki, the investigator must explain to the 
patient and guardian(s) (where applicable) that they have the right to withdraw from 
the study at any time, and that this will in no way prejudice their future treatment. The 
reason for any kind of withdrawal must be recorded on the appropriate CRF. 
 
There will be different categories for withdrawals from the study: 
 
Complete withdrawal (i.e. stopping investigational product and also continued 
efficacy and safety evaluations) 
 
Standard reasons for withdrawing from further participation in the study and from the 
follow-up visits (and <e.g. blood tests>) may be: 
• 
Patient’s and/or guardian(s) decision (withdrawal of consent to participate) 
• 
Patient lost to follow-up  
 
Standard reasons from withdrawing from taking further investigational product, but 
continuing follow-up visits and safety evaluations may be: 
• 
Unacceptable adverse events 
• 
Patient and/or guardian(s) request 
• 
Investigator's discretion 
• 
Patient lost to follow-up/non-attendance 
• 
Intercurrent illness 
• 
The patient becomes pregnant 
 
Thus intra lymph node GAD-Alum should not be given to the patient if the patient 
after inclusion in the study has got 
- brain damage, epilepsia, head trauma, neurological disease 

 
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- any active, serious hormonal disease other than Type 1 diabetes 
- other severe autoimmune disease (except celiac disease which is accepted for 
inclusion) 
- immune-suppressive treatment 
- cancer, cancer treatment 
- any other diabetes drugs other than insulin 
- any vaccination  
- drug/alcohol abuse 
or if the patient has 
- become pregnant or is no longer willing to use safe contraceptives during the study 
 
 
However, whenever a patient is withdrawn from a study, or for whatever reason is not 
coming to any further visits, a final study evaluation must be completed for that 
patient (visit <>) - stating the reason(s) why the patient was withdrawn from the 
study. All documentation concerning the patient must be as complete as possible. 
 
Withdrawals due to non-attendance must be followed up by the investigator to obtain 
the reason for non-attendance. Withdrawals due to intercurrent illnesses or adverse 
events must be fully documented in the case record form, with the addition of 
supplementary information if available and/or appropriate. 
 
 
6. Treatment procedures 
6.1 Study Design and Treatment 
 
The trial is double center, open-label, pilot study in GADA positive T1D patients of 
either gender, 12.00 to 29.99 years old, diagnosed with T1D within 6 months at time 
of screening (Visit 1) and fasting C-peptide levels equal to or above 0.12 nmol/L. In 
total, approximately 15 patients will be recruited at one site in Linköping, Sweden. 
 
The patients will be assessed for eligibility at the screening visit (Visit 1) 10 to 21 
days prior to the start of treatment. The screened patients will be assigned a 
sequential screening number and this screening number will be used as patient 
identification throughout the study.   
 
Patients who qualify for inclusion in the study will then be enrolled in the study to 
receive investigational study drug at the subsequent visits according to table 1 below.  
 
The patients will be followed for a total study period of 30 months which includes 8 
visits to the site. 
 
See table 1 below for an overview of the study visits.  
 
 
 

 
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Table 1 Schedule of Patient Visits, Visit Windows and Study Drug Administration 
 
Study 
Screening 
Intervention – Main Study Period 
Follow-up  – 
Extension Study Period 
 
Day 
-10 to - 21 
Screening 
Day 1 
Baseline 
Day 30 
Month 1 
Day 60 
Month 2 
Day 90 
Month 3 
Day 180 
Month 6 
Day 450 
Month 15 
Day 900 
Month 30 
 
Visit 1 
 
Visit 2 
 
Visit 3  
± 3 
 
Visit 4 
± 3 
 
Visit 5 
± 3 
 
Visit 6 
± 14 
 
 
Visit 7 
± 14 
 
 
Visit 8 
± 30 
 
 
Appr 15 
subjects 
 
 Oral Vitamin D 
14 000 IE per week from Day 1 to Day 120 
 
 
 
 
 
1st  
GAD-
Alum 
treat-
ment 
2nd 
GAD-
Alum 
treat-
ment 
3rd 
GAD-
Alum 
treat-
ment 
 
 
 
 
 
6.2 Assessments and procedures 
 
1. Standard insulin treatment, education and psychosocial support for newly 
diagnosed Type 1 diabetes patients. 
2. Normalization of fluid, electrolyte and acid-base balance. 
3. Thereafter information about the study.  
4. When the patients and/or guardian(s) have given their informed consent, at 
the latest 6 months after diagnosis, screening is performed with a fasting 
venous sample from patients who are eligible according to other criteria than 
C-peptide and GADA concentrations (Visit 1).  
5. At Baseline (Visit 2), 6, 15 and 30 months, assessment of residual 
endogenous insulin secretion by MMTT.  
6. Blood sampling for Vitamin D in serum at Visit 1 and then after one month of 
treatment at Visit 3 (before first GAD-Alum treatment) and at Visit 7 (15 
months) 
7. HbA1c, safety (haematology and chemistry), autoantibody titres (GAD65, IA-
2), immunology, are followed by blood samples at every study visit. 
8. Exogenous insulin dose/24 hours four days prior to each visit, AEs and 
concomitant medication is registered at every study visit. 
9. Self-reported hypoglycaemia (defined as needing help from others and/or 
seizures and/or unconscious) registered at every study visit.  
10. Any symptoms or signs of other medical problem should be treated at the 
discretion of the clinical doctor. 
 
Examinations will be performed according to Table 2 in Section 7 below, and in the 
order outlined in the case report form (CRF).  
 
 
6.2.1 All Visits, Visit 1 through 8 
Note that the patient should attend all study visits in the morning following an 
overnight fast (> 10 hours, water allowed).  
 
For patients with evidence of an infection (including fever), the complete visit should 
be postponed for 5 days or until the patient has recovered. 

 
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6.2.2 Administrations of GAD-Alum, Visits 3, 4 and 5 
After administration, the patient shall remain in the vicinity of the study site for the 
next hour, and the administration site will be examined by investigator/study nurse 1 
hour post injection. 
 
6.2.3 Mixed Meal Tolerance Test (MMTT), Visits 2, 6, 7 and 8 
 
The MMTT must be performed according to the instructions in the CRF. 
 
The patient should: 
 
• 
Come to the study site following an overnight fast (>10hr), i.e. the patient may 
not eat but is permitted to drink water  
• 
Not take short acting/direct acting insulin within 6 hours before the MMTT. 
The patient is allowed to take base-insulin day/night before, but not in the 
morning before the MMTT.  
• 
Patients with CSII (insulin pump) must continue with their basal dose insulin, 
but not add bolus dose during the last 6 hours before the MMTT 
• 
Have a fasting plasma glucose level in the range defined by 4-12 mmol/L on 
the patient’s home blood glucose meter in the morning of the test  
 
If the patient does not fulfill all of the above criteria, the MMTT should be rescheduled 
and the patient should return to the study site within 5 days if possible. 
 
If for safety reasons, subjects need to eat or take insulin, the visit should also be 
rescheduled. 
 
6.3 Laboratory tests and examinations:  
 
1. Immunological tests: 
a. Autoantibodies (Anti-GAD65, Anti-Insulin, Anti-IA-2, ZnT8) 
b. Relevant cytokines and chemokines are determined (see Table 2 and 
section 9.1.1 below) 
c. T-cells are classified and studied (see Table 2 and section 9.1.1 below) 
2. Genetics: 
a. HLA determinations is done and genes related to diabetes development 
b. Array studies to elucidate the importance of diabetes-related genes 
3. Diabetes status:  
a. HbA1c 
b. Fasting glucose and fasting C-peptide 
c. Meal stimulated glucose and C-peptide 
4. Blood sampling for safety: 
a. Hematology  
b. Chemistry 
5. Urine analysis 
6. Urine pregnancy test as appropriate 
7. Other:  
a. Vitamin D in serum 
 

 
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6.4 Medical history  
A complete review of the subject’s past medical history will be undertaken by the 
investigator and documented on the Medical History CRF. 
 
All pre-existing conditions/diseases will be reported on the Medical History CRF page 
at the screening visit (Visit 1).  
 
The subject’s Type 1 diabetes diagnosis date and family history of Type 1 diabetes 
will also be documented. 
 
6.5 Physical Examination Including Neurological Examination 
 
At the screening visit (Visit 1) the patient will undergo a general physical examination 
and a neurological examination and any findings will be reported as pre-existing 
conditions on the Medical History CRF page. 
 
During the subsequent study visits the patient will be examined for any new medical 
conditions or worsening of the pre-existing ones.  Any change in pre-existing 
conditions or new conditions must be entered on the AE page in the CRF and any 
medication given on the concomitant medication pages. 
 
The patients will, in addition to the limited physical examination by the physician, 
undergo a standardized clinical neurological examination at screening, 6, 15 and 30 
months. The neurological tests are performed in order to detect possible mild signs of 
neuromuscular disease such as disturbance of strength, balance, and coordination. 
 
The neurological examination includes:   
 
• 
Extremity reflexes 
• 
Romberg (balance and coordination) 
• 
Walk on a line, 2 meters (balance and coordination) 
• 
Standing on 1 leg, left and right, 15 seconds per leg (balance and 
coordination) 
• 
Finger-nose (coordination) 
• 
Mimic (cranial nerves) 
• 
Babinski reflex (central function) 
• 
Muscle strength (shake hands) biceps, triceps, distal extensors, and flexors 
 
These examinations may also be repeated between scheduled visits at the discretion 
of the investigator. Screening for neurological disease with electroencephalogram 
(EEG) is not included due to low sensitivity and specificity. However, if any signs of 
neurological dysfunction are detected, the patient should be referred to a neurologist 
for further evaluation. 

 
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6.6 Adverse events 
See section 9.2.2 below. 
6.7 Concomitant Medication  
 
Any concomitant medication used during the study, whether considered relevant for 
the study or not by the investigator must be reported on the concomitant medication 
log of the CRF. Please also see section 8.5, below. 
 

 
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7. Scheduling of procedures 
 
Table 2 Pilot DIAGNODE-1 Study, Schedule of Study Events, T1D patients 
Study Period 
Scree-
ning 
Intervention 
Follow-up 
Visit number 
1 
2 
3 
4 
5 
6 
7 
8 
Time 
(Day/Week/Month) 
D 
-10 to -21 
D1 
Base-
line 
M1 
(D30 
± 3) 
 M2 
(D60 
± 3) 
M3 
(D90 
± 3) 
M 6 
(D180
± 14) 
M 15 
(D450 
± 14) 
M 30 
(D900
± 30)  
Informed Consent 
X 
 
 
 
 
 
 
 
GAD-alum (Diamyd)  
treatment  
 
 
X 
X 
X 
 
 
 
Vitamin D 
administration start 
and stop 
 
Start 
Day 1 
 
 
Stop Day 120 
 
 
Medical History 
X 
 
 
 
 
 
 
 
Physical Examination 
X 
X 
X 
X 
X 
X 
X 
X 
Neurological 
Assessment 
X 
 
 
 
 
X 
X 
X 
Concomitant 
Medication 
X 
X 
X 
X 
X 
X 
X 
X 
Height a 
X 
X 
X 
X 
X 
X 
X 
X 
Weight, BMI 
X 
X 
X 
X 
X 
X 
X 
X 
Pubertal Stage, if 
applicable b 
X 
 
 
 
X 
X 
X 
X 
Urine pregnancy test 
(females) 
X 
X 
X 
X 
X 
X 
X 
X 
Injection site 
inspection c 
 
 
X 
X 
X 
 
 
 
Insulin dose d  
X 
X 
X 
X 
X 
X 
X 
X 
Self Reported 
Hypoglycemia e 
 
X 
X 
X 
X 
X 
X 
X 
Adverse Events 
 
X 
X 
X 
X 
X 
X 
X 
Blood sample safety: 
*   Hematology 
X 
X 
X 
X 
X 
X 
X 
X 
*   Chemistry 
X 
X 
X 
X 
X 
X 
X 
X 
Urinalysis: 
* Microalbuminuria 
X 
X 
X 
X 
X 
X 
X 
X 
* Creatinine 
X 
X 
X 
X 
X 
X 
X 
X 
Blood sampling for Auto-antibodies: 
*  GADA 
X 
X 
X 
X 
X 
X 
X 
X 
* other diabetes-
related autoantibodies   
X 
X 
X 
X 
X 
X 
X 
X 
Blood sampling for Diabetes status: 
*  HbA1c 
X 
X 
X 
X 
X 
X 
X 
X 
*  Fasting glucose/C-
peptide 
X 
X 
X 
X 
X 
X 
X 
X 
*  MMTT glucose/ 
C-peptide 
 
X 
 
 
 
X 
X 
X 
Blood sampling for 
genetics 
X 
X 
X 
X 
X 
X 
X 
X 
* HLA 
 
X 
 
 
 
 
 
 
Blood sampling for immunology  

 
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* TNF-alfa, IL-1 beta, 
IL-2, IL-17, IL-5,10, 13  
IFN-gamma and T-
regulatory cells 
X 
X 
X 
X 
X 
X 
X 
X 
Vitamin D in serum 
 
X 
X 
 
 
 
X 
 
Blood sampling for 
biobank 
 
X 
X 
X 
X 
X 
X 
X 
a Hight will only be documented for adult patients at visit 1. For patients <18 years of age the height will 
be documented at all visits 
b Pubertal Stage should be measured when applicable. Not applicable >1.5 years after the patient have 
reached final height 
c Inspection of injection site before and 60 minutes after GAD-Alum injection by investigator or nurse 
d Insulin dose should be collected 4 days prior to each visit 
e Severe hypoglycemia defined as needing help from others and/or seizures and/or unconscious 

 
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7.1 Visits 
The first visit, the screening visit (Visit 1) should be performed 10 to 21 days before 
planned Visit 2 (Baseline), when Vitamin D treatment starts. One month (30 days) 
later, at Visit 3, the first injection of GAD-Alum will be administered. For Visit 4 
(second GAD-Alum administration), the visit date must be set in accordance with 
Visit 3 (i.e. the first GAD-Alum administration) so that the first and second GAD-Alum 
doses will be 30 days apart (±3 days). For Visit 5 (third GAD-Alum administration) the 
visit date must be set in accordance with Visit 4 (i.e. the second GAD-Alum 
administration) so that the second and third GAD-Alum doses will be 30 days apart (± 
3 days). For Visit 6 and 7, the visit date must be calculated from baseline (Visit 2) 
±14 days and ±30 days from baseline for Visit 8.   
 
Please see table 1 and 2 above, for schedule of patient visits, visit windows and 
study drug administration. 
 
 
8. Study medication 
8.1 Study medication 
 
The following medication supplies will be used in the study: 
 
 
A. 
Study medication:  
GAD-Alum (Diamyd) subcutaneous injection 
Dosage and interval: One injection of 4 µg Diamyd will be 
administered once per month during three months (4 µg 
given with one month interval three times)  
 
 
IMP supplier: 
Diamyd Medical AB, Stockholm, Sweden. 
 
B. 
Study medication 
Vitamin D (Calciferol) in oral solution, 14 000 IE/week until 
day 120 
Dosage and interval: 2000 IE daily for 120 days 
 
 
IMP supplier 
Commercially available 
8.2 Supply 
 
GAD-Alum (Diamyd) will be supplied by Diamyd Medical. It will be supplied as pre-
packed medication from Diamyd Medical to a local pharmacy. All dosing will take 
place in the hospital, and handled only by trained and authorised study personnel. 
 
GAD-Alum will be stored in a refrigerator at 2-8 ºC in a secure area (e.g. a locked 
cabinet or drug storage room), protected from unintended use. 
 
Vitamin D (Calciferol) will be handled and distributed by a local pharmacy. 
 
All study medication will be labelled with information according to local regulations. 
 

 
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8.3 Dosage and administration 
 
GAD-Alum:  4 µg given into lymph node in the inguinal area (by help of ultra sound 
technique) three times with one month interval 
 
Vitamin D: 
14 000 IE per week, given per os until Day 120  
8.4 Duration of treatment 
See 8.3 
8.5 Concomitant medication 
 
No systemic immune modulating medication, and no other diabetes medication other 
than insulin, and no Vitamin D, whether marketed or not, are allowed.  
 
8.6 Study medication accountability 
 
All study medications supplied for this study must be retained in a safe place at all 
times of the study. Only personnel authorised by the investigator should dispense the 
study medication, and the accountability is the responsibility of investigator.  
 
A study medication inventory (dispensing records) for all medication dispensed must 
be maintained at all times and always kept current. Used and unused medication 
must be stored at the site or pharmacy throughout the study. The 
investigator/pharmacist must keep record of all drugs received, used and returned. 
Both pharmacies and study sites are obliged to properly measure and record the 
storage temperature. 
 
When the study is completed all unused and used study medication containers must 
be returned to the drug supplier unless the drug supplier has approved other 
arrangements.   
 
 
9. Response variables and outcomes 
9.1 Assessments 
9.1.1. Variables 
 
The safety assessments includes occurrence of adverse events (AEs), laboratory 
measurements, physical examinations including neurological assessments (See 
section 6.3-6.7). 
 
Adverse events will be recorded by the physician at every visit throughout the study. 
 
Blood tests for safety:   
• 
Chemistry:  Creatinine, Calcium, Liver function tests (alanine aminotransferase 
[ALT], aspartate aminotransferase [AST], alkaline phosphatase, bilirubin) 
• 
Haematology (MHC, MCV, MCHC, Hemoglobin, Platelets, Leukocytes) 
 

 
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Urinalysis for safety: 
• 
Urine pregnancy test as appropriate 
• 
Microalbuminuria 
• 
Creatinine 
 
Other Variables which will be evaluated: 
 
• 
Inflammatory markers, especially TNF-alfa, IL-1 beta, IL-2, IL-17  
• 
Th2-deviation of cell-mediated immune response seen e.g. as increased ratio 
of IL-5,10, 13 in comparison with IFN-gamma, TNF-alfa, IL-1 beta and IL-17, 
and  increase of T-regulatory cells  
• 
C-peptide (90 minute value and AUCmean 0-120 min) during an MMTT  
• 
Fasting C-peptide 
• 
Hemoglobin A1c (HbA1c) 
• 
Exogenous insulin dose per kg body weight and 24 hours 
 
 
9.2 Adverse events and Serious Adverse Events 
9.2.1 Definitions of Adverse Events 
 
An Adverse Event (AE) is defined as any untoward medical occurrence in a subject 
during a clinical study administered a medicinal product and which does not 
necessarily have a causal relationship with this treatment(s).  
 
An AE can therefore be any unfavorable and unintended clinical sign or symptom, 
any illness or disease, which develops or worsens in intensity during the course of 
the trial. It also includes an abnormal laboratory finding, if e.g., the abnormality 
results in trial withdrawal, is serious, is associated with clinical signs or symptoms, or 
is considered being of clinical relevance. 
 
It could also include accidents and reasons for changes in medication (drug and/or 
dose), any medical/nursing/pharmacy consultation and admission to hospital/surgical 
operations. 
 
Any new findings, clinically significant laboratory values or worsening of pre-existing 
condition must be reported as an AE by the investigator, whether or not considered 
related to the medicinal product(s). 
 
Note that hospital admission and/or surgical operations for illness, which existed 
before the study drug was given or the subject was enrolled in the clinical trial and 
did not worsen during the study, are not AEs. 
 
 
9.2.2.1 Seriousness 
 
A Serious Adverse Events (SAE) is defined as: an Adverse Event that is fatal, life- 
threatening, significant or persistent disabling or requires hospitalisation or 
prolongation of hospitalisation, a congenital anomaly or birth defect. 
 
These characteristics/consequences have to be considered at the time of the event. 
For example, regarding a life- threatening event, this refers to an event in which the 

 
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subject was at risk of death at the time of the event; it does not refer to an event 
which hypothetically might have caused death if it were more severe.  
 
Some medical events may jeopardise the subject or may require an intervention to 
prevent one of the above characteristics/consequences. Such events (referred to as 
important medical events) should also be considered as serious in accordance with 
the definition.  
 
 
9.2.2.2 Intensity 
 
Mild:  
The adverse event is transient and easily tolerated. 
Moderate: 
 The adverse event causes the patient discomfort and interrupts the 
patient's usual activities. 
Severe: 
  The adverse event causes considerable interference with the patient's 
usual activities, and may be incapacitating or life-threatening. 
 
Note: a distinction should be drawn between serious and severe AEs. The term 
severe is used to describe the intensity of the event and the event does not 
necessarily need to be considered serious. The term serious is based on the 
patient/event outcome or action and serves as a guide for defining regulatory 
reporting obligations. 
 
9.2.2.3 Relationship to study medication 
 
Relationship to study medication will be assessed for the two treatments (GAD-Alum 
and Vitamin D) separately. 
 
Unrelated:  
This category is applicable to those adverse events which, after careful medical 
consideration at the time of evaluation, are judged to be clearly and incontrovertibly 
due to extraneous causes (disease, environment, etc.) and do not meet the criteria 
for study medication relationship listed under remote, plausible or probable. 
 
Remote:  
In general, this category is applicable to those adverse events which, after careful 
medical consideration at the time they are evaluated, are judged to be remotely 
related to the test study medication. An adverse event may be considered remote if, 
or when, for example: (i) it does not follow a reasonable temporal sequence from 
administration; (ii) it could readily have been produced by the patient's clinical state, 
environmental or toxic factors, or other modes of therapy administered to the patient; 
(iii) it does not follow a known response pattern to the suspected study medication; 
(iv) it does not reappear or worsen when the study medication is re-administered. 
 
 
Plausible: 
This category is applicable to those adverse events which, after careful medical 
consideration at the time they are evaluated, the connection with the test study 
medication administration appears unlikely but cannot be ruled out with certainty. An 
adverse event may be considered plausible if, or when: (i) it follows a reasonable 
temporal sequence from administration; (ii) it could not readily have been produced 
by the patient's clinical state, environmental or toxic factors, or other modes of 
therapy administered to the patient; (iii) it follows a known response pattern to the 

 
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suspected study medication; (iv) it does not reappear or worsen when the study 
medication is re-administered. 
 
Probable: 
This category is applicable to those adverse events, which, after careful medical 
consideration at the time they are evaluated, the connection with the test study 
medication administration appears to, with a high degree of certainty, be related to 
the test study medication. An adverse event may be considered probable if: (i) it 
follows a reasonable temporal sequence from administration; (ii) it could not be 
reasonably explained by the known characteristics of the patient's clinical state, 
environmental or toxic factors, or other modes of therapy administered to the patient; 
(iii) it disappears or decreases on cessation or reduction in dose. There are important 
exceptions when an adverse event does not disappear upon discontinuation of the 
study medication, yet study medication-relatedness exists; e.g. bone marrow 
depression, fixed study medication eruptions, and tardive dyskinesias; (iv) it follows a 
known response pattern to the suspected study medication; (v) it reappears upon re-
challenge. 
 
 
9.2.2.4 Reporting of Adverse Events  
All Adverse Events must be recorded in the CRF, defining relationship to study 
medication, severity and seriousness. Adverse Events should also be recorded by 
the investigator in the patient file/notes. 
 
9.2.2.4.1 Timelines and Reporting of SAE 
 
All SAEs must be reported, whether or not considered attributable to the study drug 
on a separate SAE Report Form. 
 
An assigned CRO, contracted by Diamyd Medical AB, will be responsible for 
reporting all Serious Adverse Events (SAEs) in accordance with ICH Good Clinical 
Practice and local regulations. The sponsor, Diamyd Medical AB and the assigned 
CRO will complete and sign a “Pharmacovigilance Working Instructions” agreement 
covering the safety reporting responsibilities in the study. This agreement will also 
ensure the sponsor and Diamyd Medical AB is directly informed of each SAE 
reported by the Investigators. 
 
In order to meet the specified reporting requirements investigators should adhere to 
the following process for recording and reporting SAEs.  
 
It is the investigator’s responsibility to, as soon as he/she is aware of a potential 
Serious Adverse Event (SAE), he/she should contact the assigned CRO by fax or e-
mail, and in any case no later than 24 hours after the knowledge of such a case. At 
the time of initial reporting, the Investigator must provide as a minimum requirement, 
the patient number, birth date, nature of the SAE, and a preliminary assessment of 
causality. The Investigator should follow-up the initial notification of the potential SAE 
by faxing or e-mailing copy of the SAE reporting form to the CRO at the numbers/e-
mail addresses provided in the Investigator Site File and on the SAE report form The 
faxed/e-mailed SAE report form should be received by The CRO within 24 hours of 
the initial notification of the event.   
It is the investigator’s responsibility to report to the CRO follow-up information on an 
existing SAE that is fatal or life-threatening within 5 days after the initial report. 
Where appropriate, hospitalisation or autopsy reports should be made available. All 
Serious Adverse Events will be followed up until resolution (i.e., asymptomatic, 

 
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stabilisation or death).  
 
It is the CRO’s responsibility to receive e-mail or fax copies of the SAE report form 
and other relevant CRF pages from the Investigators. The Drug Safety unit at the 
CRO will review the information provided on the form and enter it into the safety data 
base. The SAE report will be assigned a unique number that will be entered on the 
SAE Report Form, and will be used to identify the report in all future communication. 
A notification of receipt of the report will be sent to the reporter, either by fax or e-mail 
within 48 hours. The CRO will contact the Investigator directly if there is any 
inconsistencies and missing information. 
The CRO is responsible for the timely submission of Suspected Unexpected Serious 
Adverse Reactions (SUSARs) to the Competent Authority and Ethics Committee 
according to appropriate Competent Authority and Ethical Committee requirements. It 
is the CRO’s responsibility to report SUSARs to investigators according to ICH Good 
Clinical Practice and to local regulations ant to notify the Competent Authorities of all 
SUSARs through the Eudravigilance database.  
 
Fatal and life-threatening SUSARs should be reported by the CRO as soon as 
possible to the Competent Authorities and Ethical Committee, and in any case no 
later than seven (7) calendar days, after first knowledge by the Sponsor/CRO of such 
a case. Relevant follow-up information on the case will be subsequently 
communicated within an additional eight (8) days. All other SUSARs shall be 
reported to the Competent Authorities concerned and to the Ethics Committee 
concerned as soon as possible but within a maximum of fifteen (15) days of first 
knowledge by the Sponsor/CRO.  
 
9.2.2.4.2 
Unresolved Events 
 
If an AE/SAE is present when the patient has completed the study the course of the 
event must be followed until final outcome is known or the condition is stable. 
 
 
9.2.2.5 Pregnancy Report Form: 
 
Pregnant and lactating women will not be included in the study. Females must have a 
negative urine pregnancy test prior to randomization and a negative urine pregnancy 
test at each study visit with study drug administration, prior to injection of study drug. 
Patients will be required to use an adequate form of birth control during the study. At 
Visit 2 the need for birth control will be re-assessed.  Patients and their partners will 
be strongly advised to avoid pregnancy for 1 year following the last dose and 
instructed to use adequate birth control. 
 
A pregnancy occurring during the trial must be recorded on the Pregnancy Report 
Form and no further drug doses will be given. If the pregnancy is verified prior to any 
of the injections, no further injection shall be given. 
 
The Pregnancy Report Form should be faxed or e-mailed within 24 hours of 
awareness to the assigned CRO. A copy of the report should be filed at the study site 
for follow-up until delivery. Any pregnancy must be followed until delivery or to the 
end of pregnancy. 

 
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10. Statistical methodology and data management 
10.1 Study design 
 
The DIAGNODE-1 study is an open-label pilot Phase I intervention study 
 
Study Participants: 
Newly diagnosed classic type 1 diabetes patients: N=15. Age 12.00-29.99 years. 
Recruited from one hospital in Sweden. 
 
10.2 Estimation of sample size 
Power analysis: 
 
No formal power analyses are done for this pilot study. 
 
 
10.3 Statistical analysis plan 
 
In brief the following analyses are planned: 
 
All continuous variables will have the following descriptive statistics displayed: 
number of observations (n), mean value, standard deviation, minimum, median, and 
maximum. All variables of a categorical nature will be displayed with frequencies and 
percentages. The tabulation of the descriptive statistics will be split by visit. Where 
appropriate, baseline (screening) descriptive statistics will also be included.   
 
Demographic and other baseline characteristics 
 
Demographics and baseline characteristics will be presented using descriptive 
statistics (summary tables).   
 
Variables  
 
The AE/SAE data will be presented using a standardized tabulation of the frequency 
and incidence rate of all observed AEs/SAEs. The frequencies and incidence rates 
are calculated on a per patient basis. Adverse events will be summarized by body 
system, causality, and severity. Other safety data will be presented by descriptive 
statistics. 
   
Data regarding C-peptide and immune system as well as Adverse events and other 
data will be summarized descriptively.    
 
After 6 months analysis of the data. (The results will be used for design of a Phase II 
DIAGNODE trial). 

 
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10.4 Study populations 
 
Intention-to-treat population 
Patients will be included in the primary intention-to-treat population for analysis of 
efficacy if they receive at least 1 dose of all study drugs in that arm, and are 
assessed at a later visit. 
 
Per protocol population 
In order to qualify for the stringent per protocol population, the subjects must have 
followed the study protocol without any major violations. Any examinations missed 
will be substituted with the last observation carried forward, but examinations from 
not more than 1 visit may be lost.  
 
Total population 
Any patient who withdraws from the study will be included in the safety analysis 
(adverse events and safety parameters). Data for all patients will be listed, and a list 
of withdrawn patients, with all reasons for withdrawal, will be given.  
 
 
10.5 Data collection / case report forms  
 
Case report forms (CRFs) will be supplied for recording data from each patient. Since 
it is important to have proper data collection in a timely manner, the investigator or 
assigned designee shall complete the CRFs promptly. When the monitor requests 
additional data or clarification of data for the CRF, the request must be answered 
satisfactorily in due time. 
 
It is the responsibility of the investigator to ensure that these case report forms are 
properly completed. The investigator will sign the designated signature pages to 
confirm that the case report form is accurate and complete. 
 
To ensure legibility the CRFs should be completed in block capitals with a black or 
blue ballpoint pen (not pencil, felt-tip or fountain pen). 
 
Any corrections to the CRFs must be carried out by the investigator or his designate. 
A single stroke must be drawn through the original entry. The correction has to be 
dated and initialled. Incorrect entries must not be covered with correcting fluid, or 
obliterated, or made illegible in any way. 
 
Even if there are no changes from a previous examination, in the interests of 
completeness of data acquisition the questions, which are repeated in each section 
of the CRFs should be answered in full. A reasonable explanation must be given by 
the investigator for all missing data. 
 
10.6 Data management 
Data will be entered into a computer database. The handling of data, including data 
quality control, will comply with regulatory guidelines (e.g., International Conference 
on Harmonization [ICH] and Good Clinical Practice [GCP]). 
 

 
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11. Regulatory and administrative procedures    
 
11.1 Ethics committee and Competent Authorities 
 
Any regulatory requirements must have been met before starting the study. The 
Sponsor will apply for the regulatory approval to the appropriate authorities. 
 
Study sites, facilities, laboratories and all data (including source data) and 
documentation must be made available for inspection by the authorities. 
 
The study will be conducted in accordance with the Brazil, (2013) amendment to the 
Declaration of Helsinki 1964. 
 
 
The Protocol and Patient Information and Informed Consent Form will be approved 
by the Ethics Committee before commencement. If a substantial protocol amendment 
is necessary, this will be signed and submitted by the Sponsor for ethical and 
regulatory approval. The approval from the Ethics Committee and Competent 
Authority should be obtained before any implementation of the amendment is done. 
When the change or deviation is to eliminate or reduce risk to human patients, the 
amendment may be implemented before review of approval by the Ethics Committee 
and Competent Authority. The sponsor should notify the Ethics Committee and 
Competent Authority of the change or deviation in writing within 10 working days after 
implementation. 
 
Minor amendments which do not affect the safety or conduct of the study from the 
patient viewpoint, and which do not significantly reduce the scientific value of the 
protocol, and which do not require a significant change to be made to the consent 
form and/or the information sheet, will not be submitted for formal ethics and 
regulatory review. These will be sent to the Ethics committee and Competent 
Authority on an ‘information only’ basis. 
 
11.2 Patient Information / Informed Consent  
 
The investigator is responsible for giving the patients and guardian(s) (where 
applicable) full and adequate verbal and written information about the nature, 
purpose, possible risk and benefit of the study. Patients and/or guardian(s) must also 
be notified that they are free to withdraw from the study at any time. The patients 
and/or guardian(s) should have reasonable time to read and understand the 
information before signing. The investigator is responsible for obtaining signed 
informed consent from all patients and/or guardian(s) before including the patient in 
any study related procedures. 
 
Should there be any amendments to the final protocol, such that would directly affect 
the patient’s participation in the trial e.g., a change in any procedure, or if new data is 
obtained during the trial that may influence the standpoint to participate in the study, 
the patient information will be amended to incorporate this modification and the 
patient and/or guardian(s) must agree to sign this amended form verifying that they 
re-consent to continue their participation in the trial. 
 
 

 
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A copy of the patient information and of the Informed Consent Form will be given to 
the patients and/or guardian(s). 
 
11.3 Patient confidentiality 
 
The investigator must ensure that patient's confidentiality will be maintained. CRFs or 
other documents submitted to the Sponsor should only identify patients by their 
initials and study number. The investigator should keep a separate log of patient 
codes and names. 
 
Documents not for submission to the Sponsor, e.g. patient's completed Consent 
Forms, should be retained by the investigator in strict confidence.  
 
The investigator is required to record safety data, concomitant medication and patient 
progress in the patient's file/notes/medical record. 
 
The patient's medical records will be reviewed by the study monitor to verify 
adequate source documentation, accuracy and completeness of Case Report Forms. 
The review will be conducted with strict adherence to professional standards of 
confidentiality. 
 
The investigator must keep a screening log, recording all patients who were 
screened, whether they were enrolled or not, and a separate Patient Identification 
List showing code numbers, names, and dates of birth to allow unambiguous 
identification of each patient included in the study. 
 
11.4 Patient treatment plan 
 
All patients will continue to receive standard care for Type 1 diabetes during the 
study. 
 
After the individual completion of the study, the patient will return to the standard 
treatment received prior to study participation. 
 
11.5 GCP 
 
The study will be managed and conducted according to the latest international (ICH) 
guidelines for Good Clinical Practice 
 
11.6 Record retention 
 
The CRFs and all medical records upon which the CRFs are based (source data) 
must be kept for at least 10 years after completion of the study.  
 
11.7 Monitoring / Quality Control 
 
Prior to the start of the study, the monitor will review the protocol and CRFs with the 
investigator and his/her staff.  The investigator will be visited by the monitor, who will 

 
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check study procedures, including safety assessments, study medication handling, 
data recording and source data verification (SDV). To assure the accuracy and 
completeness of the data recorded in the trial, the monitor will compare CRFs with 
medical records and other relevant documentation during the on-site monitoring 
visits. The monitor must therefore be allowed direct access to all source data 
according to ICH GCP to confirm that required protocol procedures are being 
followed and check consistency between patient record and CRF data. Incorrect or 
missing entries into the CRFs will be queried and must be corrected. Study 
monitoring will not jeopardise patient confidentiality.   
 
11.8 Quality Assurance  
 
During or after the study is completed, regulatory authorities, Diamyd Medical, 
assigned CRO or other involved party may wish to carry out an audit. These 
representatives must have the same access to study data and patient source data as 
the monitor. 
 
11.9 Insurance  
 
Patients insurance is covered by the ordinary Patientskadeförsäkringen. 
12. End of Trial 
 
The end of the trial is defined as the last visit of the last patient included in the trial 
and all data have been collected.  
 
12.1 Study report 
 
A clinical study report will be prepared covering clinical and statistical aspects and 
summarising all findings of the clinical study. The content has to be treated as strictly 
confidential.  
 
12.2 Study Stopping Criteria 
 
The Sponsor and the investigators reserve the right to discontinue the study at any 
time for safety reasons or other reasons jeopardizing the justification of the study. 
Such a termination will be implemented in a time frame that is compatible with the 
patient’s wellbeing. 
 
If the study is prematurely terminated or suspended, the investigator should promptly 
inform the patients and assure appropriate therapy and follow-up. The Sponsor will 
notify the Regulatory Authorities and the Ethics Committee of any plans to terminate 
the study. 
 
12.3 Publication and Data Rights 
 
It is envisaged that the findings of the study will, in due course and by mutual 
agreement, be published in a scientific journal and/or presented at a scientific 
meeting. The authorship of this publication/ will remain as specified below. 

 
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The published international guidelines for authorship (International Committee of 
Medical Journal Editors, 1997) will be adhered to; i.e. ‘All persons designed as 
authors should qualify for authorship. Each author should have participated 
sufficiently in the work to take public responsibility for the content.’  Authorship credit 
will therefore be based only on substantial contributions to 1) conception and design, 
or analysis and interpretation of data; and to 2) drafting the article or revising it 
critically for important intellectual content; and on 3) final approval of the version to 
be published. Conditions 1), 2) and 3) must all be met. Participation solely in 
acquisition of funding or the collation of data does not justify authorship. General 
supervision of the research group is not sufficient for authorship. It is intended that 
information on what each author has contributed will be published. It is emphasised 
however, that only those who entirely meet the above mentioned criteria will be listed 
as authors. The principal investigator, who will be first or last author of publications 
based on this trial, has the final decision of the list of authors. 
 

 
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13. References 
 
1. Nordwall M, Ludvigsson J.Submitted.  
2. Ludvigsson J, Heding LG, et al Acta Paediatrica Scand 1977; 66:177-184. 
3. Ludvigsson J, Heding LG: Diabetes 1978; 27 suppl 1:230-234. 
4. Pozzilli P, Manfrini S,  et al Diabetes Res Clin Pract 2005; 68:258-264. 
5. Madsbad S, Alberti KG, et al  Br Med J 1979; 2:1257-1259. 
6. Steffes MW, Sibley S et al Diabetes Care 2003; 26: 832–836.   
7. Wahren J, Ekberg Ket al  . Diabetologia 2007, 50: 503-509 
8. Shah SC, Malone JI et al N Engl J Med 1989; 320:550-554 
9. The Diabetes Control and Complications Trial Research Group Ann Intern 
Med 1998; 128:517-523. 
10. Keller RJ, Eisenbarth GS et al  Lancet 1993; 10:927-928. 
11. Diabetes Prevention Trial -Type 1 Diabetes Study Group. N Engl J Med. 
2002; 346:1685-1691 
12. Skyler JS, Krischer Jpet al  Wolfsdorf J, Cowie C, Palmer JP, Greenbaum C, 
Cuthbertson D, Rafkin-Mervis LE, Chase HP, Leschek E.  
Diabetes Care. 2005; 28:1068-1076. 
13. Ludvigsson J, Heding L, Lieden G, Marner B, Lernmark A.  
Br Med J 1983; 286:176-178. 
14. Baekkeskov S, Nielsen JH, Marner B, Bilde T, Ludvigsson J, Lernmark A. 
Nature. 1982; 298:167-169. 
15. Heinze E.. Clin Exp Rheumatol 1996; 14 suppl 15:S99-102. 
16. Dupre J, Stiller CR et al  Diabetes Care 1988,  suppl 1, 37-44 
17. Silverstein J, Maclaren  et.alN Engl J Med 1988; 319:599-604. 
18. Coutant R, Landais P et Diabetologia.1998; 41:1040-1046 
19. Eisenbarth GS, Srikanta S, et al Diabetes Res 1985; 2:271-276 
20. Faresjö M, Ernerudh J, Berlin G, Garcia J, Ludvigsson JPediatr Res 2005; 
58:459-466 
21. Ludvigsson J, Samuelsson U et Arch Dis Child 2001; 85:149-154. 
22. Elliot RB, Chase HP Diabetologia 1991; 34:362-365. 
23. Ludvigsson J, Samuelsson U et al Diabetes Metab Res Rev 2001; 17:131-
136 
24. Örtqvist E, Björk, Wallensteen M, Ludvigsson J et al Diab Care 2004; 
27:2191-2197. 
25. Keymeulen B, Vandemeulebroucke E et al N Engl J Med 2005; 352:2598-
2608. 
26. Elias D, Cohen IR.  Diabetes 1996; 45:1168-1172. 
27. Sherry, Hagopian, Ludvigsson etc al Lancet 2011 
28. Ludvigsson J. Adequate doses of autoantigen administered using the 
appropriate route may create tolerance and stop autoimmunity. Diabetologia 
2009;52:175-176. 
29. Raz I, Elias D et al Lancet 2001; 358:1749-1753. 
30. Nanette C. Schloot et al  . Diabetes Metab Res Rev. 2007;  22; [Epub ahead 
of print] 
31. Kaufman et al. (1993).. Nature 366:69-72 
32. Tisch et al. (1993Nature 366:72-75 
33. Tian et al. (1996). GAD65)  J Exp Med 183:1561-1567 
34. Tian et al. (1996). Nature Medicine 2:1348-1353 
35. Petersen et al. (1994 )Diabetes 44:1478-1484 
36. Pleau et al. (1995Clin Immunol Pathol 76:90-95 
37. Tisch et al. (1998) Diabetes 47:894-899 
38. Plesner et al. (1998). J Autoimmunity 11:335-341 
39. Yoon et al. (1999). Science 284:1183-1190 

 
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40. Tisch et al. (2001J Immunol 166:2122-2132 
41. Jun et al (2002). Diabetologia 45:668-676 
42. Plesner et al. (1998). J Autoimmunity 11:335-341 
43. Agardh C-D, Corrado MC et. Diabetes 2004; 53 suppl 2: 272–OR 
44. Ludvigsson J, Faresjö M, Hjorth M, Axelsson S, Chéramy M, Pihl M, Vaarala 
O, Forsander G, Ivarsson S, Johansson C, Lindh A, Nilsson NO, Aman J, 
Ortqvist E, Zerhouni P, Casas R. N Engl J Med. 2008 .  
45. Ludvigsson et al Diabetologia 2011. 
46. Ludvigsson  J, Krisky D, Casas R etc al. New Engl J  Med  2012 Feb 
2;366(5):433-42. 
47.  Maloy KJ, et al: Intralymphatic immunization enhances DNA vaccination. 
(2001) PNAS, 98(6), 3299-3303,  
48. Johansen PAC,et al: Direct intralymphatic injection of peptide vaccines 
enhances immunogenicity.  (2005) Eur J Immunolo. 35(2): 568-574 
49. Von Beust BR et al: Improving the therapeutic index for CpG 
oliogdeoxynucleotides by intralymphatic administration (2005) Eur J immunol 
35: 1869-1876 
50. Senti G et al: Intralymphatic allergen administration renders specifi 
immunotherapy faster and safer: a randomized controlled trial.  (2008) PNAS 
105(46): 17908-17912 
51. Vitamin D supplement in early childhood and risk for type I (insulin-
dependent) diabetes mellitus. The Eurodiab Substudy 2 Study Group. 
Diabetologia 1999; 42: 51–54. [PubMed] 
52. Hyppönen E, Läärä E, Reunanen A, Järvelin MR, Virtanen SM.: Intake of 
vitamin D and risk of type 1 diabetes; a birth-cohort study. Lancet 2001; 358: 
1500–1503. [PubMed] 
53. Zipitis CS, Akobeng AK.: Vitamin D supplementation in early childhood and 
risk of type 1 diabetes: a systematic review and meta-analysis. Arch Dis Child 
2008; 93: 512–517. [PubMed] 
54. Baumgartl HJ, Standl E, Schmidt-Gayk H, Kolb HJ, Janka HU, Ziegler AG.: 
Changes of vitamin D3 serum concentrations at the onset of immune-
mediated type 1 (insulin-dependent) diabetes mellitus. Diabetes Res 1991; 
16: 145–148. [PubMed] 
55. Piemonti L, Monti P, Sironi M, Fraticelli P, Leone BE, Dal Cin E, Allavena P, 
Di Carlo V.: Vitamin D3 affects differentiation, maturation, and function of 
human monocyte-derived dendritic cells. J Immunol 2000; 164: 4443–4451. 
[PubMed] 
56. Penna G, Adorini L.: 1α,25-Dihydroxyvitamin D3 inhibits differentiation, 
maturation, activation, and survival of dendritic cells leading to impaired 
alloreactive T cell activation. J Immunol 2000; 164: 2405–2411. [PubMed] 
57. Griffin MD, Lutz W, Phan VA, Bachman LA, McKean DJ, Kumar R.: Dendritic 
cell modulation by 1α,25 dihydroxyvitamin D3 and its analogs: a vitamin D 
receptor-dependent pathway that promotes a persistent state of immaturity in 
vitro and in vivo. Proc Natl Acad Sci USA 2001; 98: 6800–6805. [PMC free 
article] [PubMed] 
58. Penna G, Amuchastegui S, Giarratana N, Daniel KC, Vulcano M, Sozzani S, 
Adorini L.: 1,25-Dihydroxyvitamin D3 selectively modulates tolerogenic 
properties in myeloid but not plasmacytoid dendritic cells. J Immunol 2007; 
178: 145–153. [PubMed] 
59. Boonstra A, Barrat FJ, Crain C, Heath VL, Savelkoul HF, O'Garra A.: 1α,25-
Dihydroxyvitamin D3 has a direct effect on naive CD4+ T cells to enhance the 
development of Th2 cells. J Immunol 2001; 167: 4974–4980. [PubMed] 
60. Mathieu C, Gysemans C, Giulietti A, Bouillon R.: Vitamin D and diabetes. 
Diabetologia 2005; 48: 1247–1257. [PubMed] 
61. Teegarden D, Donkin SS.: Vitamin D: emerging new roles in insulin 
sensitivity. Nutr Res Rev 2009; 22: 82–92. [PubMed] 

 
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62. Markus Walter, MD,1 Thomas Kaupper, MD,1 Kerstin Adler, PHD,1 Johannes 
Foersch,1 Ezio Bonifacio, PHD,2 and Anette-G. Ziegler, No Effect of the 
1α,25-Dihydroxyvitamin D3 on β-Cell Residual Function and Insulin 
Requirement in Adults With New-Onset Type 1 Diabetes. Diabetes Care. 
2010 July; 33(7): 1443–1448. 
63. Carla Bizzarri, MD,1 Dario Pitocco, MD,2 Nicola Napoli, MD,3 Enrico Di 
Stasio, MD,2 Daria Maggi, MD,3 Silvia Manfrini, MD,3 Concetta Suraci, MD,4 
Maria Gisella Cavallo, MD,5 Marco Cappa, MD,1 Giovanni Ghirlanda, MD,2 
Paolo Pozzilli, MD,3 and the IMDIAB Group* No Protective Effect of Calcitriol 
on β-Cell Function in Recent-Onset Type 1 Diabetes .The IMDIAB XIII trial. 
Diabetes Care. 2010 September; 33(9): 1962–1963.  
64. Chéramy M, Skoglund C, Johansson I, Ludvigsson J, Hampe CS, Casas R. 
GAD-Alum treatment in patients with type 1 diabetes and the subsequent 
effect on GADA IgG subclass distribution, GAD(65) enzyme activity and 
humoral response. ClinImmunol. 2010 Jun 25. 
65. Axelsson S, Hjorth M, Akerman L, Ludvigsson J, Casas R. Early induction of 
GAD(65)-reactive Th2 response in type 1 diabetic children treated with alum-
formulated GAD(65). Diabetes Metab Res Rev. 2010 Oct;26(7):559-68 
66. Skoglund C, Chéramy M, Casas R, Ludvigsson J, Hampe CS. GAD 
autoantibody epitope pattern after GAD-Alum treatment in children and 
adolescents with type 1 diabetes. Pediatr Diabetes. 2011 Aug 16. doi: 
10.1111/j.1399-5448.2011.00802. 
67. Axelsson S, Chéramy M, Hjorth M, Pihl M, Akerman L, Martinuzzi E, Mallone 
R, Ludvigsson J, Casas R. Long-lasting immune responses 4 years after 
GAD-Alum treatment in children with type 1 diabetes. PLoS One. 
2011;6(12):e29008. Epub 2011 Dec 12 
 
 
 
 

 
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14. Investigator/Sponsor signatures 
 
 
Investigator’s Statement: 
 
I have read and understand the foregoing protocol with the title: 
 
“Open Label Pilot Trial in patients with recent-onset T1D to evaluate the safety, 
diabetes status and immune response of GAD-antigen (Diamyd®) therapy 
administered into lymph nodes in combination with an oral and vitamin D regimen” 
 
Trial number DIAGNODE-1 and agree to conduct the trial, in compliance with ICH 
notes on Good Clinical Practice (CPMP/ICH/135/95), designated Standard Operating 
Procedures, National Laws and regulations and within the principles of the current 
revision of Declaration of Helsinki (Brazil 2013). 
 
 
Principal Investigator’s Printed Name: 
 
 
…………..………………………………………… 
 
Principal Investigator’s Signature: 
 
 
…………..………………………………………… 
 
 
Date: ………………………….. 
 
 
 
Sponsor and Principal Investigator’s signature: 
 
 
Name and function 
Signature 
Date 
 
Johnny Ludvigsson 
Coordinating & Principal 
Investigator and Sponsor 
 
 
 
 
 
 

 
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APPENDIX TO CLINICAL TRIAL PROTOCOL (AMENDMENT NO 5): 
“Prolonged Extension Study Period for study DIAGNODE-1” 
 
Open Label Pilot Trial in patients with recent-onset T1D to evaluate the safety, 
diabetes status and immune response of GAD-antigen (Diamyd®) therapy 
administered into lymph nodes in combination with an oral vitamin D regimen 
 
Acronym: DIAGNODE-1. (Trial to evaluate the safety and diabetes status in patients 
with recent-onset Type 1 diabetes by giving GAD-antigen (Diamyd®) therapy into 
lymph NODEs in combination with an oral Vitamin D regimen) 
 
 
 
 
Study No. DIAGNODE-1 
EudraCT Number: 2014-001417-79 
Study Development Phase: I/II 
Version 5.1: 2018-06-11 
 
 
Sponsor: 
Johnny Ludvigsson 
 
Div of Pediatrics, Linköping university, 
University Hospital, SE-581 85 Linköping, 
Sweden 
Phone: 
+ 46 13 286854 
Fax: 
+ 46 13 148265 
 
Coordinating & Principal Investigator: 
 
 
Professor Johnny Ludvigsson 
Linköping University Hospital,  
Div of Pediatrics, Dept of Clinical and 
Experimental Medicine, 
Faculty of Health Medicine, Linköping university 
SE-581 85 Linköping, Sweden 
 
Contract Research Organization: 
Linköping Academic Research Centre (LARC) 
 

 
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TABLE OF CONTENTS 
1 
INTRODUCTION ....................................................................................................................... 44 
2 
OBJECTIVES .............................................................................................................................. 45 
3. POPULATION ................................................................................................................................. 45 
3.1 INCLUSION CRITERIA ..................................................................................................................... 45 
3.2 EXCLUSION CRITERIA .................................................................................................................... 45 
4. 
TREATMENT PROCEDURES ................................................................................................. 46 
4.1 STUDY VISITS AND SCHEDULE OF EVENTS ..................................................................................... 46 
4.2 
ASSESSMENTS AND PROCEDURES ......................................................................................... 48 
4.2.1 All Visits, Visit 9, 10, 11, 12 and 13 ..................................................................................... 48 
4.2.2 Administrations of GAD-Alum, Visits 10 ............................................................................ 48 
4.2.3 Mixed Meal Tolerance Test (MMTT), Visits 12 and 13 ..................................................... 48 
4.3 LABORATORY TESTS AND EXAMINATIONS ..................................................................................... 49 
4.4 PHYSICAL EXAMINATION INCLUDING NEUROLOGICAL EXAMINATION ......................................... 49 
4.5 ADVERSE EVENTS.......................................................................................................................... 50 
4.6 CONCOMITANT MEDICATION ........................................................................................................ 50 
5. STUDY MEDICATION ................................................................................................................... 51 
5.1 STUDY MEDICATION ...................................................................................................................... 51 
5.2 SUPPLY ......................................................................................................................................... 51 
5.3 DOSAGE AND ADMINISTRATION .................................................................................................... 51 
5.4 DURATION OF TREATMENT ............................................................................................................ 51 
5.5 CONCOMITANT MEDICATION ......................................................................................................... 52 
5.6 STUDY MEDICATION ACCOUNTABILITY ......................................................................................... 52 
6. RESPONSE VARIABLES AND OUTCOMES ............................................................................. 53 
6.1 ASSESSMENTS ............................................................................................................................... 53 
6.1.1. Variables .............................................................................................................................. 53 
6.2 ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS ...................................................................... 53 
6.2.1 Definitions of Adverse Events .............................................................................................. 53 
6.2.1.1 Seriousness ........................................................................................................................ 54 
6.2.1.2 Intensity ............................................................................................................................. 54 
6.2.1.3 Relationship to study medication ...................................................................................... 54 
6.2.1.4 Reporting of Adverse Events ............................................................................................. 55 
6.2.1.4.1 Timelines and Reporting of SAE .................................................................55 
6.2.1.4.2 
Unresolved Events .....................................................................................56 
7. STATISTICAL METHODOLOGY AND DATA MANAGEMENT ........................................... 57 
7.1 STATISTICAL ANALYSIS PLAN ........................................................................................................ 57 
7.2 STUDY POPULATIONS .................................................................................................................... 57 
7.3 DATA COLLECTION / CASE REPORT FORMS .................................................................................... 57 
7.4 DATA MANAGEMENT ..................................................................................................................... 58 
8. REGULATORY AND ADMINISTRATIVE PROCEDURES ..................................................... 59 
8.1 ETHICS COMMITTEE AND COMPETENT AUTHORITIES .................................................................... 59 
8.2 PATIENT INFORMATION / INFORMED CONSENT ............................................................................. 59 
8.3 PATIENT CONFIDENTIALITY ........................................................................................................... 60 
8.4 PATIENT TREATMENT PLAN ........................................................................................................... 60 
8.5 GCP .............................................................................................................................................. 60 
8.6 RECORD RETENTION ...................................................................................................................... 60 
8.7 MONITORING / QUALITY CONTROL ............................................................................................... 60 
8.8 QUALITY ASSURANCE ................................................................................................................... 61 
8.9 INSURANCE ................................................................................................................................... 61 
9. END OF TRIAL ............................................................................................................................... 61 
9.1 STUDY REPORT .............................................................................................................................. 61 
9.2 STUDY STOPPING CRITERIA .......................................................................................................... 61 

 
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9.3 PUBLICATION AND DATA RIGHTS ................................................................................................. 61 
10. REFERENCES ............................................................................................................................... 63 
11. INVESTIGATOR/SPONSOR SIGNATURES ............................................................................ 64 
 

 
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1 
 Introduction  
This is an amendment to Study Protocol DIAGNODE-1 and describes the prolongation of the 
Extension Study Period from approx. 31 months to 43 months. During the Prolonged 
Extension Study Period three adult patients will be offered treatment with a fourth injection 
with 4 µg GAD-Alum (Diamyd) into an inguinal lymph gland. The Prolonged Extension 
Study Period includes five visits. Although the treatment with three GAD-Alum (Diamyd) 
injections have shown encouraging results with preservation of the residual beta cell function, 
decreased insulin requirement parallel to a low HbA1c, we see tendencies to a gradual decline 
of the desired effect1, 2. One can fear that the immunological effect fades away. To prolong an 
immune response it is usual to give a booster dose in vaccinations, and it is reasonable to try 
this approach also when auto-antigen is used to modify the autoimmune process destroying 
the insulin producing pancreatic beta cells. 
 
This Prolonged Extension Study Period will include three adult patients in the study 
DIAGNODE-1 and evaluate safety after a fourth injection with 4 µg GAD-Alum into an 
inguinal lymph gland. The Prolonged Extension Study Period is 12 months and will start 14 
days (±5 days) after Visit 8 in the Main study (approx. 31 months after baseline). At the end 
of the Prolonged Extension Study Period the patients will have been followed for approx. 43 
months.  

 
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2 
Objectives 
 
The objective of this Prolonged Extension Study Period is to evaluate safety after a fourth 
injection with 4 µg GAD-Alum direct into an inguinal lymph gland and to evaluate how the 
above mentioned treatment influences the immune system and endogenous insulin secretion. 
 
 
3. Population 
 
Adult patients who participated in DIAGNODE-1 (Visit 1-8) are given information about the 
Prolonged Extension Study Period and will be asked to participate in the Prolonged Extension 
Study Period. 
 
3.1 Inclusion criteria 
 
1. Informed consent given by patients according to national regulations 
2. Participated in DIAGNODE-1 (Visit 1-8) 
3. Females must agree to avoid pregnancy and have a negative urine pregnancy test 
4. Patients of childbearing potential must agree to using adequate contraception, until 1 year 
after the fourth administration of GAD-Alum (Diamyd). Adequate contraception is as 
follows:  
 
For females of childbearing potential: 
a. oral (except low‐dose gestagen (lynestrenol and norestisteron)), 
injectable, or implanted hormonal contraceptives 
b. combined (estrogen and progestogen containing)  
c. oral, intravaginal or transdermal progesterone hormonal 
contraception associated with inhibition of ovulation  
d. intrauterine device 
e. intrauterine hormone-releasing system (for example, 
progestin‐releasing coil) 
f. bilateral tubal occlusion 
g. vasectomized male (with appropriate post vasectomy documentation 
of the absence of sperm in the ejaculate) 
h. male partner using condom 
i. 
abstinence from heterosexual intercourse  
 
For males of childbearing potential: 
a. condom (male) 
b.  abstinence from heterosexual intercourse 
 
3.2 Exclusion criteria 
 
1. Previous or current treatment with immunosuppressant therapy (although topical or 
inhaled steroids are accepted) 
2. Continuous treatment with any inflammatory drug (sporadic treatment e.g. because of 
headache or in connection with fever a few days will be accepted) 
3. Treatment with any oral or injected anti-diabetic medications other than insulin 
4. Treatment with Vitamin D, marketed or not, or unwilling to abstain from such medication 
during the trial 
5. A history of anaemia or significantly abnormal haematology results at screening 

 
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6. A history of epilepsy, head trauma or cerebrovascular accident, or clinical features of 
continuous motor unit activity in proximal muscles 
7. Clinically significant history of acute reaction to vaccines or other drugs in the past 
8. Treatment with any vaccine, including influenza vaccine, within 4 months prior to 
planned fourth injection of study drug dose or planned treatment with any vaccine up to 4 
months after the fourth injection with study drug.  
9. Participation in other clinical trials with a new chemical entity within the previous 3 
months 
10. Inability or unwillingness to comply with the provisions of this protocol 
11. A history of alcohol or drug abuse 
12. Known human immunodeficiency virus (HIV) or hepatitis 
13. Females who are lactating or pregnant (the possibility of pregnancy must be excluded by 
urine βHCG on-site within 24 hours prior to the GAD-Alum treatment) 
14. Males or females not willing to use adequate contraception until 1 year after the last 
GAD-Alum treatment 
15. Presence of associated serious disease or condition, including active skin infections that 
preclude subcutaneous injection, which in the opinion of the investigator makes the 
patient non-eligible for the study 
16. Deemed by the investigator not being able to follow instructions and/or follow the study 
protocol 
 
 
4. Treatment procedures 
4.1 Study visits and schedule of events 
 
The Prolonged Extension Study Period comprises of 5 study visits: 
 
• 
Visit 9: Day 1 (Screening for Prolonged Extension Study Period and Informed 
Consent, corresponds to approximately Month 31 from Baseline Visit (Visit 2))  
• 
Visit 10: Day 30, Month 1 (Fourth injection with GAD-Alum, corresponds to 
approximately Month 32 from Baseline Visit (Visit 2)) 
• 
Visit 11: Day 90, Month 3 (Safety visit, corresponds to approximately Month 34 from 
Baseline Visit (Visit 2)) 
• 
Visit 12: Day 180, Month 6 (Follow-up and MMTT, corresponds to approximately 
Month 37 from Baseline Visit (Visit 2)) 
• 
Visit 13: Day 360, Month 12 (Follow-up and MMTT, corresponds to approximately 
Month 43 from Baseline Visit (Visit 2)) 
 
 
See table 3 below for an overview of the study visits.  
 
Table 3 Schedule of Patient Visits, Visit Windows and Study Drug Administration 
 
Study 
DIAGNODE-1 Prolonged Extension Study Period 
Visit number 
Visit 9* 
 
Visit 10 
 
Visit 11 
 
Visit 12 
 
Visit 13 
 
Time (Month/Day) 
 Day 1 
 
M 1 
(D30 ± 3) 
M 3 
(D90 ± 14) 
M 6 
(D180 ± 14) 
 
M 12 
(D360± 14) 
 
3 adult patients 
 
4th 
GAD-Alum 
treatment 
 
 
 
*Visit 9 should be scheduled 14 days (+/- 5 days) after Visit 8 in the main study period. 
 
The procedures and the timelines for data collection are given in Table 4. 

 
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Table 4.   Schedule of Procedures and Assessments 
 
Study Period 
Prolonged Extension Study Period 
Visit number 
9a 
10 
11 
12 
13 
Time (Day/Week/Month) 
 Day 1 
 
M 1 
(D30 ± 3) 
M 3 
(D90 ± 14) 
M 6 
(D180 ± 14) 
 
M 12 
(D360± 14) 
 
Informed Consent 
X 
 
 
 
 
GAD-Alum (Diamyd) treatment  
 
X 
 
 
 
Vitamin D administration start 
and stop 
Start at  
Visit 9 
Stop 60 days  
after Visit 9 
 
 
Physical Examination 
X 
X 
X 
X 
X 
Neurological Assessment 
X 
X 
X 
X 
X 
Concomitant Medication 
X 
X 
X 
X 
X 
Weight, BMI 
X 
X 
X 
X 
X 
Urine pregnancy test (females) 
X 
X 
X 
X 
X 
Injection site inspection b 
 
X 
 
 
 
Insulin dose c 
X 
X 
X 
X 
X 
Self-Reported Hypoglycemia d 
X 
X 
X 
X 
X 
Adverse Events 
X 
X 
X 
X 
X 
Blood sample safety: 
 
 
* Hematology 
X 
X 
X 
X 
X 
* Chemistry 
X 
X 
X 
X 
X 
Urinalysis: 
* Microalbuminuria 
X 
X 
X 
X 
X 
* Creatinine 
X 
X 
X 
X 
X 
Blood sampling for Auto-antibodies: 
 
 
* GADA 
X 
X 
X 
X 
X 
* other diabetes-related 
autoantibodies   
X 
X 
X 
X 
X 
Blood sampling for Diabetes status: 
 
 
* HbA1c 
X 
X 
X 
X 
X 
* Fasting glucose/C-peptide 
X 
X 
X 
X 
X 
* MMTT glucose/ C-peptide 
 
 
 
X 
X 
Blood sampling for immunology:  
 
 
* TNF-alfa, IL-1 beta, IL-2, IL-17, 
IL-5,10, 13  
IFN-gamma and T-regulatory 
cells 
X 
X 
X 
X 
X 
Vitamin D in serum 
X 
 
X 
 
 
Blood sampling for biobank 
X 
X 
X 
X 
X 
a) 
Visit 9 should be scheduled 14 days (+/- 5 days) after Visit 8 in the main study period. 
b) 
Inspection of injection site before and 120 minutes after GAD-Alum injection by investigator or 
nurse 
c) 
Insulin dose should be collected 4 days prior to each visit 
d) 
Severe hypoglycemia defined as needing help from others and/or seizures and/or unconscious 
 
 
 
 
 
 

 
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4.2 Assessments and procedures 
 
1. Information about the Prolonged Extension Study Period.  
2. The patient gives their informed consent. 
3. When the patients have given their informed consent, all inclusion and exclusion 
criteria will be checked for eligibility according to the listed inclusion and exclusion 
criteria in section 3.1 and 3.2  
4. At Visit 12 and 13 assessment of residual endogenous insulin secretion by MMTT.  
5. HbA1c, safety (haematology and chemistry), autoantibody titres (GAD65, IA-2), 
immunology, are followed by blood samples at every study visit. 
6. Exogenous insulin dose/24 hours, AEs and concomitant medication is registered at 
every study visit. 
7. Self-reported hypoglycaemia (defined as needing help from others and/or seizures 
and/or unconscious) registered at every study visit.  
8. Any symptoms or signs of other medical problem should be treated at the discretion 
of the clinical doctor. 
 
Examinations will be performed according to Table 4 above, and in the order outlined in the 
case report form (CRF).  
 
4.2.1 All Visits, Visit 9, 10, 11, 12 and 13 
Note that the patient should attend all study visits in the morning following an 
overnight fast (> 10 hours, water allowed).  
 
For patients with evidence of an infection (including fever), the complete visit should be 
postponed for 5 days or until the patient has recovered. 
4.2.2 Administrations of GAD-Alum, Visits 10 
After administration, the patient shall remain in the vicinity of the study site for the next two 
hours, and the administration site will be examined by investigator/study nurse 2 hours post 
injection. 
 
4.2.3 Mixed Meal Tolerance Test (MMTT), Visits 12 and 13 
 
The MMTT must be performed according to the instructions in the CRF. 
 
The patient should: 
 
• 
Come to the study site following an overnight fast (>10hr), i.e. the patient may not eat 
but is permitted to drink water  
• 
Not take short acting/direct acting insulin within 6 hours before the MMTT. The 
patient is allowed to take base-insulin day/night before, but not in the morning before 
the MMTT.  
• 
Patients with CSII (insulin pump) must continue with their basal dose insulin, but not 
add bolus dose during the last 6 hours before the MMTT 
• 
Have a fasting plasma glucose level in the range defined by 4-12 mmol/L on the 
patient’s home blood glucose meter in the morning of the test  
 
If the patient does not fulfill all of the above criteria, the MMTT should be rescheduled and 
the patient should return to the study site within 5 days if possible. 
 
If for safety reasons, subjects need to eat or take insulin, the visit should also be rescheduled. 
 

 
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4.3 Laboratory tests and examinations 
 
1. Immunological tests: 
a. Autoantibodies (Anti-GAD65, Anti-Insulin, Anti-IA-2, ZnT8) 
b. Relevant cytokines and chemokines are determined (see Table 4) 
c. T-cells are classified and studied (see Table 4) 
2. Genetics: 
a. HLA determinations is done and genes related to diabetes development 
b. Array studies to elucidate the importance of diabetes-related genes 
3. Diabetes status:  
a. HbA1c 
b. Fasting glucose and fasting C-peptide 
c. Meal stimulated glucose and C-peptide 
4. Blood sampling for safety: 
a. Hematology  
b. Chemistry 
5. Urine analysis 
6. Urine pregnancy test as appropriate 
7. Other:  
a. Vitamin D in serum 
 
4.4 Physical Examination Including Neurological Examination 
 
At Visit 9, 10, 11, 12 and 13 the patient will be examined for any new medical conditions or 
worsening of the pre-existing ones.  Any change in pre-existing conditions or new conditions 
must be entered on the AE page in the CRF and any medication given on the concomitant 
medication pages. 
 
The patients will, in addition to the limited physical examination by the physician, undergo a 
standardized clinical neurological examination at Visit 9, 10, 11, 12 and 13. The neurological 
tests are performed in order to detect possible mild signs of neuromuscular disease such as 
disturbance of strength, balance, and coordination. 
 
The neurological examination includes:   
 
• 
Extremity reflexes 
• 
Romberg (balance and coordination) 
• 
Walk on a line, 2 meters (balance and coordination) 
• 
Standing on 1 leg, left and right, 15 seconds per leg (balance and coordination) 
• 
Finger-nose (coordination) 
• 
Mimic (cranial nerves) 
• 
Babinski reflex (central function) 
• 
Muscle strength (shake hands) biceps, triceps, distal extensors, and flexors 
 
These examinations may also be repeated between scheduled visits at the discretion of the 
investigator. Screening for neurological disease with electroencephalogram (EEG) is not 
included due to low sensitivity and specificity. However, if any signs of neurological 
dysfunction are detected, the patient should be referred to a neurologist for further evaluation. 

 
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4.5 Adverse events 
 
See section 6.2 below. 
4.6 Concomitant Medication  
 
Any concomitant medication used during the study, whether considered relevant for the study 
or not by the investigator must be reported on the concomitant medication log of the CRF. 
Please also see section 5.5, below. 

 
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5. Study medication 
5.1 Study medication 
 
The following medication supplies will be used in the Prolonged Extension Study Period: 
 
A. 
Study medication:  
GAD-Alum (Diamyd) subcutaneous injection 
Dosage and interval: the fourth injection of 4 µg GAD-Alum 
(Diamyd) will be administered at Visit 10 (approx. 32 months 
from baseline, i.e. 1 month after Visit 9) 
 
IMP supplier:  
Diamyd Medical AB, Stockholm, Sweden. 
 
B. 
Study medication 
Vitamin D (Calciferol) in oral solution, 14 000 IE/week for 60 
days in this Prolonged Extension Study Period. 
Dosage and interval: 2000 IE daily (25 drops per day) for 60 
days starting at Visit 9 (approx. 31 months from baseline, i.e. 14 
days (± 5 days) after Visit 8) 
 
IMP supplier 
Commercially available 
 
5.2 Supply 
 
GAD-Alum (Diamyd) will be supplied by Diamyd Medical. It will be supplied as pre-packed 
medication from Diamyd Medical to a local pharmacy. All dosing will take place in the 
hospital, and handled only by trained and authorised study personnel. 
 
GAD-Alum will be stored in a refrigerator at 2-8 ºC in a secure area (e.g. a locked cabinet or 
drug storage room), protected from unintended use. 
 
Vitamin D (Calciferol) will be handled and distributed by a local pharmacy.  
 
Vitamin D (Calciferol) should be stored at room temperature (< 25 ºC) in a secure area (e.g. a 
locked cabinet or drug storage room), protected from unintended use. 
 
All study medication will be labelled with information according to local regulations. 
 
5.3 Dosage and administration 
 
GAD-Alum:  4 µg given into lymph node in the inguinal area (by help of ultra sound 
technique) fourth injection will be administrated at Visit 10 (approx. 32 months 
from baseline, i.e. 1 month after Visit 9) 
 
Vitamin D: 
14 000 IE per week, given per os for 60 days (start at Visit 9)  
5.4 Duration of treatment 
 
See section 5.3 above. 

 
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5.5 Concomitant medication 
 
No systemic immune modulating medication, and no other diabetes medication other than 
insulin, whether marketed or not, are allowed.  
 
5.6 Study medication accountability 
 
All study medications supplied for this Prolonged Extension Study Period must be retained in 
a safe place at all times of the study. Only personnel authorised by the investigator should 
dispense the study medication, and the accountability is the responsibility of investigator.  
 
A study medication inventory (dispensing records) for all medication dispensed must be 
maintained at all times and always kept current. Used and unused medication must be stored 
at the site or pharmacy throughout the study. The investigator/pharmacist must keep record of 
all drugs received, used and returned. Both pharmacies and study sites are obliged to properly 
measure and record the storage temperature. 
 
When the study is completed all unused and used study medication containers must be 
returned to the drug supplier unless the drug supplier has approved other arrangements.   

 
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6. Response variables and outcomes 
6.1 Assessments 
6.1.1. Variables 
 
The safety assessments include occurrence of adverse events (AEs), laboratory measurements, 
physical examinations including neurological assessments (See section 4.2-4.6). 
 
Adverse events will be recorded by the physician at every visit throughout the Prolonged Extension 
Study Period. 
 
Blood tests for safety:   
• 
Chemistry:  Creatinine, Calcium, Liver function tests (alanine aminotransferase [ALT], 
aspartate aminotransferase [AST], alkaline phosphatase, bilirubin) 
• 
Haematology (MHC, MCV, MCHC, Hemoglobin, Platelets, Leukocytes) 
 
Urinalysis for safety: 
• 
Urine pregnancy test as appropriate 
• 
Microalbuminuria 
• 
Creatinine 
 
Other Variables which will be evaluated: 
 
• 
Inflammatory markers, especially TNF-alfa, IL-1 beta, IL-2, IL-17  
• 
Th2-deviation of cell-mediated immune response seen e.g. as increased ratio of IL-
5,10, 13 in comparison with IFN-gamma, TNF-alfa, IL-1 beta and IL-17, and increase 
of T-regulatory cells  
• 
C-peptide (90-minute value and AUCmean 0-120 min) during an MMTT  
• 
Fasting C-peptide 
• 
Hemoglobin A1c (HbA1c) 
• 
Exogenous insulin dose per kg body weight and 24 hours 
 
6.2 Adverse events and Serious Adverse Events 
6.2.1 Definitions of Adverse Events 
 
An Adverse Event (AE) is defined as any untoward medical occurrence in a subject during a 
clinical study administered a medicinal product and which does not necessarily have a causal 
relationship with this treatment(s).  
 
An AE can therefore be any unfavorable and unintended clinical sign or symptom, any illness 
or disease, which develops or worsens in intensity during the course of the trial. It also 
includes an abnormal laboratory finding, if e.g., the abnormality results in trial withdrawal, is 
serious, is associated with clinical signs or symptoms, or is considered being of clinical 
relevance. 
 
It could also include accidents and reasons for changes in medication (drug and/or dose), any 
medical/nursing/pharmacy consultation and admission to hospital/surgical operations. 
 

 
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Any new findings, clinically significant laboratory values or worsening of pre-existing 
condition must be reported as an AE by the investigator, whether or not considered related to 
the medicinal product(s). 
 
Note that hospital admission and/or surgical operations for illness, which existed before the 
study drug was given or the subject was enrolled in the clinical trial and did not worsen 
during the study, are not AEs. 
 
 
6.2.1.1 Seriousness 
 
A Serious Adverse Events (SAE) is defined as: an Adverse Event that is fatal, life- 
threatening, significant or persistent disabling or requires hospitalisation or prolongation of 
hospitalisation, a congenital anomaly or birth defect. 
 
These characteristics/consequences have to be considered at the time of the event. For 
example, regarding a life- threatening event, this refers to an event in which the subject was at 
risk of death at the time of the event; it does not refer to an event which hypothetically might 
have caused death if it were more severe.  
 
Some medical events may jeopardise the subject or may require an intervention to prevent one 
of the above characteristics/consequences. Such events (referred to as important medical 
events) should also be considered as serious in accordance with the definition.  
6.2.1.2 Intensity 
 
Mild:  
The adverse event is transient and easily tolerated. 
Moderate: 
 The adverse event causes the patient discomfort and interrupts the patient's 
usual activities. 
Severe: 
  The adverse event causes considerable interference with the patient's usual 
activities, and may be incapacitating or life-threatening. 
 
Note: a distinction should be drawn between serious and severe AEs. The term severe is used 
to describe the intensity of the event and the event does not necessarily need to be considered 
serious. The term serious is based on the patient/event outcome or action and serves as a 
guide for defining regulatory reporting obligations. 
 
6.2.1.3 Relationship to study medication 
 
Relationship to study medication will be assessed for the two treatments (GAD-Alum and 
Vitamin D) separately. 
 
Unrelated:  
This category is applicable to those adverse events which, after careful medical consideration 
at the time of evaluation, are judged to be clearly and incontrovertibly due to extraneous 
causes (disease, environment, etc.) and do not meet the criteria for study medication 
relationship listed under remote, plausible or probable. 
 
Remote:  
In general, this category is applicable to those adverse events which, after careful medical 
consideration at the time they are evaluated, are judged to be remotely related to the test study 
medication. An adverse event may be considered remote if, or when, for example: (i) it does 
not follow a reasonable temporal sequence from administration; (ii) it could readily have been 

 
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produced by the patient's clinical state, environmental or toxic factors, or other modes of 
therapy administered to the patient; (iii) it does not follow a known response pattern to the 
suspected study medication; (iv) it does not reappear or worsen when the study medication is 
re-administered. 
 
 
Plausible: 
This category is applicable to those adverse events which, after careful medical consideration 
at the time they are evaluated, the connection with the test study medication administration 
appears unlikely but cannot be ruled out with certainty. An adverse event may be considered 
plausible if, or when: (i) it follows a reasonable temporal sequence from administration; (ii) it 
could not readily have been produced by the patient's clinical state, environmental or toxic 
factors, or other modes of therapy administered to the patient; (iii) it follows a known 
response pattern to the suspected study medication; (iv) it does not reappear or worsen when 
the study medication is re-administered. 
 
Probable: 
This category is applicable to those adverse events, which, after careful medical consideration 
at the time they are evaluated, the connection with the test study medication administration 
appears to, with a high degree of certainty, be related to the test study medication. An adverse 
event may be considered probable if: (i) it follows a reasonable temporal sequence from 
administration; (ii) it could not be reasonably explained by the known characteristics of the 
patient's clinical state, environmental or toxic factors, or other modes of therapy administered 
to the patient; (iii) it disappears or decreases on cessation or reduction in dose. There are 
important exceptions when an adverse event does not disappear upon discontinuation of the 
study medication, yet study medication-relatedness exists; e.g. bone marrow depression, fixed 
study medication eruptions, and tardive dyskinesias; (iv) it follows a known response pattern 
to the suspected study medication; (v) it reappears upon re-challenge. 
 
6.2.1.4 Reporting of Adverse Events  
All Adverse Events must be recorded in the CRF, defining relationship to study medication, 
severity and seriousness. Adverse Events should also be recorded by the investigator in the 
patient file/notes. 
 
6.2.1.4.1 Timelines and Reporting of SAE 
 
All SAEs must be reported, whether or not considered attributable to the study drug on a 
separate SAE Report Form. 
 
An assigned CRO, contracted by Diamyd Medical AB, will be responsible for reporting all 
Serious Adverse Events (SAEs) in accordance with ICH Good Clinical Practice and local 
regulations. The sponsor, Diamyd Medical AB and the assigned CRO will complete and sign 
a “Pharmacovigilance Working Instructions” agreement covering the safety reporting 
responsibilities in the study. This agreement will also ensure the sponsor and Diamyd Medical 
AB is directly informed of each SAE reported by the Investigators. 
 
In order to meet the specified reporting requirements investigators should adhere to the 
following process for recording and reporting SAEs.  
 
It is the investigator’s responsibility to, as soon as he/she is aware of a potential Serious 
Adverse Event (SAE), he/she should contact the assigned CRO by fax or e-mail, and in any 
case no later than 24 hours after the knowledge of such a case. At the time of initial reporting, 
the Investigator must provide as a minimum requirement, the patient number, birth date, 
nature of the SAE, and a preliminary assessment of causality. The Investigator should follow-

 
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up the initial notification of the potential SAE by faxing or e-mailing copy of the SAE 
reporting form to the CRO at the numbers/e-mail addresses provided in the Investigator Site 
File and on the SAE report form. The faxed/e-mailed SAE report form should be received by 
The CRO within 24 hours of the initial notification of the event.   
It is the investigator’s responsibility to report to the CRO follow-up information on an 
existing SAE that is fatal or life-threatening within 5 days after the initial report. Where 
appropriate, hospitalisation or autopsy reports should be made available. All Serious Adverse 
Events will be followed up until resolution (i.e., asymptomatic, stabilisation or death).  
 
It is the CRO’s responsibility to receive e-mail or fax copies of the SAE report form and other 
relevant CRF pages from the Investigators. The Drug Safety unit at the CRO will review the 
information provided on the form and enter it into the safety data base. The SAE report will 
be assigned a unique number that will be entered on the SAE Report Form, and will be used 
to identify the report in all future communication. A notification of receipt of the report will 
be sent to the reporter, either by fax or e-mail within 48 hours. The CRO will contact the 
Investigator directly if there is any inconsistencies and missing information. 
The CRO is responsible for the timely submission of Suspected Unexpected Serious Adverse 
Reactions (SUSARs) to the Competent Authority and Ethics Committee according to 
appropriate Competent Authority and Ethical Committee requirements. It is the CRO’s 
responsibility to report SUSARs to investigators according to ICH Good Clinical Practice and 
to local regulations ant to notify the Competent Authorities of all SUSARs through the 
Eudravigilance database.  
 
Fatal and life-threatening SUSARs should be reported by the CRO as soon as possible to the 
Competent Authorities and Ethical Committee, and in any case no later than seven (7) 
calendar days, after first knowledge by the Sponsor/CRO of such a case. Relevant follow-up 
information on the case will be subsequently communicated within an additional eight (8) 
days. All other SUSARs shall be reported to the Competent Authorities concerned and to the 
Ethics Committee concerned as soon as possible but within a maximum of fifteen (15) days of 
first knowledge by the Sponsor/CRO.  
 
6.2.1.4.2 
Unresolved Events 
 
If an AE/SAE is present when the patient has completed the study the course of the event 
must be followed until final outcome is known or the condition is stable. 
 
 
6.2.1.5 Pregnancy Report Form 
 
Pregnant and lactating women will not be included in the study. Females must have a negative 
urine pregnancy test at each study visit with study drug administration, prior to injection of 
study drug. Patients will be required to use an adequate form of birth control during the study. 
At Visit 9 the need for birth control will be re-assessed.  Patients will be strongly advised to 
avoid pregnancy for 1 year following the last dose and instructed to use adequate birth 
control. 
 
A pregnancy occurring during the trial must be recorded on the Pregnancy Report Form and 
no further drug doses will be given. If the pregnancy is verified prior to any of the injections, 
no further injection shall be given. 
 
The Pregnancy Report Form should be faxed or e-mailed within 24 hours of awareness to the 
assigned CRO. A copy of the report should be filed at the study site for follow-up until 
delivery. Any pregnancy must be followed until delivery or to the end of pregnancy. 

 
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7. Statistical methodology and data management 
7.1 Statistical analysis plan 
 
In brief the following analyses are planned: 
 
All continuous variables will have the following descriptive statistics displayed: number of 
observations (n), mean value, standard deviation, minimum, median, and maximum. All 
variables of a categorical nature will be displayed with frequencies and percentages. The 
tabulation of the descriptive statistics will be split by visit. Where appropriate, baseline 
(screening) descriptive statistics will also be included.   
 
Variables  
 
The AE/SAE data will be presented using a standardized tabulation of the frequency and 
incidence rate of all observed AEs/SAEs. The frequencies and incidence rates are calculated 
on a per patient basis. Adverse events will be summarized by body system, causality, and 
severity. Other safety data will be presented by descriptive statistics. 
   
Data regarding C-peptide and immune system as well as Adverse events and other data will 
be summarized descriptively.    
 
7.2 Study populations 
 
Intention-to-treat population 
Patients will be included in the primary intention-to-treat population for analysis of efficacy if 
they receive at least 1 dose of all study drugs in that arm, and are assessed at a later visit. 
 
Per protocol population 
In order to qualify for the stringent per protocol population, the subjects must have followed 
the study protocol without any major violations. Any examinations missed will be substituted 
with the last observation carried forward, but examinations from not more than 1 visit may be 
lost.  
 
Total population 
Any patient who withdraws from the study will be included in the safety analysis (adverse 
events and safety parameters). Data for all patients will be listed, and a list of withdrawn 
patients, with all reasons for withdrawal, will be given.  
 
7.3 Data collection / case report forms  
 
Case report forms (CRFs) will be supplied for recording data from each patient. Since it is 
important to have proper data collection in a timely manner, the investigator or assigned 
designee shall complete the CRFs promptly. When the monitor requests additional data or 
clarification of data for the CRF, the request must be answered satisfactorily in due time. 
 
It is the responsibility of the investigator to ensure that these case report forms are properly 
completed. The investigator will sign the designated signature pages to confirm that the case 
report form is accurate and complete. 
 
To ensure legibility the CRFs should be completed in block capitals with a black or blue 
ballpoint pen (not pencil, felt-tip or fountain pen). 

 
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Any corrections to the CRFs must be carried out by the investigator or his designate. A single 
stroke must be drawn through the original entry. The correction has to be dated and initialled. 
Incorrect entries must not be covered with correcting fluid, or obliterated, or made illegible in 
any way. 
 
Even if there are no changes from a previous examination, in the interests of completeness of 
data acquisition the questions, which are repeated in each section of the CRFs should be 
answered in full. A reasonable explanation must be given by the investigator for all missing 
data. 
 
7.4 Data management 
Data will be entered into a computer database. The handling of data, including data quality 
control, will comply with regulatory guidelines (e.g., International Conference on 
Harmonization [ICH] and Good Clinical Practice [GCP]). 
 

 
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8. Regulatory and administrative procedures    
 
8.1 Ethics committee and Competent Authorities 
 
Any regulatory requirements must have been met before starting the study. The Sponsor will 
apply for the regulatory approval to the appropriate authorities. 
 
Study sites, facilities, laboratories and all data (including source data) and documentation 
must be made available for inspection by the authorities. 
 
The study will be conducted in accordance with the Brazil, (2013) amendment to the 
Declaration of Helsinki 1964. 
 
 
The Protocol and Patient Information and Informed Consent Form will be approved by the 
Ethics Committee before commencement. If a substantial protocol amendment is necessary, 
this will be signed and submitted by the Sponsor for ethical and regulatory approval. The 
approval from the Ethics Committee and Competent Authority should be obtained before any 
implementation of the amendment is done. When the change or deviation is to eliminate or 
reduce risk to human patients, the amendment may be implemented before review of approval 
by the Ethics Committee and Competent Authority. The Sponsor should notify the Ethics 
Committee and Competent Authority of the change or deviation in writing within 10 working 
days after implementation. 
 
Minor amendments which do not affect the safety or conduct of the study from the patient 
viewpoint, and which do not significantly reduce the scientific value of the protocol, and 
which do not require a significant change to be made to the consent form and/or the 
information sheet, will not be submitted for formal ethics and regulatory review. These will 
be sent to the Ethics committee and Competent Authority on an ‘information only’ basis. 
 
8.2 Patient Information / Informed Consent  
 
The investigator is responsible for giving the patients full and adequate verbal and written 
information about the nature, purpose, possible risk and benefit of the Prolonged Extension 
Study Period. Patients must also be notified that they are free to withdraw from the study at 
any time. The patients should have reasonable time to read and understand the information 
before signing. The investigator is responsible for obtaining signed informed consent from all 
patients before including the patient in any study related procedures. 
 
Should there be any amendments to the final protocol, such that would directly affect the 
patient’s participation in the trial e.g., a change in any procedure, or if new data is obtained 
during the trial that may influence the standpoint to participate in the study, the patient 
information will be amended to incorporate this modification and the patient must agree to 
sign this amended form verifying that they re-consent to continue their participation in the 
trial. 
 
 
A copy of the patient information and of the Informed Consent Form will be given to the 
patients. 

 
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8.3 Patient confidentiality 
 
The investigator must ensure that patient's confidentiality will be maintained. CRFs or other 
documents submitted to the Sponsor should only identify patients by their initials and study 
number. The investigator should keep a separate log of patient codes and names. 
 
Documents not for submission to the Sponsor, e.g. patient's completed Consent Forms, should 
be retained by the investigator in strict confidence.  
 
The investigator is required to record safety data, concomitant medication and patient 
progress in the patient's file/notes/medical record. 
 
The patient's medical records will be reviewed by the study monitor to verify adequate source 
documentation, accuracy and completeness of Case Report Forms. The review will be 
conducted with strict adherence to professional standards of confidentiality. 
 
The investigator must keep a screening log, recording all patients who were screened, whether 
they were enrolled or not, and a separate Patient Identification List showing code numbers, 
names, and dates of birth to allow unambiguous identification of each patient included in the 
study. 
 
8.4 Patient treatment plan 
 
All patients will continue to receive standard care for Type 1 diabetes during the study. 
 
After the individual completion of the study, the patient will return to the standard treatment 
received prior to study participation. 
 
8.5 GCP 
 
The study will be managed and conducted according to the latest international (ICH) 
guidelines for Good Clinical Practice 
 
8.6 Record retention 
 
The CRFs and all medical records upon which the CRFs are based (source data) must be kept 
for at least 10 years after completion of the study.  
 
8.7 Monitoring / Quality Control 
 
The investigator will be visited by the monitor, who will check study procedures, including 
safety assessments, study medication handling, data recording and source data verification 
(SDV). To assure the accuracy and completeness of the data recorded in the trial, the monitor 
will compare CRFs with medical records and other relevant documentation during the on-site 
monitoring visits. The monitor must therefore be allowed direct access to all source data 
according to ICH GCP to confirm that required protocol procedures are being followed and 
check consistency between patient record and CRF data. Incorrect or missing entries into the 

 
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CRFs will be queried and must be corrected. Study monitoring will not jeopardise patient 
confidentiality.   
 
8.8 Quality Assurance  
 
During or after the study is completed, regulatory authorities, Diamyd Medical, assigned 
CRO or other involved party may wish to carry out an audit. These representatives must have 
the same access to study data and patient source data as the monitor. 
 
8.9 Insurance  
 
Patients insurance is covered by the ordinary Patientskadeförsäkringen. 
9. End of Trial 
 
The end of the trial is defined as the last visit of the last patient included in the Prolonged 
Extension Study Period and all data have been collected.  
 
9.1 Study report 
 
A clinical study report will be prepared covering clinical and statistical aspects and 
summarising all findings of the Prolonged Extension Study Period. The content must be 
treated as strictly confidential.  
 
9.2 Study Stopping Criteria 
 
The Sponsor and the investigators reserve the right to discontinue the Prolonged Extension 
Study Period at any time for safety reasons or other reasons jeopardizing the justification of 
the study. Such a termination will be implemented in a time frame that is compatible with the 
patient’s wellbeing. 
 
If the Prolonged Extension Study Period is prematurely terminated or suspended, the 
investigator should promptly inform the patients and assure appropriate therapy and follow-
up. The Sponsor will notify the Regulatory Authorities and the Ethics Committee of any plans 
to terminate the study. 
 
9.3 Publication and Data Rights 
 
It is envisaged that the findings of the Prolonged Extension Study Period will, in due course 
and by mutual agreement, be published in a scientific journal and/or presented at a scientific 
meeting. The authorship of this publication/ will remain as specified below. 
 
 
The published international guidelines for authorship (International Committee of Medical 
Journal Editors, 1997) will be adhered to; i.e. ‘All persons designed as authors should qualify 
for authorship. Each author should have participated sufficiently in the work to take public 
responsibility for the content.’  Authorship credit will therefore be based only on substantial 
contributions to 1) conception and design, or analysis and interpretation of data; and to 2) 
drafting the article or revising it critically for important intellectual content; and on 3) final 

 
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approval of the version to be published. Conditions 1), 2) and 3) must all be met. Participation 
solely in acquisition of funding or the collation of data does not justify authorship. General 
supervision of the research group is not sufficient for authorship. It is intended that 
information on what each author has contributed will be published. It is emphasised however, 
that only those who entirely meet the above mentioned criteria will be listed as authors. The 
principal investigator, who will be first or last author of publications based on this trial, has 
the final decision of the list of authors. 
 
 

 
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10. References 
1. Ludvigsson J, Wahlberg J, et al, N Engl J Med 2017 Feb 16;376(7):697-699 
2. Ludvigsson J, Tavira B, et al, N Engl J Med 2017 Jul 27;377(4):403-5 
 

 
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11. Investigator/Sponsor signatures 
 
 
Investigator’s Statement: 
 
I have read and understand this amendment to the foregoing protocol with the title: 
 
“Open Label Pilot Trial in patients with recent-onset T1D to evaluate the safety, diabetes 
status and immune response of GAD-antigen (Diamyd®) therapy administered into lymph 
nodes in combination with an oral and vitamin D regimen” 
 
Trial number DIAGNODE-1 and agree to conduct the trial, in compliance with ICH notes on 
Good Clinical Practice (CPMP/ICH/135/95), designated Standard Operating Procedures, 
National Laws and regulations and within the principles of the current revision of Declaration 
of Helsinki (Brazil 2013). 
 
 
Principal Investigator’s Printed Name: 
 
 
…………..………………………………………… 
 
Principal Investigator’s Signature: 
 
 
…………..………………………………………… 
 
 
Date: ………………………….. 
 
 
 
Sponsor and Principal Investigator’s signature: 
 
 
Name and function 
Signature 
Date 
 
Johnny Ludvigsson 
Coordinating & Principal 
Investigator and Sponsor