Clinical Characteristics, Natural History, Health Care Measures, and the Frequency of Genetic Variants in the Genes of SOD1, C9orf72, FUS and TARDBP in Patients With Sporadic and Familial Amyotrophic Lateral Sclerosis (ALS)
Conditions: Motor Neuron Disease, Amyotrophic Lateral Sclerosis
Sponsor: Ambulanzpartner Soziotechnologie APST GmbH

1 
 
Protocol  
 
Full Study Protocol 
 
 
 
TRACKING NUMBER: 
 
 
 
TITLE:  
Clinical characteristics, natural history, health care measures, 
and the frequency of genetic variants in the genes of SOD1, 
C9orf72, FUS and TARDBP in patients with sporadic and 
familial amyotrophic lateral sclerosis (ALS) 
 
INVESTIGATOR: 
Prof. Dr. Thomas Meyer 
Charité – Universitätsmedizin Berlin 
Center for ALS and other motor neuron disorders  
Augstenburger Platz 1 
13353 Berlin 
Germany 
 
 
 
Telephone: +4930450560028  
E-Mail: thomas.meyer@charite.de  
 
 
DATE:  
 
 
June 2, 2021 
Version 2.5 
 
Amendment 
November 06, 2022 
Version 2.6 
 
 

 
 
 
2 
Table of Contents 
 
Investigator information 
 
 
 
 
 
 
 
 
4 
Protocol signature page 
 
 
 
 
 
 
 
 
5 
Abbreviations  
 
 
 
 
 
 
 
 
 
6 
Study Synopsis 
 
 
 
 
 
 
 
 
 
7 
1. Visit schedule 
 
 
 
 
 
 
 
 
 
11 
2. Introduction  
 
 
 
 
 
 
 
 
 
13 
2.1. Background 
 
 
 
 
 
 
 
 
 
13 
2.2. Study rationale 
 
 
 
 
 
 
 
 
 
13 
2.3. Own previous work 
 
 
 
 
 
 
 
 
14 
2.3.1 ALS center at the Charité – Universitätsmedizin Berlin (principal investigator) 
14 
2.3.2 APST (Sponsor) 
 
 
 
 
 
 
 
 
14 
3. Objectives and endpoints  
 
 
 
 
 
 
 
14 
3.1. Objectives 
 
 
 
 
 
 
 
 
 
14 
3.2. Primary objective  
 
 
 
 
 
 
 
 
14 
3.3. Additional objectives 
 
 
 
 
 
 
 
 
14 
3.4. Endpoints  
 
 
 
 
 
 
 
 
 
15 
3.4.1. Primary endpoints 
 
 
 
 
 
 
 
 
15 
3.4.2. Additional endpoints 
 
 
 
 
 
 
 
 
15 
4. Overall study design 
 
 
 
 
 
 
 
 
16 
4.1. Study design 
 
 
 
 
 
 
 
 
 
16 
4.2. Participating centers 
 
 
 
 
 
 
 
 
16 
4.3. Overall study duration and assessments 
 
 
 
 
 
16 
4.4. Study stopping rules 
 
 
 
 
 
 
 
 
16 
5. Study subjects 
 
 
 
 
 
 
 
 
 
16 
5.1. Number of study subjects 
 
 
 
 
 
 
 
16 
5.2. Inclusion criteria  
 
 
 
 
 
 
 
 
16 
5.3. Exclusion criteria  
 
 
 
 
 
 
 
 
17 
6. Enrollment of subjects 
 
 
 
 
 
 
 
 
17 
7. Withdrawal of subjects 
 
 
 
 
 
 
 
 
17 
8. Study procedures and data processing 
 
 
 
 
 
 
17 
8.1. Study procedures 
 
 
 
 
 
 
 
 
17 
8.2. Data collection 
 
 
 
 
 
 
 
 
 
17 
8.3. Molecular genetic analysis 
 
 
 
 
 
 
 
18 
9. Assessments 
 
 
 
 
 
 
 
 
 
18 
9.1. Demographic data 
 
 
 
 
 
 
 
 
18 
9.2. Social characteristics 
 
 
 
 
 
 
 
 
19 
9.3. Disease history  
 
 
 
 
 
 
 
 
20 
9.4. Family history 
 
 
 
 
 
 
 
 
 
20 
9.5. Clinical classification 
 
 
 
 
 
 
 
 
21 
9.6. Functional deficits and progression 
 
 
 
 
 
 
21 
9.6.1 ALS Functional Rating Scale 
 
 
 
 
 
 
 
21 
9.6.2 ALS progression rate 
 
 
 
 
 
 
 
 
21 
9.6.3 King’s clinical stage of ALS 
 
 
 
 
 
 
 
21 
9.7. Interventions and health care measures  
 
 
 
 
 
22 
9.8. Patient´s expectations towards ALS therapy 
 
 
 
 
 
23 
9.9. Genetic data 
 
 
 
 
 
 
 
 
 
23 
10. Quality assurance  
 
 
 
 
 
 
 
 
24 
10.1. Data quality 
 
 
 
 
 
 
 
 
 
24 
10.2. Review of data  
 
 
 
 
 
 
 
 
24 
10.3. Genetic review board 
 
 
 
 
 
 
 
 
24 
11. Statistical methods and analysis plan 
 
 
 
 
 
 
25 
12. Ethical and legal principles 
 
 
 
 
 
 
 
25 
12.1. Ethical and regulatory requirements 
 
 
 
 
 
 
25 
12.2. Responsibilities of the investigator 
 
 
 
 
 
 
25 

 
 
 
3 
12.3. Informed consent procedures  
 
 
 
 
 
 
25 
12.3.1 Informed consent procedures of study participants  
 
 
 
25 
12.3.2 Genetic consultation on genetic study results 
 
 
 
 
27 
12.3.3 Informed consent procedures of first and second-degree relatives  
 
29 
12.3.4 Genetic consultation of first and second-degree relatives 
 
 
 
30 
12.3.5 Follow-up on study results with therapeutic relevance 
 
 
 
31 
12.4. Insurance and reimbursement  
 
 
 
 
 
 
31 
12.5. Data protection and confidentiality 
 
 
 
 
 
 
31 
12.6. Access rights to personal data  
 
 
 
 
 
 
31 
12.7. Archiving 
 
 
 
 
 
 
 
 
 
32 
13. Reports 
 
 
 
 
 
 
 
 
 
 
32 
13.1. Internal reports  
 
 
 
 
 
 
 
 
32 
13.2. Interim report 
 
 
 
 
 
 
 
 
 
32 
13.3 Publication of results 
 
 
 
 
 
 
 
 
32 
14. References 
 
 
 
 
 
 
 
 
 
33 
 
Table 1: Visit schedule 
 
 
 
 
 
 
 
 
11 
Table 2: Items used to describe demographic data  
 
 
 
 
19 
Table 3: Items used to describe social characteristics 
 
 
 
 
19 
Table 4: Items used to describe the disease history  
 
 
 
 
20 
Table 5: Items used to describe the family history of ALS or FTD  
 
 
20 
Table 6: Items used to describe clinical classification 
 
 
 
 
21 
Table 7: Items used to describe functional deficits and progression  
 
 
22 
Table 8: Items used to describe clinical interventions and health care measures  
22 
Table 9: Items used to describe patient’s expectations towards ALS therapy 
 
23 
Table 10: Description of the genes and respective mutation type 
 
 
 
23 
Table 11: Differentiated notification of study results in relation to patients´ directives 
29 
Table 12: Differentiated provision of study results first and second-degree relatives 
30    
and modes of notification 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
4 
 
INVESTIGATOR INFORMATION 
 
This study is a collaboration of the Ambulanzpartner Soziotechnologie APST GmbH 
(Sponsor) and the Charité – Universitätsmedizin Berlin, Center for ALS and other motor 
neuron disorders (principal investigator).  
 
Principal Investigator information: 
Prof. Dr. Thomas Meyer 
Charité – Universitätsmedizin Berlin 
Center for ALS and other motor neuron disorders  
Augustenburger Platz 1 
13353 Berlin 
Germany 
 
Sponsor information: 
Prof. Dr. Christoph Münch 
Ambulanzpartner Soziotechnologie APST GmbH 
Westhafenstraße 1 
13353 Berlin 
Germany 
 
 
 
 

 
 
 
5 
 
Protocol signature page 
The undersigned has read and understood the trial protocol detailed above and agrees to 
conduct the trial in compliance with the protocol.   
 
 
Sponsor 
 
Date 
 
 
 
 
 
 
 
 
 
 
 
Prof. Dr. Christoph Münch 
 
 
 
Principal Investigator 
 
Date 
 
 
 
 
 
 
 
 
 
 
 
Prof. Dr. Thomas Meyer 
 
 
 

 
 
 
6 
 
Abbreviations 
 
ALS 
 
Amyotrophic Lateral Sclerosis 
ALS-FRS 
ALS Functional Rating Scale 
APST  
Ambulanzpartner Soziotechnologie 
DSGVO 
Datenschutzgrundverordnung (engl.: General data protection regulation) 
fALS 
 
Familial Amyotrophic Lateral Sclerosis 
FTD 
 
Frontotemporal Dementia 
GDPR  
General Data Protection Regulation 
GenDG 
Genetic Diagnostics Act (Gendiagnostikgesetz) 
IEC 
 
Independent Ethics Committee 
MYMOP 
Measure your Medical Outcome Profile 
ODP 
 
Order Data Processing 
PEG 
 
Percutaneous endoscopic gastrostomy  
PI 
 
Principal Investigator 
sALS  
Sporadic Amyotrophic Lateral Sclerosis 
SMD  
Standard Mean Difference 
 
 
 
 
 

 
 
 
7 
Study Synopsis 
 
Tracking Number:  
 
 
 
Protocol Title: 
Clinical characteristics, natural history, health care measures, 
and the frequency of genetic variants in the genes of SOD1, 
C9orf72, FUS and TARDBP in patients with sporadic and 
familial amyotrophic lateral sclerosis (ALS) 
 
Version Number: 
 
            2.6 
 
Study indication: 
 
            Amyotrophic Lateral Sclerosis (ALS) 
 
Study rationale: 
There is only limited data available on the frequency of genetic 
variants in patients with sporadic ALS (sALS) and familial ALS 
(fALS). In patients with sALS (patients without family history of 
ALS), genetic investigations do not belong to the standard of 
care. As a result, the patient’s mutation status is commonly un-
known. Even in patients with fALS (with known family history of 
ALS), screening for genetic mutations is not performed on a re-
gular basis, due to lacking treatment options in the field of gene 
therapy. However, this paradigm is about to be changing as clini-
cal trials on genetic medicines are ongoing and might result in 
the approval of new genetically investigated drugs in the future. 
This project is intended to investigate a large cohort of ALS 
patients on family history, clinical characteristics, health care 
measures and genetic variants in SOD1, C9orf72, FUS and TAR-
DBP – the most commonly mutated genes in ALS. This cohort 
study will allow to determine the frequency of gene mutations in 
ALS patients in a real-world setting of ALS centers in Germany. 
Furthermore, the project shall enhance insights into potential 
differences between genetically defined cohorts by means of the 
course of disease and the provision of health care measures. The 
investigation of genetically distinct ALS cohorts is particularly 
relevant, as an improved understanding of the relationship bet-
ween the genotype and the journey of disease is scientifically in-
dispensable, in order to determine the therapeutic potential of 
future genetic therapies.  
 
Objectives and Endpoints: 
Primary objective 
• To identify the frequency of genetic variants in the genes of 
SOD1, C9orf72, FUS and TARDBP in patients with sALS and 
fALS 
 
Secondary objectives 
• To investigate the demographic and social characteristics 
• To investigate the family history for ALS or FTD 
• To investigate the clinical classification, functional deficits 
and progression  

 
 
 
8 
• To register interventions and health care measures including 
percutaneous endoscopic gastrostomy (PEG), ventilation the-
rapy,  
• To register the provision with assistive technology devices, 
symptomatic pharmacotherapy and physical, occupational 
and speech therapy  
• To investigate the clinical classification, functional deficits, di-
sease progression and health care measures in a subset of 
ALS patients with pathogenic variants in the genes of SOD1 
or C9orf72 as compared to ALS patients with no ALS-asso-
ciated mutations in the investigated genes 
• To register the values of serum concentration of neurofilament 
light chain (sNfL) 
• To identify patient´s treatment expectations towards ALS the-
rapy using the Measure Your Medical Outcome Profile (MY-
MOP2) 
 
Endpoints 
Primary endpoint 
• 
Genetic variants in the genes of SOD1, C9orf72, FUS and 
TARDBP 
 
Additional endpoints 
• 
The following additional endpoints will be explored:  
 
Family history of ALS and FTD 
• Family members living with ALS or FTD 
• Family members who have died from ALS or FTD 
 
Clinical classification, functional deficits and progression 
• ALS subtypes (classic ALS, progressive muscular atrophy 
(PMA) and primary lateral sclerosis (PLS) 
• Topic of the initial symptoms 
• ALS Functional Rating Scale (ALS-FRS) 
• ALS progression (ALS-FRS per months) 
• King's classification of clinical stages of ALS 
• Serum neurofilament light chain (sNfL)  
 
Interventions and health care measures 
• Percutaneous endoscopic gastrostomy (PEG)  
• Non-invasive ventilation 
• Tracheostomy 
• Provision with assistive technology devices 
• Symptomatic pharmacotherapy 
• Physical, occupational and speech therapy 
 
Patient´s expectations towards ALS therapy 
• Measure Your Medical Outcome Profile (MYMOP2) 
 

 
 
 
9 
This evaluation is exploratory. There is no formal hypothesis 
that is tested. 
 
Study design: 
This study is a prospective, non-interventional registry study 
(analytical observational study) in an inter-cohort comparison at 
18 study centers in Germany. 
 
Study location: 
 
18 study sites in Germany 
 
Number of subjects: 
Approximately 2,000 subjects  
 
Study period: 
The study period is about two years  
(August 2021 until December 2024) 
 
Study population: 
This study will be conducted in subjects aged at least 18 years, 
inclusive, with a diagnosis of sporadic or familial ALS.  
 
Assessment Schedule 
Study subjects will have up to 3 assessments over a period of 
approximately 1 year.  
 
Key study assessments:  
Genetic variants in four ALS-associated genes 
• SOD1 gene  
• C9orf72 gene 
• FUS gene  
• TARDBP gene  
 
Family history for ALS or FTD 
• Family members living with ALS or FTD 
• Family members who have died from ALS or FTD 
 
Clinical classification, functional deficits, and progression 
• ALS subtypes (classic ALS, progressive muscular atrophy 
(PMA) and primary lateral sclerosis (PLS) 
• Topic of the initial symptoms 
• ALS Functional Rating Scale (ALS-FRS) 
• ALS progression (ALS-FRS per months) 
• King's classification of clinical stages of ALS 
• Serum neurofilament light chain (sNfL)  
 
Interventions and health care measures 
• Percutaneous endoscopic gastrostomy (PEG)  
• Non-invasive ventilation 
• Tracheostomy 
• Provision with assistive technology devices 
• Symptomatic pharmacotherapy 
• Physical, occupational and speech therapy 
 
 
 
 
 
Patient´s expectations towards ALS therapy 
• Measure Your Medical Outcome Profile (MYMOP2) 

 
 
 
10 
 
Statistical methods: 
The standardized mean difference (SMD) will be applied in this 
study. The SMD of each measure over up to 12 months will be 
estimated using the change in measure between each subject’s 
assessments. The standardized mean difference expresses the 
size of intervention effect.  
 
Sample size determination: Due to this partly exploratory background of study project, a sam-
ple size justification is not applicable. The sample size is based 
on the feasibility of eligible patients to be enrolled at this site and 
is not based on power calculation. 
 
 
Interim analysis: 
An interim analysis may be performed.  
 
Study stopping rules: 
Not applicable for an observational study. 
 
 
 

11 
 
1. Visit schedule 
 
Table 1: Visit schedule 
Visit schedule 
V1 
M1-M3 
(Baseline) 
V2 
M4-M8* 
(Follow-Up) 
V3 
M9-M14 
(Closure) 
Demographic data  
 
 
 
Age 
x 
 
 
Gender 
x 
 
 
Place of residence 
x 
 
 
Social characteristics 
 
 
 
Employment status 
x 
 
 
Marital status 
x 
 
 
Education level 
x 
 
 
Living arrangement  
x 
 
 
Disease history 
 
 
 
Date of disease onset 
x 
 
 
Date of initial diagnosis 
x 
 
 
Age at disease onset 
x 
 
 
Duration of disease  
x 
 
 
Date of death (if applicable) 
 
 
 
Family history 
 
 
 
Family members who are living with ALS  
x 
 
 
Family members who died of ALS 
x 
 
 
Family members who are living with FTD 
x 
 
 
Family members who died of FTD 
x 
 
 
Family members who are suffering from 
neurological/psychiatric disorder 
x 
 
 
Family members who died of any 
neurological/psychiatric disorder 
x 
 
 
Clinical classification 
 
 
 
ALS subtypes 
x 
 
 
Region of onset  
x 
 
 
Functional deficits and progression 
 
 
 
ALS Functional Rating Sale (ALS-FRS) 
x 
x(2) 
x 
ALS progression rate (loss of ALS-FRS per 
month) 
x 
x(2) 
x 
King’s classification of clinical stages of ALS 
x 
 
x 
Serum neurofilament light chain (sNfL) 
x 
x(2) 
X(2) 
Interventions and health care measures 
 
 
 
Use of PEG  
x 
 
x 
Use of non-invasive ventilation  
x 
 
x 

 
 
 
12 
Use of tracheotomy  
x 
 
x 
Provision of a manual wheelchair (1) 
x 
 
 
Provision of complex power wheelchair (1) 
x 
 
 
Provision of a communication device (1) 
x 
 
 
Provision of assistive technology (1) 
x 
 
 
Physical, occupational and speech therapy (1) 
x 
 
 
Riluzol and symptomatic pharmacotherapy (1) 
x 
 
 
Treatment expectation 
 
 
 
MYMOP2, measure yourself outcome profile 
x 
x(2) 
x(2) 
Molecular genetic analysis 
 
 
 
C9orf72 
x 
 
 
FUS 
x 
 
 
SOD1 
x 
 
 
TARDP 
x 
 
 
 
M: month, V: visit; 1 = subgroup of users of APST management platform, 2 = in subgroup of patients with SOD1 mutation data 
will be collected more frequently (up to monthly collection of existing data of sNfL; up to weekly self-assessment of ALS-FRS 
using the ALS-App in addition to on-site assessment of ALSFRS-R during site visits). In the main cohort of non-SOD1 patients 
the collection of sNfL data is limited to the visits V1 (baseline) and V2 (follow-up). 
 
 

 
 
 
13 
2. Introduction  
2.1. Background  
ALS is an adult-onset degenerative motor neuron disorder leading to progressive motor deficits 
and eventually to death within a few years (Brown et al. 2017). Currently, there is no effective 
disease modifying drug available. A distinction is made between sporadic and familial ALS 
(Kiernan et al. 2021). Sporadic ALS (sALS) refers to the occurrence of ALS in a single indivi-
dual without known family history of ALS or frontotemporal dementia (FTD). Reportedly, popu-
lation genetic studies in ALS found sALS in more than 90% of all ALS patients (Brenner et al. 
2019, Kim et al. 2020, Volk et al. 2017, Zou et al. 2017). The term "familial ALS" (fALS) relates 
to the occurrence of ALS or FTD in several family members of a given trait. The definition of 
fALS encompasses positive cases of FTD as this neurodegenerative disorder may share com–
mon pathogenic pathways with ALS.  
 
In patients with sALS, genetic tests for SOD1, C9orf72, TARDBP or other genes are not 
subject to standard care. The previous findings on the frequency of genetic variants in ALS-
associated genes can be traced back to a few populations genetic studies of ALS (Volk et al., 
2018). As a result, sALS patients and treating neurologists are commonly unaware of the 
patient’s mutation status. Even in patients with positive or uncertain family history of ALS or 
FTD, screening for genetic mutations is not performed on a regular basis. Reportedly, ALS-
associated genetic variants are mostly found in the genes of SOD1, C9orf72, FUS, and TARDP 
(Brenner et al. 2019, Kim et al. 2020, Volk et al. 2017, Zou et al. 2017). More specifically, 
mutations in SOD1 were found in 14.8% of patients with fALS and 1.2% of the sALS population. 
The disease is causing repeat expansions of the C9orf72 gene, among which 6.5% are 
identified of the total ALS cohort (34% of fALS, 5% of sALS) (Zou et al. 2017).  
Most of the data on the prevalence of genetic variants in ALS genes are derived from European 
studies and deduced to the German ALS population. Furthermore, previous studies where 
confined – or focused – on families with fALS, whereas the frequency of gene mutations in 
sALS has not been systematically investigated. In the result, the actual frequency of gene 
mutations in ALS, particularly in sALS, is basically unknown. It is well conceivable that the 
frequency of SOD1, C9orf72, FUS, and TARDP might be underestimated. Moreover, fALS 
may be more frequent than expected as family history is not always obtained by scrutiny 
leading to an uncertain number of fALS patients being undetected. Given the few systematic 
data on genetic variants in fALS and sALS, little is known about the clinical, prognostic and 
interventional characteristics genetically defined cohorts in ALS.  
 
2.2. Study rationale 
There is only limited data available on the frequency of genetic variants in patients with ALS. 
In patients with sALS, genetic testing is not subject of standard of care. As a result, the patient’s 
mutation status is commonly unknown. Even in patients with fALS, screening for genetic muta-
tions is not performed on a regular basis, as there are no genetically defined treatment options 
available. However, this paradigm is about to be changing as controlled clinical trials on genetic 
medicines are ongoing which might be approved in the future (Kiernan et al. 2021, Miller al et. 
2021, Hardiman et al. 2020). This project is intended to investigate a large cohort of ALS 
patients on family history, clinical characteristics, health care measures and genetic variants 
in SOD1, C9orf72, FUS and TARDBP. This cohort study will allow to determine the frequency 
of gene mutations in ALS patients in a real-world setting of ALS centers in Germany. Further-
more, the project shall enhance insights into potential differences between genetically defined 
cohorts by means of the course of disease and the provision of health care measures. The 
investigation of genetically distinct ALS cohorts is particularly relevant, as an improved under-

 
 
 
14 
standing of the relationship between the genotype and the journey of disease is scientifically 
indispensable, in order to determine the therapeutic potential of future genetic therapies.  
 
2.3. Own previous work 
2.3.1 ALS center at the Charité – Universitätsmedizin Berlin (principal investigator) 
The ALS center at the Charité was founded in 2002 by the principal investigator (PI) and evol-
ved to a multidisciplinary care center serving more than 700 ALS patients. A major emphasis 
of the PI and his team has been the contribution to industry-sponsored and investigator-
initiated trials. Prototyping, service engineering and implementation of digital and web-based 
solutions for managed care in ALS and other complex neurological disorders, such as Spinal 
Muscular Atrophy (SMA) has been realized since 2010. A current emphasis is on outcome 
research by means of biomarkers (large-scale investigation on neurofilament light-chain), 
patient reported outcomes (on innovative drugs, assistive technology devices), digital outcome 
markers (including sensory recognition of voice and facial expression in ALS) and clinical 
research with a main focus on medicines, ventilation intervention, robotic assistive systems in 
ALS (Meyer et al. 2018, 2019, 2020, Spittel et al. 2020). 
 
2.3.2 APST (Sponsor) 
APST was founded in 2010, being a spin-off of the ALS Center at the Charité. The digital 
platform “Ambulanzpartner” is the main product of APST. It serves as a digital case manage-
ment and research platform with a main focus on ALS, SMA and other related disorders 
(Fürstenau et al, in press). The APST platform is used in more than 20 specialized care centers 
in Germany, serving as a digital demand platform and case management architecture connec-
ting patients, neurological centers and health care providers. Since March 2011, more than 
6.000 ALS patients and +200 subjects with adult 5q-SMA have been registered. More than 
300.000 provisions of assistive devices, medicines and nutrition products have been managed 
at this platform. Beyond case management, the platform is being used for clinical research 
(Meyer et al. 2018, 2019, 2020; Holm et al. 2013), systematic analysis of health care provision 
(Funke et al. 2015; Funke et al. 2018) and digital assessment of patient reported outcomes, 
such as online capture of ALS functional rating scale (Maier et al. 2012). At the platform, the 
infrastructure for online assessment, in terms of legal framework, technology, usability and 
long-term experience, has been established. With the use of APST, a bi-directional digital 
communication with patients and the online assessment of questionnaires, scores and scales 
are facilitated. Thus, the ALS-FRS will be obtained during this study, by means of the “ALS 
App” smart phone application, which has been implemented recently.  
 
3. Objectives and endpoints  
3.1. Objectives 
3.2. Primary objective  
• To identify the frequency of genetic variants in the genes of SOD1, C9orf72, FUS and 
TARDBP in patients with sALS and fALS 
 
3.3. Additional objectives 
The additional objectives of this study are as follows:  
• To investigate the demographic and social characteristics 
• To investigate the family history for ALS or FTD 
• To investigate the clinical classification, functional deficits, disease progression and health 
care measures in a subset of ALS patients with pathogenic variants in the genes of SOD1 

 
 
 
15 
or C9orf72 as compared to ALS patients with no ALS-associated mutations in the investi-
gated genes 
• To register available data on serum concentration of neurofilament light chain (sNfL) 
• To register the history of interventions and health care measures including percutaneous 
endoscopic gastrostomy (PEG) and ventilation therapy 
• To register the provision with assistive technology devices, symptomatic pharmacotherapy 
and physical, occupational and speed therapy 
• To identify patient´s treatment expectations towards ALS therapy using the Measure Your 
Medical Outcome Profile (MYMOP2) 
 
3.4. Endpoints  
3.4.1. Primary endpoints 
• 
Genetic variants in the genes of SOD1, C9orf72, FUS and TARDBP 
 
3.4.2. Additional endpoints 
• 
The following additional endpoints will be explored:  
 
Demographic data, disease history and social setting 
• Age, gender, place of residence 
• Disease onset and duration 
• Education, employment, housing 
 
Family history of ALS and FTD 
• Family members living with ALS or FTD 
• Family members who have died from ALS or FTD 
 
Clinical classification 
• ALS subtypes (classic ALS, progressive muscular atrophy (PMA) and primary lateral 
sclerosis (PLS) 
• Type of onset (bulbar region, trunk or extremities) 
 
Functional deficit and progression 
• ALS Functional Rating Scale (ALS-FRS) 
• ALS progression rate (loss of ALS-FRS per months) 
• King's classification of clinical stages of ALS 
• Serum concentration of neurofilament light chain (sNfL) 
 
Interventions and health care measures 
• Percutaneous endoscopic gastrostomy (PEG)  
• Non-invasive ventilation 
• Tracheostomy 
• Provision with assistive technology devices 
• Symptomatic pharmacotherapy 
• Physical, occupational and speech therapy 
 
Patient´s expectations towards ALS therapy 
• Measure Your Medical Outcome Profile (MYMOP2) 
 
This evaluation is exploratory. There is no formal hypothesis that is tested. 

 
 
 
16 
 
4. Overall study design  
4.1. Study design 
This is a longitudinal, non-interventional, non-randomized, multicenter, prospective study con-
ducted in subjects with ALS. Duration of study participation for each subject will be up to 
approximately 12 months. Subjects will be enrolled to receive questionnaires, in order to 
assess the variables and to provide blood samples for molecular genetic testing. Approxima-
tely 1,000 subjects are planned to complete the study. It is anticipated that up to approximately 
18 sites will be activated in Germany. This registry study will be reported according to STRO-
BE-statement. 
 
4.2. Participating centers 
The study follows a multicenter research trial. Results we be conducted at approximately 18 
ALS centers in Germany participating in the observation study. ALS centers in different geo-
graphical regions of Germany will be activated: 
 
• Northern Germany: Berlin, Hannover, Rostock, Lübeck 
• Eastern Germany: Dresden, Jena, Halle, Leipzig  
• Western Germany: Essen, Bonn, Göttingen, Münster, Bochum,  
• Southern Germany: Ulm, München, Mannheim 
 
4.3. Overall study duration and assessments  
The study will include ALS patients at specialized outpatient clinics (study sites). All subjects 
will undergo 3 assessments over a period of approximately 12 months. The assessment 
schedule will be as follows:  
 
• Assessment at baseline: initial assessment of subjects including blood sampling and 
molecular genetic analysis 
• Assessment at follow-up: follow-up assessment that is realized in a 6-month interval 
• Assessment at the end of the study: final assessment after 10 to 14 months interval  
 
and optional 
 
• Assessment for interims analysis: interim analyses performed for this study at variable 
time points, at least after all subjects complete the 6-month assessments. 
 
4.4. Study stopping rules  
Not applicable for an observational study.  
 
5. Study subjects  
5.1. Number of study subjects 
2,000 subjects are planned to be recruited. More than 1000 subjects are expected to 
complete the end-of-study assessments, after an observation period of 12 months.  
 
5.2. Inclusion criteria 
Being eligible to participate in this study, study candidates must meet the following eligibility 
criteria at the baseline assessment: 
 

 
 
 
17 
• ALS, including classical ALS, Progressive Muscle atrophy (PMA) or Primary Lateral 
Sclerosis (PLS) 
• Ability to understand the purpose and risks of the study and provide signed and dated 
informed consent and authorization to use protected health information (PHI) in 
accordance with national and local subject privacy regulations   
• Age of 18 years old at the time of informed consent 
 
5.3. Exclusion criteria 
• Inability to provide patient´s directives about the notification of individual study results on 
genetic variants of SOD1, C9orf72, FUS and TARDBP 
• Inability to comply with study requirements 
• Unspecified reasons that, in the opinion of the site investigator, perceiving the subject 
unsuitable for enrollment 
 
6. Enrollment of subjects  
The enrollment of subjects takes place in specialized ALS-outpatient centers in Germany. ALS 
patients being eligible for the investigation, will be invited to participate in this cohort study. 
After obtaining informed consent, subjects will be enrolled in the study. Approximately, 2,000 
subjects will be observed in this study. Participating sites will be informed once 2,000 subjects 
have been enrolled.  
 
7. Withdrawal of subjects  
Subjects must be withdrawn from the study for any one of the following reasons: 
 
• The subject withdraws informed consent 
• The subject is unwilling or unable to comply with the protocol 
• At the discretion of the investigator 
  
The reason for the subject’s withdrawal from the study must be recorded. In case of withdrawal 
before the end of the genetic investigation, another patient can be enrolled to surrogate the 
other. 
 
8. Study procedures and data processing 
8.1. Study procedures 
Subjects will be registered at baseline, after the investigator has verified the eligibility of the 
subjects by means of inclusion and exclusion criteria. After obtaining informed consent, all data 
defined in the protocol will be collected from different sources:  
 
• Data capture from medical records (registry): clinical characteristics, family history, 
interventions and health care measures 
• Assessment and data capture at study site (on-site assessment): clinical characteristics, 
family history, interventions and health care measures, self-assessment scales (ALS-FRS, 
MYMOP) 
• Assessment and data capture from remote (digital self-assessment): self-assessment 
scales (ALS-FRS, MYMOP) 
• Assessment and data capture at molecular genetic laboratory (genetic analysis): genetic 
variants in the genes of SOD1, C9orf72, FUS and TARDBP 
• Capture from APST platform (registry): provision with assistive technology devices 
 

 
 
 
18 
8.2. Data collection 
Data will be collected from various sources and by different means. Some data are obtainable 
retrospectively as from medical records (at study sites) and platform-based registry (APST 
platform). Other data will be collected prospectively using on-site or assessments.  
 
Data defined in the protocol will be assessed and captured by different means: 
 
• Data from medical records and on-site assessments: data on clinical characteristics, family 
history, interventions and health care measures) will be collected on data sheets and trans-
ferred to predefined data fields on the web-based study software “studioMED+” or may 
captured on the electronic case report form (eCRF) of “studioMED+” directly.  
• Data from remote assessment: data from digital self-assessments (ALS-FRS, MYMOP) will 
be captured on a smart phone application (“ALS-App”) and stored in the data base of the 
APST platform (https://www.ambulanzpartner.de/). The “ALS-App” serves as a mobile 
application of the APST platform.  
• Data from genetic laboratory: molecular genetic analysis will be performed on blood 
samples provided by study participant. Results from the genetic investigation will be gene-
rated by the genetic laboratory and transferred to predefined data fields on the web-based 
study software “studioMED+”. 
• Data on health care measures: data on the provision with assistive technology (complex 
power wheelchairs, communication devices, robotic assistive systems, symptomatic phar-
macotherapy, physical, occupational and speech therapy will be captured on the APST 
platform directly.  
 
8.3. Molecular genetic analysis 
Molecular genetic analysis will be performed by a qualified and certified (ISO15189) laboratory. 
The procedures undertaken include DNA isolation from blood samples collected in EDTA tubes 
and DNA quality analysis. QF-PCR and RT-PCR analysis of the C9orf72 will be performed for 
repeat expansion analysis. Pathogenic repeat expansions as determined by PCR will be con-
firmed by Southern blot. Molecular genetic analysis of SOD1, FUS and TARDBP Will be carried 
out by sequencing of the coding region of the SOD1, FUS and TARDBP gene. Bioinformatics, 
diagnostic analysis, confirmation of the positive result in an independent experiment, as well 
as interpretation of genetic variants will be delivered by the service provider. The molecular 
genetic analysis and all associated services will be provided by ARCHIMED Life Science 
GmbH (ARCHIMEDlife), Vienna (Austria). 
 
 
 

 
 
 
19 
9. Assessments 
9.1. Demographic data  
Demographic data will be collected as follows: 
 
Table 2: Items used to describe demographic data 
Item  
Description  
Date of Birth 
MM/YYYY 
Gender  
Male  
Female  
Place of residence 
PLZ (first 3 digits), NNNXX 
 
9.2. Social characteristics  
Data on social characteristics will be collected as follows: 
 
Table 3: Items used to describe social characteristics 
Item  
Description  
Marital status 
married 
single 
divorced 
widowed 
Highest level of education 
 
No formal education  
Primary school 
Secondary school 
Advanced or higher certificate 
Bachelor’s degree or national diploma 
Postgraduate diploma/Master’s degree  
Doctorate (PhD) 
Employment status 
Student 
Working for payment or profit 
Unemployed  
Retired from employment 
Looking after home/family 
Unable to work due to permanent sickness or disability 
Other (Please specify) 
Working hours in employment  
Working hours per week 
Living arrangement 
Own home 
Assisted living 
Nursing home 
Hospice 
 
9.3. Disease history  
Data on disease history will be collected as follows. Onset of ALS will be defined at time of 
paresis in extremities, dysarthria or dysphagia. 
 

 
 
 
20 
Table 4: Items used to describe the disease history 
Item  
Description  
Date of onset 
MM-YYYY 
Date of diagnosis 
MM-YYYY 
Age of onset  
YY 
Duration of disease 
MM 
Data of death (if applicable) 
MM-YYYY 
 
9.4. Family history  
The number and degree of relatedness of family members who are living with ALS (or FTD) or 
who died of ALS (FTD) will be investigated. Furthermore, family members suffering from any 
neurological/psychiatric disorder or who died of any neurological/psychiatric disorder will be 
determined. A first-degree relative (FDR) is a person's parent (father or mother), full sibling 
(brother or sister) or child. It constitutes a category of family members that largely overlaps 
with the term nuclear family, but without spouses. A second-degree relative (SDR) is someone 
who shares 25% of a person's genes. It includes uncles, aunts, nephews, nieces, grand-
parents, grandchildren, half-siblings, and double cousins. 
 
Table 5: Items used to describe the family history of ALS or FTD 
Item  
1st degree relative (n) 
2nd degree relative (n) 
ALS (living) 
Suspected 
Probable 
Definite 
Genetically confirmed 
Suspected 
Probable 
Definite 
Genetically confirmed 
ALS (deceased) 
Suspected 
Probable 
Definite 
Genetically confirmed 
Suspected 
Probable 
Definite 
Genetically confirmed 
FTD (living) 
Suspected 
Probable 
Definite 
Genetically confirmed 
Suspected 
Probable 
Definite 
Genetically confirmed 
FTD (deceased) 
Suspected 
Probable 
Definite 
Genetically confirmed 
Suspected 
Probable 
Definite 
Genetically confirmed 
Neurological/psychiatric 
disorder (living) 
Definite 
 
Definite 
 
Neurological/psychiatric 
disorder (deceased) 
Definite 
 
Definite 
 
n = number of individuals 
 

 
 
 
21 
9.5. Clinical classification 
Data on clinical classification will be collected as follows: 
 
Table 6: Items used to describe clinical classification 
Item  
Description  
ALS subtypes (domination of upper or lower 
motor neuron) 
Classical ALS 
Progressive Muscle Atrophy (PMA) 
Primary Lateral Sclerosis (PLS) 
Type of onset (region of onset) 
Bulbar region 
Trunk 
Upper extremities 
Lower extremities 
 
9.6. Functional deficits and progression  
9.6.1. ALS Functional Rating Scale 
The functional impairment will be described by using the ALS functional rating scale (ALS-
FRS). The ALS-FRS is a questionnaire that is frequently used in ALS, in order to describe 
functional impairment (Cedarbaum et al. 1999). Furthermore, motoric function and skills of 
arms and legs, the bulbar function as well as the respiratory function is described. Interventions 
in the areas of nutrition and ventilation as well as the ability to use communication devices are 
also targeted. The questionnaire contains 12 short, clear questions, each with five possible 
answers (0-4). In total, 0 to 48 points can be achieved. The lower the number of points achiev-
ed, the higher the defined degree of severity of the functional impairment. The online assess-
ment of ALS-FRS complements the well-established face-to-face application of the ALS-FRS 
(Maier et al. 2012). 
 
9.6.2. ALS progression rate  
The ALS progression rate (∆ALS-FRS) can be derived from the ALS-FRS. The loss of ALS-
FRS value per month, or delta ALS-FRS, indicates the rate of deterioration and predicts sur-
vival (Kimura et al. 2006). ∆ALS-FRS is calculated using the following formula: 
 
∆ALS-FRS=
(48-ALSFRSR)
Duration of disease since diagnosis (months)  
 
9.6.3. King´s clinical stage of ALS 
The course of disease was classified according to the King´s clinical stage of ALS (Balendra 
et al. 2014). Stage 1: involvement of one clinical region; Stage 2: involvement of second clinical 
region; Stage 3: involvement of third clinical region; Stage 4: nutritional or respiratory failure.  
 
Table 7: Items used to describe functional deficits and progression 
Item  
Description  
ALS-FRS 
ALS-FRS, total score 
ALS-FRS, score points per item (1-12) 
ALS progression rate  
Loss of ALS-FRS score points per month 
King´s clinical ALS stages 
Stage 1-4 

 
 
 
22 
Neurofilament light chain (sNfL) 
Serum concentration of neurofilament light 
chain (sNfL) in pg/mL 
 
9.7. Interventions and health care measures 
Data on clinical interventions and health care measures will be collected as follows: 
 
Table 8: Items used to describe clinical interventions and health care measures 
Item  
Description  
Percutaneous endoscopic gastrostomy 
(PEG)  
Y/N 
Date of provision (MM/YYYY) 
Non-invasive ventilation (NIV) 
 
Y/N 
Date of provision (MM/YYYY) 
Usage up to 8 hours per day 
Usage 8 to 16 hours per day 
Usage more than 16 hours per day 
Invasive ventilation (IV) 
 
Y/N 
Date of provision (MM/YYYY) 
Provision of manual wheelchair (1) 
Y/N 
Date of provision (MM/YYYY) 
Provision of complex power wheelchair (1) 
Y/N 
Date of provision (MM/YYYY) 
Provision of augmented communication 
device (1) 
Y/N 
Date of provision (MM/YYYY) 
Provision of assistive technology (e. g. 
robotic arms), (1) 
Y/N 
Date of provision (MM/YYYY) 
Physical therapy (2) 
Y/N 
Treatment units per week 
Occupational therapy (2) 
 
Y/N 
Treatment units per week 
Speech and swallowing therapy (2) 
Y/N 
Treatment units per week 
Pharmacological therapy (3) 
Riluzol, Y/N 
Symptomatic drugs, number of medicines 
(1) Data will be obtained in a multi-center subset of up to 300 participants 
(2) Data will be obtained in a single-center subset of up to 100 participants 
(3) Data will be obtained in a multi-center subset of up to 200 participants 
 
9.8. Patient´s expectations towards ALS therapy 
Treatment expectations will be assessed by the Measure Yourself Medical Outcome Profile 
(MYMOP2, Hermann et al., 2014, Monnery et al., 2018, Ishaque et al., 2019). The MYMOP is 
a brief, patient-generated, problem-specific questionnaire, which requires participants to quali-
fy – and by that means prioritize – bothersome symptoms or impairments. The MYMOP con-
sists of four questions and is a brief, patient-generated, problem-specific questionnaire. The 
first two questions require participants to specify symptoms that concern them most. Sub-

 
 
 
23 
sequently, participants evaluate the severity of this symptom on a 7-point Likert scale (e.g., 
weakness of the right leg could score 0 for “as good as it could be” to 6 for “as bad as it could 
be”). The third question of the questionnaire uses the same 7-point Likert scale to assess 
whether the symptom is limiting or preventing a daily activity (such as walking). In the fourth 
question participants rate their general well-being. All domains (symptom severity, restriction 
of activity, and general well-being) can be analyzed individually or as a total score. 
 
Table 9: Items used to describe patient’s expectations towards ALS therapy 
Item  
Description 
Symptom 1 
Qualitative description 
Likert scale 0-6 
Symptom 2  
Qualitative description 
Likert scale 0-6 
Activity 
Qualitative description 
Likert scale 0-6 
Well-Being 
Likert scale 0-6 
 
9.9. Genetic data 
Each of the following genes will be tested: SOD1, C9orf72, FUS and TARDBP. Where appli-
cable, detailed information about the mutation (e. g. expansion, expansion number, substitu-
tion and location, deletion/duplication and location) will be collected along with an assessment 
of pathogenicity as adjudicated by the laboratory (e. g. benign, likely benign, likely pathogenic, 
pathogenic, variant of uncertain significance). 
 
Table 10: Description of the genes and respective mutation type 
Gene  
Variant 
Mutation type 
Interpretation and classification 
SOD1 
Y/N 
Substitution 
Deletion 
Insertion 
Duplication 
Inversion 
Benign 
Likely Benign 
Likely Pathogenic 
Pathogenic 
Variant of Uncertain Significance 
C9orf72  
Y/N 
Expansion 
Benign 
Pathogenic 
FUS 
Y/N 
Substitution 
Deletion 
Insertion 
Duplication 
Inversion 
Benign 
Likely Benign 
Likely Pathogenic 
Pathogenic 
Variant of Uncertain Significance 
TARDBP 
Y/N 
Substitution 
Deletion 
Insertion 
Duplication 
Inversion 
Benign 
Likely Benign 
Likely Pathogenic 
Pathogenic 
Variant of Uncertain Significance 
 

 
 
 
24 
10. Quality assurance 
10.1. Data quality 
During and/or after completion of the registry, quality assurance officers named by APST or 
the regulatory authorities may wish to perform onsite audits. The Investigator will be expected 
to cooperate with any audit and to provide assistance and documentation (including source 
data) as requested. Data quality is facilitated on a web-based secure clinical research software 
(studioMED+, Germany) that encompasses a study management component and an electro-
nic case report form (eCRF). It digitally enables the multi-step workflow of data capture linking 
all data entry roles at participating ALS centers. At the studioMED+ software, the data from all 
different data sources are captured and processed.  
 
10.2. Review of data  
The study software studioMED+ is used as a data management system in this study and en-
ables the storage and tracking of study data, especially study visits, by means of an electronic 
case report form (eCRF). StudioMED+ provides study-related documents and an overview of 
all study patients. Received data will be controlled for completeness using the studioMED+ 
study software. The reporting tool of the same software will be used to report registry numbers 
and collected data at regular intervals (monthly).  
 
10.3. Genetic review board 
A review board on genetic results will be implemented. The genetic review board will serve as 
a consulting body for the interpretation of complex or uncertain genetic research results. This 
refers mostly to result in the categories "likely pathogenic and “variant of uncertain significance” 
(details in 9.9). The genetic review board comprises of the following members: 
 
• Prof. Dr. Jochen Weishaupt, Mannheim University Hospital, certified neurologist and 
expert in ALS genetics  
• Prof. Dr. Denise Horn, Charité – Universitätsmedizin Berlin, certified geneticist, expert in 
genetic consulting 
• PD Dr. Peter Körtvélyessy, Charité – Universitätsmedizin Berlin, certified neurologist and 
expert in neurogenetic consulting 
 
11. Statistical methods and analysis plan 
Descriptive statistics will be presented for each assessment of all subjects at study visit. 
Subgroup analyses by genetic or clinical criteria or other baseline characteristics will be 
performed. Secondary endpoints in the genetically defined subsets of ALS with confirmed 
SOD1 or C9orf72 mutations will be compared to genetically tested patients with ALS not 
revealing any ALS-associated mutation in any of the tested genes. Descriptive statistics will 
be used for the statistical analysis (frequency in percentage, mean, median, standard deviation 
in ±, interquartile ranges (Q1, Q3), and ranges (min, max). The standardized mean difference 
(SMD) will be applied in this study. The SMD of each measure over up to 12 months will be 
estimated using the change in measure between each subject’s assessments and within each 
individual. The standardized mean difference expresses the size of intervention effect. 
Difference of frequencies between two groups will be assessed by Fisher’s exact test or Chi-
square test, or within metric data by using the Shapiro–Wilk test, Kruskal–Wallis test and 
Mann–Whitney U-test. The Wilcoxon test will be employed for the analysis of statistical power 
of ordinally-scaled data, while metric data were subjected to the t-test (ALS-FRS, MYMOP). 
This analysis applies to the comparison of genetically defined subsets of ALS (baseline 
characteristics and changes over time). The analysis of follow-up data is limited to complete 

 
 
 
25 
cases, since not all patients are expected to complete end-of-study assessments due to 
disease progression, e.g., death. It is aimed to compare the baseline characteristics and the 
proportion of death between those who completed and not those not completed 6 months and 
12-month assessment. Statistical significance will be ascertained by according to an error risk 
of up to 5% (p-value < 0.05). Associations for the clinical outcomes will be assessed by linear 
regression models adjusted for potential cofounding factors. Results of the longitudinal 
observations will be also controlled for the influence of any covariate (sex, age, intervention 
history). Longitudinal analysis by means of group comparisons will be applied by using a 
multivariate analysis. 95% confidence intervals with p-values will be reported. In order to draw 
conclusions from the samples with censored data, missing data records will be omitted and 
treated as missing values. Data analysis will be performed using SPSS (Version 25.0). 
 
12. Ethical and legal principles 
12.1. Ethical and regulatory requirements 
APST must comply with all instructions, regulations, and agreements in this protocol and ap-
plicable ICH and GCP guidelines and conduct the observational study according to local regu-
lations. The Investigator may delegate responsibilities for study-related tasks where appropria-
te to individuals sufficiently qualified by education, training, and experience, in accordance with 
applicable ICH and GCP guidelines. The Investigator should maintain a list of the appropriately 
qualified persons to whom significant study-related duties have been delegated. 
 
12.2. Responsibilities of the investigator  
The observational study is realized in collaboration of APST and Charité – Universitätsmedizin 
Berlin. The study protocol will be approved by the Independent Medical Ethics Committee (IEC) 
of the Charité – Universitätsmedizin Berlin, Germany. The protocol, and other required study 
documents must be approved prior to starting the study. It is the responsibility of the 
investigator to ensure that all aspects of institutional review are conducted in accordance with 
current governmental regulations. APST must receive a letter documenting ethics committee 
approval, which specifically identifies the amendments prior to the initiation of the study.  
 
12.3. Informed consent procedures 
12.3.1. Informed consent procedures of study participants 
Prior to any data collection informed consent will be obtained from all eligible and participating 
patients. Information about the study and that study participation is voluntary will be explained 
to the subject. The informed procedure will be organized in a multi-step process of 1) patient 
information, 2) genetic counselling prior to study participation, 3) written informed consent and 
selection of modalities for the notification of genetic study results. The patient information en-
compasses the option, that study participants are, however, entitled to refuse genetic coun-
selling in writing, if they have already been informed about its content. The study information 
and the offered genetic counselling will address the potential medical, psychological and social 
burden that may be associated with pathogenic gene mutations as well as the individual or 
societal benefits aimed with the study. Participating patients will decide to provide blood 
samples for the following research purposes: 
 
• Use for exclusive analysis of the genes SOD1, C9orf72, FUS and TARDBP as defined in 
this protocol 
• Optional and future use for analysis of other known ALS-related genes 
• Optional and future use for the search of still unknown ALS-related genes 
 

 
 
 
26 
The subject must be given sufficient time to consider, whether to participate in the study. A 
copy of the informed consent, signed and dated by the subject, will be given to the subject. 
Confirmation of a subject’s informed consent will also be documented in the subject’s medical 
record prior to any data collection under this protocol. The signed informed consent will be 
retained with the study records. The informed consent procedure will be performed in align-
ment with the “Genetic Diagnosis Act” (Gendiagnostikgesetz, GenDG).  
 
Given the potential, diagnostic and therapeutic relevance of individual study results on genetic 
variants of SOD1, C9orf72, FUS and TARDBP genes, all study participants are offered the 
principal option to be informed about the result of genetic investigation. Conversely, the know-
ledge and awareness about own study results – encompassing the potential implications for 
genetically related family members – might be perceived as psychologically burdensome. 
Therefore, study participants will be informed about the requirement to select between noti-
fication options of their individual study results. Study participants who decided to be notified 
about the genetic study results are offered to seek genetic consultation prior to the notification 
of study results. The offered genetic consultation will include the information on the mutation 
type, the interpretation of results (benign, likely benign, likely pathogenic, pathogenic or variant 
of uncertain significance) as well as the potential medical, psychological and social implications 
of the findings. The procedure of genetic counseling is described in more detail in section 
12.3.3. Study participants will be informed that genetic study results of uncertain significance 
may be discussed within the genetic review board which is described in section 10.3. The 
patient´s directive concerning the notification about the individual study results is subject to the 
study information and mandatory part of the informed consent. Study participants are 
requested to select one of the following options of notification about individual study results: 
 
• No notification about genetic study results 
• Notification about all genetic study results  
• Notification about selected genetic study results with therapeutic relevance 
 
Patients who refuse to be notified about study results will not be informed about the outcome 
of genetic analysis. This patient´s directive explicitly includes pathogenic mutations that might 
be of diagnostic or therapeutic relevance. The patient´s directive of notification of all genetic 
study results will include normal findings (no or benign variants) genetic, genetic variants of 
unknown significance and pathogenetic mutations (likely pathogenic or pathogenic genetic 
variants in the investigated genes of SOD1, C9orf72, FUS and TARDBP. Results of diagnostic 
relevance are defined as genetic variants being known to cause ALS or can increase the risk 
of ALS or can modify the phenotype of the disease including the progression rate. The finding 
of pathogenic variants can lead to the diagnosis of fALS although the disorder – given the 
negative family history of ALS – has prior been classified as sALS. The diagnostic relevance 
can extend to other family members as likely pathogenic of pathogenic mutations in the study 
at ALS genes might substantiate a genetic risk for ALS to first- and second-degree relatives of 
study participants. Therapeutic relevance is defined by the planning or performance of a phase 
3 clinical trial, a planned or ongoing early access program or an expected approval of genetic 
medicine targeting one of the studied genes within the next 12 months. Currently, therapeutic 
relevance can be stated for mutations found in the SOD1 gene. Therapeutic relevance of 
C9orf72 and FUS can be expected within the next few years post-approval of this study 
protocol. The definition of diagnostic and therapeutic relevance and the scheme of notification 
of individual study results is provided in table 11.  
 

 
 
 
27 
12.3.2. Genetic consultation on genetic study results 
All study participants are offered the principal option to seek genetic consulting. Genetic coun-
seling on study participation (prior to genetic testing) and prior to the notification of study results 
(after genetic testing) will be differentiated (Table 11). The counseling prior entering the study 
will be performed by the study neurologist. However, under certain circumstances, such as the 
family history of fALS, the additional counseling by a neurologist being certified for genetic 
counseling or by a certified geneticist can be required. The consultation prior participating in 
the study will include the potential medical, psychological and social implications that can be 
associated with pathogenic gene mutations as well as the potential individual treatment options 
indicating gene-specific treatment options, which are available or in clinical development.  
Study participants will be offered a genetic consultation on the genetic study results. In 
principle, study results showing no genetic variants or benign variants will lead to the study 
neurologist consulting about the specific results. In contrast, study results of likely pathogenic 
or pathogenic mutations will be primarily consulted by the study neurologist, in order to refer 
the patient to a specialized neurologist being certified for genetic counseling or to a certified 
geneticist. Recruiting study sites are prepared to refer patients (or their advice seeking relativ-
es) to certified geneticists who are experienced in the consultation on genetic variants in ALS. 
In preparation of external genetic consultation, patients are provided with a sealed envelope 
containing the pseudonymized study results. Subsequently, the patient will forward the 
envelope to the genetic consultant. The genetic consultant can contact the study center for 
additional clinical information and might decide for an independent genetic investigation, in 
order to confirm the study results. The confirmation can be done by retesting or, preferably, by 
means of de-pseudonymization of study results. As authorized by the study participant – upon 
request of consulting geneticist – the genetic study results might be de-pseudonymized by the 
study center. Based on the de-pseudonymization order, the unblinded genetic report on SOD1, 
C9orf72, FUS and TARDBP will be provided by genetic laboratory and used for genetic 
consultation. The unblinded genetic results are suitable for genetic consulting, such as the 
laboratory ARCHIMED Life Science GmbH (ARCHIMEDlife, Vienna, Austria). ARCHIMEDlife 
complies to all required certifications for genetic analysis (including ISO15189). Thus, the 
genetic results – primarily generated for research purposes – allow the unrestricted use for 
genetic counseling. 
 
 
 
Table 11: Differentiated notification of study results in relation to patients´ directives  
Informed 
consent 
Genetic 
consulting 
prior study 
participation 
Patient´s 
directive on 
notification 
about genetic 
results 
 
Genetic result 
Genetic consulting 
on genetic results 
informed 
consent of all 
patients as 
obtained by 
study 
neurologist 
refusal of 
genetic con-
sultation 
no notification 
about genetic 
results  
not applicable 
not applicable 
genetic counsel-
ling on the po-
notification about 
all genetic results  
• no variant 
• benign variant 
counseling by study 
neurologist 

 
 
 
28 
tential burden of 
pathogenic gene 
mutations and 
the potential dia-
gnostic and the-
rapeutic mea-
sures as offered 
by study neuro-
logist (sALS) or 
certified gene-
ticist (fALS) 
 
 
• uncertain 
significance 
• likely benign  
• likely pathogenic  
• pathogenic 
counseling by study 
neurologist followed 
by geneticist 
notification about 
genetic results 
with therapeutic 
relevance 
• likely pathogenic 
• pathogenic 
variant with 
treatment option 
counseling by study 
neurologist followed 
by geneticist 
 
12.3.3. Informed consent procedures of first and second-degree relatives 
Study results on genetic variants of SOD1, C9orf72, FUS and TARDBP genes might be of 
diagnostic and therapeutic relevance of study participant´s first and second-degree relatives. 
Relatives may include individuals with symptoms of ALS or FTD (established or probable dia-
gnosis of fALS) as well as asymptomatic individuals (unknown risk of ALS). In principle, study 
participants are offered to provide the genetic study results to authorized family members. 
However, the knowledge and awareness about genetic research of study participants might 
be perceived as psychologically burdensome for first and second-degree relatives. The infor-
mation includes the advice of genetic counseling prior to the notification of genetic study re-
sults. The study information and the offered genetic counselling will address the potential medi-
cal, psychological and social burden that can be associated with pathogenic gene mutations 
as well as the individual or societal benefits aimed with the study. Therefore, the provision of 
the study participant´s genetic study results will be restricted and must comply with the follow-
ing requirements:  
 
• Authority for provision of study results to first and second-degree relatives by the study 
participant in a written manner 
• Written information to first or second-degree relatives on the option of receiving genetic 
results of study participant 
• Genetic counseling of first or second-degree relatives prior to signing informed consent on 
receiving genetic results of study participant 
• Informed consent of first or second-degree relatives for receiving the study participant´s 
genetic study results  
• Directives of first or second-degree relative about the notification criteria of study 
participant´s genetic results 
 
The relative´s directives concerning the notification criteria is part of the informed consent pro-
cedure. The notification criteria for relatives are the same as for the patient (see Table 12). 
The study results might be provided to authorized first and second-degree relatives after the 
death of the study participant (postmortem provision of participant´s genetic study results).  
 
Table 12: Differentiated provision of genetic study results to first and second-degree relatives and 
modes of notification  
Patient´s directive  
Notification 
Provision of study results  
no notification  
not applicable 
not applicable 
notification about all individual 
study results  
by request of 
relative 
provision of study results to gene-
tic consultant for subsequent use 
in genetic counseling  

 
 
 
29 
notification about selected study 
results with therapeutic relevance  
by study center 
Counseling by study neurologist 
and referral to genetic consultant  
 
12.3.4. Genetic consultation of first and second-degree relatives  
First and second-degree relatives of study participants will be advised for genetic counseling 
1) prior to signing the informed consent on receiving genetic results of study participant and 2) 
prior to notification of study participant´s genetic results (when the relative has signed the 
informed consent). The subject of the counseling will be differentiated according to the patient’s 
directives and the genetic study results. An overview on the scheme of genetic counseling is 
provided in Table 12. As part of the study, recruiting study sites are prepared to refer patients 
(or their advice seeking relatives) to certified geneticists who are experienced in the consulta-
tion on genetic variants in ALS. The genetic results of the study participant will be provided by 
the study on request of the genetic consultant and used for counseling of first and second-
degree relatives. In case that study results are of therapeutic relevance, first and second-de-
gree relatives will be actively informed by study center and invited respectively to genetic coun-
seling by the study neurologist. Subsequently, a referral to a certified geneticist will be offered. 
For referral, the relative will receive study results being handed over to the certified geneticist. 
The genetic counseling of the first and second- degree relatives is considered independent 
from this observational study and is not subject of this study protocol.  
 
12.3.5. Follow-up on study results with therapeutic relevance 
Therapeutic relevance is defined by the planning or performance of a phase 3 clinical trial, a 
planned or ongoing early access program or an expected approval of a genetic medicine tar-
geting one of the studied genes within the next 12 months. The principal investigator and the 
genetic review board will analyze, review and interpret published information on the planning, 
beginning and completion of phase 3 clinical trials, early access programs or approvals of 
genetic medicines targeting one of the studied genes. The therapeutic residence will be de-
fined as described at least every 12 months for 3 years after the beginning of the study. The 
extension of this review activity is of great scientific and medical value and will be subject of 
further investigations and related protocols.  
 
12.4. Insurance and reimbursement 
Not applicable for an observational study. 
 
12.5. Data protection and confidentiality 
The subject will not be identified by name in any of study reports being solely used for research 
purpose. The ethics committees, and various government health agencies can inspect the 
records of this study. Every effort will be made to keep the subjects´ personal medical data 
confidential. This register study is subject to the regulations set forth in the Data Protection Act 
which shall be fully adhered to. APST and the Charité agreed on the Order Data Processing 
(ODP) Agreement in accordance with Council of the European Union General Data Protection 
Regulation (EC-GDPR; transl: EU-Datenschutzgrundverordnung, EU-DSGVO). The patient 
data shall be pseudonymized for further processing and statistical analysis. For this purpose, 
the patient data shall be encoded. Data assessment shall take place exclusively using the 
encoded (pseudonymized) data sets so as to exclude any tracing of an individual patient’s 
identity. Data pseudonymization shall be performed in accordance with the regulations set forth 
in the general data protection regulation (§ 4 clause 5 DSGVO). The APST shall be responsible 
for the storage and processing of patient data that have previously been captured via the study 
software (studioMED+). The patient data is stored in an encrypted and pseudonymized pattern 

 
 
 
30 
in a database on its own root server in Germany. In addition, a principle of roles and rights is 
integrated, which guarantees decryption and de-pseudonymization only for authorized per-
sons. 
 
12.6. Access rights to personal data 
Participants in the study are entitled to view any of their personal data captured in the context 
of the study. At that, patients themselves – or their authorized proxy - are granted the option 
to receive a print copy of all the data captured on clinical research software (studioMED+). 
Patients are furthermore entitled to notify us of any errors in the data captured on them and to 
request data correction. 
 
12.7. Archiving 
Data from all different primary data sources (see 8.3) shall be captured and stored on the 
clinical research software (studioMED+). Any data from questionnaires that have been filled in 
manually shall be transferred to the eCRF component of studioMED+. All the data shall be 
pseudonymized and transferred to suitable computer programs for statistical evaluation. Foll-
owing statistical analysis, the results shall be illustrated and published as tables, graphs, and 
in text format. The publishing of the results shall take place in strict observation of the DSGVO, 
thus excluding the possibility of tracing an individual patient’s identity. The pseudonymization 
of data excludes by guarantee any direct or indirect linking of data to personal patient informa-
tion and the identification of individual patients. The pseudonymized cohort study data used 
for statistical and scientific purposes are not subject to any data retention or erasure period. 
The data captured in the context of this study shall be retained for a minimum of 10 years 
following study completion. Data erasure is not envisaged with the objective of upholding care 
research in the long term. The erasure of single data sets is exempt from this regulation and 
shall be performed upon the respective patient’s request or upon withdrawal of the respective 
patient’s consent to participating in the study at any time and without giving reasons.  
 
13. Reports 
13.1. Internal reports 
Reports on the study will be generated on a monthly base. The reports will provide information 
about the number of registered patients and delivered genetic investigations per study center. 
 
13.2. Interim report  
Interim analyses performed for this study at variable time points, at least after all subjects 
complete the 6-month assessments. 
 
13.3. Publication of results 
The main results of the study will be published in a peer-review journal.  
 
 

31 
 
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