A Phase 3, Randomized, Double-Blind, Parallel Group Safety Trial to Evaluate the Immunogenicity of Dasiglucagon and GlucaGen® Administered Subcutaneously in Patients With Type 1 Diabetes Mellitus (T1DM)
Phase: PHASE3
Conditions: Hypoglycemia, Diabetes Mellitus, Type 1
Sponsor: Zealand Pharma

CLINICAL TRIAL REPORT 
ZP4207-16136 (ZEA-DNK-01711) 
 
 
Section 16.1.1: Protocol and Protocol Amendments 
16.1  TRIAL INFORMATION 
16.1.1 
PROTOCOL AND PROTOCOL AMENDMENTS  
 
This appendix includes 
 
Document 
Date, Version 
Clinical Trial Protocol 
18 January 2017, Version 1 
Amendment 01 
08 May 2017 
Clinical Trial Protocol 
08 May 2017, Version 2 
Amendment 02 
21 August 2017 
Clinical Trial Protocol 
21 August 2017, Version 3 
 

 
 
 
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Clinical Trial Protocol 
A phase 3, Randomized, Double-Blind, Parallel Group Safety Trial to Evaluate the 
Immunogenicity of Dasiglucagon Compared to GlucaGen® Administered Subcutaneously 
in Patients with Type 1 Diabetes Mellitus (T1DM) 
Sponsor code: ZP4207-16136 
SynteractHCR: ZEA-DNK-01711 
EudraCT number: 2017-000062-30 
 
 
Coordinating investigator:  
Linda Morrow, MD 
 
Prosciento 
 
855 Third Avenue 
 
91911 Chula Vista 
 
CA, USA 
 
 
 
Sponsor:  
Zealand Pharma A/S 
 
Smedeland 36 
 
2600 Glostrup, Copenhagen 
 
Denmark 
 
 
 
Version: final version 1 
Date: 18 January 2017 
 
 
 
 
 
GCP statement 
This trial will be performed in compliance with Good Clinical Practice (GCP),  
the Declaration of Helsinki (with amendments) and local legal and regulatory requirements.

 
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Title: A phase 3, randomized, double-blind, parallel group safety trial to evaluate the 
immunogenicity of dasiglucagon compared to GlucaGen® administered subcutaneously in 
patients with type 1 diabetes mellitus (T1DM) 
I agree to conduct this trial according to the Trial Protocol.  
I agree that the trial will be carried out in accordance with Good Clinical Practice (GCP), with the 
Declaration of Helsinki (with amendments) and with the laws and regulations of the countries in 
which the trial takes place. 
 
 
 
Investigator 
  
 
 
 
 
 
 
Date 
 
Signature 
 
 
 
 
 
Name and 
address 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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2. Trial synopsis 
Title of the trial: 
A phase 3, randomized, double-blind, parallel group safety trial to evaluate the immunogenicity of 
dasiglucagon*) compared to GlucaGen® administered subcutaneously in patients with type 1 diabetes 
mellitus (T1DM) 
* Dasiglucagon is the proposed international nonproprietary name 
EudraCT number: 
2017-000062-30 
 
Protocol codes: 
Sponsor: ZP4207-16136 
SynteractHCR: ZEA-DNK-01711 
Sponsor or sponsor's representative in the European Union: 
Zealand Pharma A/S, Smedeland 36, 2600 Glostrup (Copenhagen), Denmark 
Coordinating investigator: 
Linda Morrow, MD, Prosciento, 855 Third Avenue, 91911, Chula Vista, CA, USA  
Trial center(s): 
2 centers in the EU, 2 centers in the US, and 3 centers in Canada 
Planned trial period: 
First Patient First Visit: March 2017 
Last Patient First Visit: September 2017 
Phase of Development:  
Phase 3 
Objectives: 
The primary objective is to evaluate the immunogenicity of repeated single doses of dasiglucagon 
following subcutaneous (s.c.) administration compared with s.c. GlucaGen in T1DM patients. 
The secondary objective is to evaluate the safety and tolerability of repeated single doses of 
dasiglucagon following s.c. administration compared with s.c. GlucaGen in T1DM patients. 
Trial design: 
This is a randomized, double-blind, parallel group trial comparing the immunogenicity of either 
dasiglucagon or GlucaGen administered to euglycemic T1DM patients. Patients will be randomized 
1:1 to receive 3 s.c. injections of dasiglucagon or GlucaGen with 1 week between doses. Patients will 
be followed for at least 3 months from the day of the first dose to assess any immune response. A 
total of 90 patients are expected to complete the trial. Handling, preparation and administration of trial 
medication will be done by unblinded trial personnel. All trial assessments will be done by blinded trial 
personnel. However, exposure assessments and anti-drug antibody (ADA) assessments will be 
performed by unblinded personnel at the specialty laboratories, to make sure that dasiglucagon or 
GlucaGen administration is matched with the applicable bioanalytical assay. 
Planned number of patients: 
90 completed patients (45 completed patients per treatment group). Prematurely discontinued 
patients will be replaced in order to reach 90 completed patients. It is expected that 112 patients in 
total will be randomized and treated. 
To qualify as completed, the patient must be dosed according to protocol and have blood drawn for 
the planned anti-drug antibody (ADA) analyses. 
Medical condition or disease under investigation: 
Given the role of the immune system in the pathogenesis of T1DM, the present trial is conducted in 
patients with T1DM. There are no data indicating an altered immune response with varying blood 
glucose levels. Therefore, for the safety and well-being of the patients, they will not be brought into 
hypoglycemia prior to dosing. Patients with previous exogenic glucagon exposure will not be excluded 
from the trial, but the information on previous glucagon administration will be recorded. 
Inclusion criteria: 
To be included in the trial, patients have to fulfill all of the following criteria: 
1. Informed consent obtained before any trial-related activities (trial-related activities are any 
procedure that would not have been performed during normal management of the patient) 
2. Availability for the entire trial period 
3. Age between 18 and 70 years, both inclusive 
4. Male or female patients with T1DM for at least 1 year. Diagnostic criteria as defined by the 

 
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American Diabetes Association 
5. Hemoglobin A1c (HbA1c) <10% 
6. Stable anti-diabetic treatment for at least 1 month (e.g. within 10% insulin dose adjustment) 
7. A female participant must meet one of the following criteria 
a. Participant is of childbearing potential and agrees to use one of the accepted contraceptive 
regimens throughout the entire duration of the trial from screening until last follow-up visit. An 
acceptable method of contraception includes at least one of the following: 
i. Abstinence from heterosexual intercourse 
ii. Systemic contraceptives (birth control pills, injectable/implant/ insertable hormonal birth 
control products, transdermal patch); if the participant is using systemic contraceptives, 
she must use an additional form of acceptable contraception (iii or iv, below) 
iii. Intrauterine device (with and without hormones) 
iv. Condom with spermicide  
or 
b. Participant is of non-childbearing potential, defined as surgically sterile (i.e. has undergone 
complete hysterectomy, bilateral oophorectomy, or tubal ligation), or in a menopausal state (at 
least 1 year without menses) 
8. A male must be surgically sterilized or willing to refrain from sexual intercourse from screening 
and until last follow-up visit or, if sexually active, uses a condom and partner practices 
contraception during the trial from screening and until the last follow-up visit 
 
Exclusion criteria: 
Patients meeting any of the following criteria during screening evaluations will be excluded from trial 
participation: 
1. Previous administration of dasiglucagon (previously referred to as ZP4207) 
2. Known or suspected allergy to trial medication(s) or related products  
3. History of anaphylaxis or symptoms of severe systemic allergy (such as angioedema)  
4. Previous participation (randomization) in this trial 
5. Females who are pregnant according to a positive pregnancy test, actively attempting to get 
pregnant, or are lactating 
6. Patients on a closed loop artificial pancreas 
7. Receipt of any investigational drug within 3 months prior to screening 
8. Active malignancy within the last 5 years 
9. Congestive heart failure, New York Heart Association class II-IV 
10. Inadequately treated blood pressure as defined as systolic blood pressure ≥180 mmHg or diastolic 
blood pressure ≥110 mmHg at screening 
11. Current bleeding disorder, including use of anticoagulant treatment 
12. Known presence or history of pheochromocytoma (i.e. adrenal gland tumor) or insulinoma 
(i.e. insulin-secreting pancreas tumor) 
13. Known or suspected HIV infection 
14. Use of a systemic beta-blocker drug, indomethacin, warfarin or anticholinergic drugs in the 
previous 28 days before Day 1 of this trial 
15. Use of systemic corticosteroids, anti-inflammatory biological agents, kinase inhibitors or other 
immune modulating agents within the last 3 months prior to screening 
16. Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >2.5 X the upper limit of 
normal (ULN), bilirubin >1.5 X ULN, estimated glomerular filtration rate (eGFR) 
<30 mL/min/1.73m2 according to the Modification of Diet in Renal Disease (MDRD) Study 
definition 
17. Clinically significant abnormal ECG at screening as evaluated by Investigator 
18. Donation of blood or plasma in the past month, or in excess of 500 mL within 12 weeks prior to 
screening 
19. Active substance or alcohol abuse 
20. Patients with mental incapacity or language barriers that preclude adequate understanding or 
cooperation, who are unwilling to participate in the trial, or who in the opinion of the Investigator 

 
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should not participate in the trial 
21. Surgery or trauma with significant blood loss within the last 2 months prior to screening 
22. Any condition interfering with trial participation or trial endpoints or that could be hazardous to the 
patient 
Test product, dose and mode of administration: 
Dasiglucagon: 0.6 mg; liquid formulation, 1 mg/mL in prefilled syringes containing 0.6 mL 
Reference product, dose and mode of administration: 
GlucaGen, 1 mg; powder and solvent for reconstitution as 1 mL solution for injection (recombinant 
glucagon hydrochloride, Novo Nordisk) 
Duration of treatment: 
Patients will receive 3 s.c. injections of trial medication (dasiglucagon or GlucaGen) with 1 week 
between each dosing. 
Prior to administration of trial medication patients must reach a target plasma glucose level of 
70-150 mg/dL. Plasma glucose levels may be adjusted by s.c. administration of a fast-acting insulin 
analog or by glucose ingestion. 
Criteria for evaluation: 
Immunogenicity: 
Primary endpoint:  
• 
Overall ADA incidence 
This will be calculated as a percentage of the combined results of treatment-induced ADA-
positive patients and treatment-boosted ADA-positive patients and the total number of 
evaluable patients, excluding baseline-positive patients without any samples available after 
drug administration.  
Key secondary endpoints: 
 
Treatment-induced ADA 
Incidence calculated as a percentage of the total number of evaluable patients that were ADA 
negative at baseline and ADA positive after drug administration and the total number of 
evaluable patients, excluding baseline positive patients without any samples available after 
drug administration.  
 
Treatment-boosted ADA 
Incidence calculated as percentage of baseline ADA-positive patients with significant increases 
(≥5-fold) in ADA titer after drug administration and the total number of evaluable patients, 
excluding baseline-positive patients without any samples available after drug administration.  
Secondary endpoints: 
Characterization of ADA response:  
 
Incidence and titer of neutralizing activity of ADA positive patients 
 
Incidence of cross-reactivity of ADA positive patients towards endogenous glucagon 
 
Kinetics of ADA: 
The timing and duration of detected ADA response  
Safety: 
 
The incidence, type and severity of AEs 
 
Changes from baseline in clinical laboratory parameters 
 
Changes from baseline in vital signs 
 
Clinically 
meaningful 
changes 
from 
baseline 
in 
physical 
examination 
and 
electrocardiogram (ECG)  
Exposure endpoints, after administration of first and third doses of trial medication:  
 
Plasma dasiglucagon and glucagon concentrations from 0-90 min after dosing will be 

 
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evaluated based on the following endpoints: AUC0-30min, AUC0-90 min, Cmax, tmax 
Pharmacodynamics, after administration of first and third doses of trial medication: 
 
Plasma glucose profiles over the period from 0-90 min after dosing will be evaluated 
based on the following endpoints: AUE0-30min, AUE0-90 min, CEmax, tmax 
Statistical methods: 
All statistical analysis will be descriptive. Continuous variables will be summarized with means, 
standard deviations, medians, minimums, and maximums, and valid cases. Other summaries (e.g. 
quartiles, 95% confidence intervals) may be used as appropriate. Categorical variables will be 
summarized by counts and by percentage of patients in corresponding categories. 
 
Sample size calculation: 
The purpose of the present trial is to generate data describing the immunogenic potential of 
dasiglucagon, when used as a rescue therapy from severe hypoglycemia and with reference to the 
immunogenic potential of GlucaGen. The sample size is based on generating data to show that the 
90% confidence of the ADA incidence is no worse than 15% as the predefined acceptability criterion 
and with a reference to similar data being generated for GlucaGen.  
Currently, no ADA incidences have been detected in the completed clinical trials, where up to 5 
repeated doses of dasiglucagon have been administered to the same patients within a week. Across 
the two phase 1 clinical trials and a completed phase 2 pharmacokinetic/pharmacodynamic trial, a 
total of 141 subjects have been exposed to dasiglucagon and no incidences of ADA development 
have been observed. The obtained data indicate that dasiglucagon has a low risk for induction of 
ADAs in the investigated settings and as a consequence the sample size is based on showing that 
the ADA incidence is no worse than the predefined margin of 15%.  

 
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3. Table of contents 
1. 
SIGNATURES AND AGREEMENT WITH PROTOCOL ..................................................... 2 
2. 
TRIAL SYNOPSIS ............................................................................................................... 4 
3. 
TABLE OF CONTENTS .................................................................................................... 10 
4. 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ............................................ 13 
4.1 
Abbreviations ..................................................................................................................... 13 
4.2 
Definitions of terms ............................................................................................................ 14 
5. 
INTRODUCTION................................................................................................................ 15 
5.1 
Background of the trial ....................................................................................................... 15 
5.2 
Trial rationale ..................................................................................................................... 17 
5.3 
Assessment of anticipated benefits and risks .................................................................... 17 
6. 
TRIAL OBJECTIVES ......................................................................................................... 19 
7. 
INVESTIGATIONAL PLAN ............................................................................................... 20 
7.1 
Overall trial design and plan .............................................................................................. 20 
7.2 
Discussion of trial design and choice of control groups ..................................................... 21 
7.3 
Selection of trial population ................................................................................................ 21 
7.3.1 
Inclusion criteria ................................................................................................................. 22 
7.3.2 
Exclusion criteria ................................................................................................................ 22 
7.3.3 
Premature removal from trial ............................................................................................. 23 
7.3.3.1 
Possible reasons for patient discontinuation ............................................................ 23 
7.3.3.2 
Center discontinuation .............................................................................................. 24 
7.3.3.3 
Trial termination ........................................................................................................ 24 
7.3.4 
Replacement of patients .................................................................................................... 24 
7.4 
Investigational medicinal product(s)................................................................................... 25 
7.4.1 
Identity of investigational medicinal product(s) .................................................................. 25 
7.4.2 
Treatments administered ................................................................................................... 25 
7.4.3 
Selection of doses in the trial ............................................................................................. 26 
7.4.4 
Treatment compliance ....................................................................................................... 26 
7.4.5 
Method of assigning patients to treatments or treatment sequences ................................ 26 
7.4.6 
Blinding .............................................................................................................................. 26 
7.4.7 
Drug accountability and disposal ....................................................................................... 27 
7.4.8 
Prior and concomitant therapy ........................................................................................... 27 
7.4.9 
Treatment after end of trial ................................................................................................. 27 
7.5 
Assessments and schedule of measurements (overview) ................................................ 27 
7.5.1 
Screening examination ...................................................................................................... 27 
7.5.2 
Instructions to patients prior to dosing ............................................................................... 28 
7.5.3 
Procedures and assessments during the treatment period of the trial .............................. 28 
7.5.4 
Follow-up period of the trial ................................................................................................ 29 
7.5.5 
Final examination at the end of the trial ............................................................................. 29 
7.5.6 
Additional (safety) examinations ........................................................................................ 29 
7.5.7 
Safety laboratory tests ....................................................................................................... 30 
7.6 
Immunogenicity, pharmacokinetic, pharmacodynamic, tolerability and safety 
measurements ................................................................................................................... 30 
7.6.1 
Immunogenicity measurements ......................................................................................... 30 
7.6.2 
Plasma concentrations of dasiglucagon and GlucaGen .................................................... 30 
7.6.3 
Pharmacodynamic measurements .................................................................................... 30 
7.6.4 
Safety and tolerability measurements ................................................................................ 31 
7.6.4.1 
Safety laboratory tests .............................................................................................. 31 
7.6.4.2 
Safety examinations ................................................................................................. 31 

 
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8. 
ADVERSE EVENTS .......................................................................................................... 31 
8.1 
Definitions .......................................................................................................................... 31 
8.2 
Collection, recording and reporting of adverse events ...................................................... 33 
8.3 
Follow-up of adverse events .............................................................................................. 34 
8.4 
Hypoglycemia ..................................................................................................................... 35 
8.5 
Pregnancy .......................................................................................................................... 35 
8.6 
Precautions ........................................................................................................................ 36 
8.7 
Safety Committee............................................................................................................... 36 
9. 
DATA MANAGEMENT AND QUALITY CONTROL ......................................................... 37 
9.1 
Case report forms .............................................................................................................. 37 
9.2 
Quality control .................................................................................................................... 37 
9.3 
Data management ............................................................................................................. 38 
10. 
STATISTICAL METHODS AND DETERMINATION OF SAMPLE SIZE ......................... 39 
10.1 
Statistical and analysis plan ............................................................................................... 39 
10.1.1 
General considerations .................................................................................................... 39 
10.1.2 
Classification of patients to subsets................................................................................. 39 
10.1.3 
Immunogenicity data ........................................................................................................ 39 
10.1.4 
Exposure and PD endpoints ............................................................................................ 40 
10.1.5 
Safety data ....................................................................................................................... 40 
10.1.6 
Further data ..................................................................................................................... 40 
10.1.7 
Withdrawals, drop-outs and missing data ........................................................................ 40 
10.1.8 
Baseline and center comparisons.................................................................................... 40 
10.1.9 
Subgroup analysis ........................................................................................................... 40 
10.1.10 
Interim analysis ............................................................................................................ 40 
10.2 
Determination of sample size ............................................................................................. 40 
11. 
ETHICS AND REGULATIONS .......................................................................................... 42 
11.1 
Independent ethics committees and competent authorities .............................................. 42 
11.2 
Ethical conduct of the trial .................................................................................................. 42 
11.3 
Patient information and consent ........................................................................................ 42 
11.4 
Legal and regulatory requirements .................................................................................... 42 
12. 
TRIAL ADMINISTRATION ................................................................................................ 43 
12.1 
Responsibilities .................................................................................................................. 43 
12.2 
Protocol deviations ............................................................................................................. 43 
12.3 
Protocol changes ............................................................................................................... 43 
12.4 
Publication of results .......................................................................................................... 43 
12.5 
Clinical trial report .............................................................................................................. 43 
12.6 
Retention of trial records .................................................................................................... 44 
13. 
REFERENCES................................................................................................................... 45 
 
Appendices: 
(1) 
List of names and addresses 
 
 

 
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Index of in-text tables 
Table 2-1: Flow chart ............................................................................................................................. 1 
Table 7-1: Identity of investigational products ................................................................................. 25 
 
Index of in-text figures 
Figure 7-1 Overview of the trial design ............................................................................................. 20 
 

 
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4. List of abbreviations and definition of terms 
4.1 
Abbreviations 
 
 
ADA 
Anti-drug Antibody 
AE 
Adverse Event 
ALT (SGPT) 
Alanine Aminotransferase (Serum Glutamic Pyruvic Transaminase) 
AST (SGOT) 
Aspartate Aminotransferase (Serum Glutamic Oxaloacetic Transaminase) 
BG 
Blood Glucose 
CA 
Competent Authority (Directive 2001/20/EC) 
CFR 
Code of Federal Regulations 
CRF/eCRF 
Case Report Form/Electronic Case Report Form 
CI 
Confidence Interval 
CRO 
Contract Research Organization 
CSII 
Continuous Subcutaneous Insulin Infusion 
CTA 
Clinical Trial Authorization (Directive 2001/20/EC) 
EC 
Ethics Committee 
ECG 
Electrocardiogram 
EDC 
Electronic Data Capture 
eGFR 
Estimated Glomerular Filtration Rate 
EoT 
End of Trial 
EudraCT 
European Clinical Trials Database 
FAS 
Full Analysis Set 
FDA 
Food and Drug Administration 
gamma-GT 
gamma-Glutamyltransferase 
GCP 
Good Clinical Practice 
HbA1c  
Hemoglobin A1c 
HEENT 
Head, Ears, Eyes, Nose, Throat 
HIV 
Human Immunodeficiency Virus 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonization  
IEC 
Independent Ethics Committee 
IM 
Intramuscular(ly) 
IMP 
Investigational Medicinal Product 
IND 
Investigational New Drug 
INR 
International Normalized Ratio 
IRB  
Institutional Review Board 
i.v. 
Intravenous(ly) 
IWRS 
Interactive Web Response System 
LOCF 
Last Observation Carried Forward 
MDRD 
Modification of Diet in Renal Disease 
MedDRA 
Medical Dictionary for Regulatory Activities  
Nab 
Neutralizing Antibody 
PG 
Plasma Glucose 
ODM 
Operational Data Model 
PD 
Pharmacodynamic(s) 

 
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PK 
Pharmacokinetic(s)  
PPS 
Per Protocol Set 
PT 
Preferred Term 
SAP 
Statistical Analysis Plan 
SAS 
Safety Analysis Set 
SAE 
Serious Adverse Event 
SC 
Safety Committee 
s.c. 
Subcutaneous(ly) 
SOC 
System Organ Class 
SOP 
Standard Operating Procedure 
T1DM 
Type 1 Diabetes Mellitus 
T2DM 
Type 2 Diabetes Mellitus 
ULN 
Upper Limit of Normal 
V 
Visit 
ZP4207 
Dasiglucagon  
 
 
Plasma concentrations of dasiglucagon/GlucaGen  
AUC0-30min 
Area under the plasma concentration curve from administration to observed 
concentration 30 min 
AUC0-90 min  
Area under the plasma concentration curve from administration to observed 
concentration at 90 min 
Cmax 
Maximum plasma concentration 
tmax 
Time until Cmax is reached  
 
 
Plasma glucose concentrations 
AUE0-30min 
Area under the effect curve from administration to 30 min 
AUE0-90 min 
Area under the effect curve from administration to 90 min 
CEmax 
Change from baseline plasma glucose to maximum plasma glucose 
measured post dose 
tmax 
Time to maximum effect 
 
4.2 
Definitions of terms 
 
Definition of the end of the trial: The trial ends with the last visit of the last patient participating in 
the trial. 

 
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5. Introduction  
5.1 
Background of the trial 
Hypoglycemia  
Hypoglycemia in patients with diabetes is defined as episodes of an abnormally low plasma 
glucose concentration.1 This is a common, unpredictable, and potentially dangerous side effect 
of treatment of diabetes mellitus with especially insulin or sulfonylureas. It is more frequent in 
patients with profound endogenous insulin deficiency, such as occurs in type 1 diabetes mellitus 
(T1DM) and advanced type 2 diabetes mellitus (T2DM). Treatment of T2DM with insulin causes 
hypoglycemia progressively and more frequently over time, whereas in T1DM, hypoglycemia is 
experienced throughout the course of established disease. 
Symptoms and signs of hypoglycemia are not specific. Patients undergoing a hypoglycemic 
episode experience unpleasant symptoms such as anxiety, sweating, hunger, tremors, 
palpitations, paresthesia, nausea and pallor. Depending on its severity, the hypoglycemia may 
lead to mild confusion, behavioral changes, loss of consciousness, seizures, coma, and death.2  
The incidence of hypoglycemic events or even the fear of hypoglycemia influences patients’ 
adherence to prescribed treatment regimens for diabetes mellitus. This leads to inadequate 
glycemic control, which in turn may lead to an increased risk of diabetic complications. 
Glucagon 
Glucagon is a naturally occurring hormone, secreted from the alpha cells of the pancreatic 
islets. Glucagon plays a central role in the regulation of glucose homeostasis and is the 
counterpart of insulin for controlling blood glucose levels (i.e. it acts in opposition to insulin in 
terms of effects on blood glucose levels). Glucagon stimulates hepatic glycogenolysis and 
gluconeogenesis in hypoglycemic states, thereby restoring glucose homeostasis. Glucagon 
receptor agonism has also been shown to exert effects on lipid metabolism, energy balance, 
body adipose tissue mass and food intake. Insulin decreases blood glucose levels and cases of 
hypoglycemia can be reversed by glucagon. Therefore, glucagon is indicated for the treatment 
of severe hypoglycemia.  
Antibodies against therapeutic peptides like glucagon and analogues hereof may develop when 
injected subcutaneously. Although important, glucagon is not considered to have a critical 
endogenous function since other counter regulatory hormones are also induced during 
hypoglycemia (e.g. growth hormone, cortisol, and epinephrine). In addition, results from 3 
mouse models defective in various pathways of the glucagon signaling have conﬁrmed that 
glucagon action is dispensable for their development and survival. Also, in non-clinical toxicity 
studies performed with dasiglucagon (see below), no consequences of ADA formation have 
currently been observed. In summary, glucagon appears to have a partly redundant 
endogenous function. These non-clinical data are of importance when evaluating the 
consequences of ADA formation. 
Dasiglucagon  
Dasiglucagon (ZP4207) is a stable peptide analog of human glucagon, available in a ready-to-
use liquid formulation and is in development for the treatment of severe hypoglycemia in insulin 
dependent patients with diabetes mellitus. Dasiglucagon is a specific and full glucagon receptor 
agonist designed to mimic the effects of glucagon, having a fast absorption and elimination 
(minutes). It is a peptide of 29 amino acids, with 7 amino acid substitutions compared to native 
glucagon. The main purpose of the substitutions is to increase the physical and chemical 
stability of the glucagon analog compared to marketed glucagon products such as Lilly 
Glucagon or GlucaGen®. Dasiglucagon exhibits improved physical and chemical stability and is 
available in an aqueous solution at neutral pH.3 

 
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Three clinical trials have been completed with dasiglucagon, a first human dose trial (ZP4207-
14013), a multiple-dose dose-escalation trial (ZP4207-15007) to evaluate the safety, tolerability, 
pharmacokinetics (PK) and pharmacodynamics (PD) of dasiglucagon, and a phase 2 crossover 
trial to assess the pharmacokinetics and pharmacodynamics of a single dose of an optimized 
formulation of dasiglucagon administered subcutaneously (s.c.) in patients with T1DM (ZP4207-
15126).3 
Pharmacokinetics and pharmacodynamics of dasiglucagon  
The results of the phase 1 and 2 clinical trials confirm dose-proportionality for dasiglucagon 
pharmacokinetics, which is characterized by a fast absorption with a peak plasma concentration 
obtained after 35 minutes. Thereafter, the plasma concentration rapidly declines with an 
average half-life of 28 minutes. The median time to the maximum plasma concentration (Cmax) 
was later for dasiglucagon than for GlucaGen (35 versus 20 minutes). Doses of 0.3 mg 
dasiglucagon and 0.5 mg GlucaGen and also 0.6 mg dasiglucagon and 1.0 mg GlucaGen were 
similar with regard to Cmax. For Cmax, the results indicated that 0.3 mg dasiglucagon was 
comparable to 0.5 mg GlucaGen (90% confidence interval (CI): 0.8167; 1.0068) and 0.6 mg 
dasiglucagon was comparable to 1.0 mg GlucaGen (90% CI: 0.8850; 1.1991).3 At these dose 
levels, the total exposures (AUC0-inf) were higher for dasiglucagon compared to GlucaGen. 
At all dose levels in the phase 2 trial, all patients achieved a plasma glucose level of at least 
70 mg/dL as well as an increase in plasma glucose by at least 20 mg/dL within 30 min post-
dose. The maximal observed time to reach the 20 mg/dL plasma glucose increase ranged from 
15 to 27 minutes across doses and decreased as the dose increased. The pharmacodynamic 
responses of 0.6 mg of dasiglucagon and 1.0 mg of GlucaGen were comparable.3 
Safety of dasiglucagon  
The safety data for dasiglucagon did not give rise to any relevant safety concerns for 
dasiglucagon beyond those related to the pharmacological effect of glucagon agonism. All 
adverse events (AEs) recorded in the trials were of mild or moderate severity. The most 
frequently reported systemic AE was nausea, which is a known side effect following 
administration of glucagon. Headache was the next most frequently reported event, occurring in 
all dose groups in the phase 2 trial. Injection site reactions were observed only sporadically after 
administration with either dasiglucagon or GlucaGen® and all were mild and transient. The most 
frequent injection site reaction was erythema, occurring in all treatment groups, including the 
placebo group, irrespective of dose. Therefore, the phase 1 and 2 results and the safety profile 
described to date do not give rise to specific safety concerns. For further information, please 
refer to the Investigator Brochure.3  
Immunogenicity of dasiglucagon  
To date, in the 3 clinical trials performed with dasiglucagon (described above), there have not 
been any anti-drug antibody (ADA) occurrences in a total of 141 subjects exposed to 1 or more 
doses. Data from the non-clinical toxicology program (7 non-clinical toxicity studies) showed that 
ADAs were detected in mice, rats, and dogs, and were most frequent in animals in the highest 
dasiglucagon dose groups. A fraction of the ADAs from rats and dogs were able to cross-react 
with native glucagon. However, the ADAs did not appear to be associated with changes in the 
safety or toxicity profiles compared to ADA-negative animals. In rats, the average exposure 
(AUC) was increased following 13 and 26 weeks of treatment in dose groups with higher ADA 
frequency (8 mg/kg/day). The ADA frequency and titers of consistently ADA-positive rats were 
reduced from 13 to 26 weeks of treatment, indicating a transient response in most animals. It 
therefore appears that dasiglucagon has a low risk for induction of ADAs. A fraction of the 
antibodies detected in the non-clinical toxicity studies was found to cross-react with glucagon 
without advert clinical or toxicity findings. These data suggest that dasiglucagon and glucagon 
share epitopes and potential ADAs induced by dasiglucagon in humans may have the ability to 
cross-react with glucagon.3  

 
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Although glucagon is an important hormone for controlling blood glucose levels it is considered 
to have a partially redundant endogenous function since hypoglycemia can also be corrected by 
other means. The overall immunogenicity risk of dasiglucagon in a clinical context is therefore 
considered to be low and the potential effects of induced ADAs judged to be of limited clinical 
consequence.  
As dasiglucagon contains 7 amino acid substitutions compared to native glucagon and historic 
data indicate that the immune system’s tolerance to glucagon can be impaired in the intended 
target population, there is an inherent risk for the induction of an ADA response against 
dasiglucagon. However, other product specific characteristics, i.e. dasiglucagon being a 
chemical synthetized product without host cell contaminants, a reduced potential for 
aggregation, a physiological compatible formulation, and a high bioavailability with a short half-
life, are all in favor of reducing the risk of dasiglucagon to induce an unwanted immune 
response. Considering the intended indication, in which dasiglucagon is administered as a 
single-dose rescue treatment on an infrequent basis (0.21 to 1.6 episodes per patient per 
year),4,5 the induction of a high titer ADA response with effects on clinical safety seems unlikely. 
Overall, the risk of dasiglucagon to induce an ADA response is considered low. The present trial 
aims to evaluate that immunogenicity risk in patients with T1DM administered multiple s.c. 
doses of dasiglucagon.  
5.2 
Trial rationale 
Dasiglucagon is in clinical development as a rescue treatment for severe hypoglycemia in 
patients with insulin-dependent diabetes mellitus. Immune responses to therapeutic peptides 
and proteins may develop after subcutaneous administration and could potentially adversely 
affect their safety and efficacy. The potential formation of high titer ADAs to dasiglucagon, 
although considered unlikely in a rescue indication, could influence the efficacy of dasiglucagon, 
either indirectly by interacting with the pharmacokinetics of dasiglucagon or directly by 
neutralizing the glucagon response.  
In recent years, regulatory agencies have outlined and recommended the use of a risk-based 
approach in the evaluation and mitigation of immune responses to therapeutic compounds that 
may adversely affect their safety and/or efficacy. Both transient and persistent antibody 
response should be combined to determine the overall immunogenicity of a product. Persistent 
antibodies are of importance since patients with persistent antibodies could experience clinical 
adverse reactions affecting safety and efficacy, while a transient antibody response can resolve 
without further consequence. 
The present trial aims to evaluate that immunogenicity risk with an assessment of the 
occurrence of ADAs and neutralizing ADAs, and of cross-reactivity with native glucagon, 
following repeated single doses of dasiglucagon by s.c. administration in T1DM patients. The 
comparator in this trial is GlucaGen, a recombinant human glucagon approved for the treatment 
of the severe hypoglycemic reactions that may occur in the management of insulin-treated 
children and adults with diabetes mellitus.  
5.3 
Assessment of anticipated benefits and risks 
As glucagon and its analogs belong to a well-known drug class with a known mode of action, 
dasiglucagon is not expected to be a high-risk molecule.  
Treatment with an investigational medicinal product may result in undesired effects or 
complaints. Undesired effects and complaints such as nausea, vomiting, and diarrhea are 
known AEs occurring with glucagon administration. Similar AEs have also been observed to a 
limited degree in the 3 clinical studies conducted with dasiglucagon. As with every novel drug 
substance, new and as yet unknown side effects also may occur.  
There are limited data available to assess the immunogenic potential of glucagon products 
available on the market, but the data available indicate that marketed glucagon only has a small 

 
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immunogenic potential. Based on the 3 clinical studies conducted with dasiglucagon to date 
(see Section 5.2), no anti-dasiglucagon or anti-glucagon antibodies have been detected.  
In relation to diabetes therapy, development of insulin-antibodies is documented more 
substantially and the route of administration has been shown to influence the immunogenic 
potential of insulins. However, antibodies against insulin do not generally have an impact on 
insulin action and are thus not clinically relevant. In terms of consequence, development of high 
titer antibodies against dasiglucagon could, in theory reduce the activity of endogenous 
glucagon, which, in theory, could influence hypoglycemic episodes. Limited suppression of 
glucagon would, however, not be considered critical, since low glucose levels can also be 
corrected by other means, including oral intake of glucose and the action of other endogenous 
hormones such as oxyntomodulin and epinephrine. 
Overall, dasiglucagon is judged to be a low-risk molecule, based upon the available clinical data 
as well as the outcome of the risk-based approach to the immunogenicity assessment. In line 
with the primary objective of this trial to assess the immunogenicity of dasiglucagon, sampling 
for measurement of antibodies against dasiglucagon will take place prior to first dosing (Visit 2), 
pre-dose at subsequent visits during the treatment period (Visits 3 and 4), and at all Follow-up 
visits (at 35, 60, and 104 days after the first dose of trial medication; i.e. at Visits 5, 6, and 7 
(End of Trial [EoT] visit), respectively).  
Administration of dasiglucagon may be associated with a risk of allergic reactions similar to 
those observed for other therapeutic peptides or proteins. Patients with known or suspected 
allergies to the trial medications or related products will be excluded from the trial. Mild or 
moderate allergic reactions may include symptoms of rash, fever, flu-like symptoms, nausea, 
headache, and myalgia. Acute generalized hypersensitivity reactions are usually very rare but 
may include symptoms of flushing, sweating, dizziness, change in blood pressure and 
difficulties in breathing. No severe acute hypersensitivity reactions have been observed in the 3 
clinical trials conducted with dasiglucagon. Direct access to resuscitation equipment is ensured 
at the clinical trial sites. 
With the exception of medical examinations, a patient participating in this trial is not likely to 
derive any personal health-related benefits. The results of the trial may contribute to the future 
use of dasiglucagon in patients with diabetes mellitus experiencing severe hypoglycemic 
reactions. 
Overall, the benefit to risk ratio for patients entering the ZP4207-16136 trial is considered 
acceptable. 

 
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6. Trial objectives  
Primary objective 
 
To evaluate the immunogenicity of repeated single doses of dasiglucagon following s.c. 
administration compared with s.c. GlucaGen in T1DM patients. 
Secondary objective 
 
To evaluate the safety and tolerability of repeated single doses of dasiglucagon following 
s.c. administration compared with s.c. GlucaGen in T1DM patients. 
Primary endpoint: 
 
Overall ADA incidence 
This will be calculated as a percentage of the combined results of treatment-induced 
ADA-positive patients and treatment-boosted ADA-positive patients and the total number 
of evaluable patients, excluding baseline-positive patients without any samples available 
after drug administration.  
Key secondary endpoints: 
 
Treatment-induced ADA 
Incidence calculated as a percentage of the total number of evaluable patients that were 
ADA negative at baseline and ADA positive after drug administration and the total number 
of evaluable patients, excluding baseline positive patients without any samples available 
after drug administration.  
 
Treatment-boosted ADA 
Incidence calculated as percentage of baseline ADA-positive patients with significant 
increases (≥5-fold) in ADA titer after drug administration and the total number of 
evaluable patients, excluding baseline-positive patients without any samples available 
after drug administration.  
Secondary endpoints: 
Characterization of ADA response:  
 
Incidence and titer of neutralizing activity of ADA positive patients 
 
Incidence of cross-reactivity of ADA positive patients towards endogenous glucagon 
 
Kinetics of ADA: 
The timing and duration of detected ADA response  
Safety: 
 
The incidence, type and severity of AEs 
 
Changes from baseline in clinical laboratory parameters 
 
Changes from baseline in vital signs 
 
Clinically 
meaningful 
changes 
from 
baseline 
in 
physical 
examination 
and 
electrocardiogram (ECG) 
Exposure endpoints, after administration of first and third doses of trial medication:  
 
Plasma dasiglucagon and glucagon concentrations from 0-90 min after dosing will be 
evaluated based on the following endpoints: AUC0-30min, AUC0-90 min, Cmax, tmax 
Pharmacodynamics after administration of first and third doses of trial medication: 
 
Plasma glucose profiles over the period from 0-90 min after dosing will be evaluated 
based on the following endpoints: AUE0-30min, AUE0-90 min, CEmax, tmax 

 
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7. Investigational plan 
7.1 
Overall trial design and plan 
This is a randomized, double-blind, parallel group trial comparing the immunogenicity of 3 fixed 
doses of either dasiglucagon or GlucaGen administered to euglycemic T1DM patients.  
Patients with T1DM will be randomized 1:1 to receive 3 s.c. injections of either dasiglucagon 
(0.6 mg) or GlucaGen (1 mg), with 1 week between each dose. Patients will be followed for at 
least 3 months from the day of the first dose to assess any immune response. Patients with 
previous exogenic glucagon exposure will not be excluded from the trial, but the information on 
previous glucagon administration will be recorded to enable subgroup analyses. A total of 
90 patients are expected to participate in and complete the trial (45 in each treatment arm). To 
qualify as completed, the patient must be dosed according to protocol and have blood drawn for 
the ADA analyses (as scheduled in  
). Prematurely discontinued patients will be replaced in order to reach 90 completed patients. It 
is expected 112 patients in total will be randomized and treated. 
For the safety and well-being of the patients, they will not be brought into hypoglycemia prior to 
dosing. Prior to administration of trial product patients must reach a target plasma glucose level 
of 70-150 mg/dL.  
The trial will include the following periods (as illustrated in Figure 7-1, below). 
 
A screening period from Day -30 to Day -3 
 
A treatment period, from Day 0 (day of randomization) to Day 14 (day of third and final 
dosing with trial medication), with s.c. trial medication administered on Day 0, Day 7, and 
Day 14. Handling, preparation and administration of trial medication will be done by 
unblinded trial personnel. All trial assessments will be done by blinded trial personnel.  
 
A follow-up period, from the end of the Treatment Period, with follow-up visits at Day 35, 
Day 60, and Day 104 (the EoT visit) 
Time windows for each trial visit are given in  
. 
Figure 7-1 Overview of the trial design 
 
An overview on the trial procedures is given in the flow chart (Table 2-1). Patients should be 
seen for all visits on the designated day or as close to it as possible.  
 

 
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7.2 
Discussion of trial design and choice of control groups 
The trial will be randomized and double-blind to increase trial validity and to reduce bias during 
evaluation of assessments with the two treatments. Since the 2 trial medications are not 
identical in appearance (dasiglucagon is a liquid formulation and GlucaGen is available as a 
powder for reconstitution), the handling, preparation and administration of trial medication will be 
done by unblinded trial personnel who will not be involved in other trial procedures and 
assessments. All trial assessments performed at the trial site will be done by blinded trial 
personnel. However, exposure assessments and ADA assessments will be performed by 
unblinded personnel at the specialty laboratories, to make sure that dasiglucagon or GlucaGen 
administration is matched with the applicable bioanalytical assay.    
Euglycemic patients with T1DM will be randomized 1:1 in order to evaluate the immunogenicity 
of dasiglucagon compared to GlucaGen. The randomized, double-blind, parallel group design, 
with administration of 3 fixed consecutive doses of randomized trial medication (dasiglucagon or 
GlucaGen) to the same patient will allow characterization of immunogenic potential and a 
relative comparison of immunogenicity between the 2 products. Treatment with the 3 repeated 
doses (each separated by 1 week), with follow-up visits at Days 35 (where potential immune 
responses are known to be most pronounced), and at 60 and 104 days after the first dose 
(following the patient for 2-3 antibody half-lives after expected peak titer), is deemed relevant 
and sufficient for evaluating any immunogenic response to treatment. Patients that test positive 
for ADA will be monitored until the ADA levels return to baseline, and samples from the ADA 
positive patients will be tested for neutralizing potential in an Nab (neutralizing antibody) assay. 
Dasiglucagon and GlucaGen will be administered at fixed doses independent of body weight 
because this is the intended therapeutic dosing regimen in the emergency treatment of 
hypoglycemia. The selected dose of 1 mg GlucaGen is the recommended dose for treatment of 
severe hypoglycemia. Based on pre-clinical and clinical studies, it has been demonstrated that 
0.6 mg of dasiglucagon results in an initial pharmacodynamic response (i.e. acute glucose 
mobilization) comparable to 1 mg GlucaGen (see also Section 5.1).  
For the safety and well-being of the patients, they will not be brought into hypoglycemia prior to 
dosing. However, very high blood glucose levels at dosing will potentially impact the reporting of 
nausea and other associated AE’s. Therefore, to enable a more precise safety assessment, 
patients are required to be dosed while at a normal blood glucose level, and a pre-treatment 
plasma glucose level of 70-150 mg/dL will be targeted. Plasma glucose levels may be adjusted 
by s.c. administration of a fast-acting insulin analog or by glucose ingestion. Even with this 
precaution, it cannot be excluded that a higher frequency of nausea may be anticipated, if this 
AE is caused by hyperglycaemia. 
The safety profile described to date does not give rise to specific safety concerns. In previous 
studies, dasiglucagon was associated with the AE’s nausea, a known side effect following 
administration of glucagon, headache, and injection site reactions (erythema).  
7.3 
Selection of trial population 
Dasiglucagon is indicated for treatment of severe hypoglycemia in patients with T1DM. Given 
the role of the immune system in the pathogenesis of T1DM, the present trial aims to evaluate 
the immune response of patients with T1DM taking repeated single doses of s.c. dasiglucagon 
compared to GlucaGen.  
There are no data indicating an altered immune response with varying blood glucose levels, 
therefore, for the safety and well-being of the patients, they will not be brought into a 
hypoglycemic state prior to dosing. Patients with previous exogenic glucagon exposure will not 
be excluded from the trial, but the information on previous glucagon administration will be 
recorded to enable subgroup analyses. 
The trial will enroll patients in centers in the EU, in the US, and in Canada.  

 
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7.3.1 Inclusion criteria 
To be included in the trial, patients have to fulfill all of the following criteria: 
(1) 
Informed consent obtained before any trial-related activities (trial-related activities 
are any procedure that would not have been performed during normal management 
of the patient) 
(2) 
Availability for the entire trial period 
(3) 
Age between 18 and 70 years, both inclusive 
(4) 
Male or female patients with T1DM for at least 1 year. Diagnostic criteria as defined 
by the American Diabetes Association 
(5) 
Hemoglobin A1c (HbA1c) <10% 
(6) 
Stable antidiabetic treatment for at least 1 month (e.g. within 10% insulin dose 
adjustment) 
(7) 
A female participant must meet 1 of the following criteria 
a. Participant is of childbearing potential and agrees to use one of the accepted 
contraceptive regimens throughout the entire duration of the trial from screening 
until last follow-up visit. An acceptable method of contraception includes at least 
one of the following: 
i. Abstinence from heterosexual intercourse 
ii. Systemic contraceptives (birth control pills, injectable/implant/ insertable 
hormonal birth control products, transdermal patch); if the participant is 
using systemic contraceptives, she must use an additional form of 
acceptable contraception (iii or iv, below) 
iii. Intrauterine device (with and without hormones) 
iv. condom with spermicide 
or 
b. Participant is of non-childbearing potential, defined as surgically sterile (i.e. has 
undergone complete hysterectomy, bilateral oophorectomy, or tubal ligation), or 
in a menopausal state (at least 1 year without menses). 
(8) 
A male must be surgically sterilized or willing to refrain from sexual intercourse from 
screening and until last follow-up visit or, if sexually active, uses a condom and 
partner practices contraception during the trial from screening and until the last 
follow-up visit. 
7.3.2 Exclusion criteria 
Patients meeting any of the following criteria during screening evaluations will be excluded from 
trial participation: 
(1) 
Previous administration of dasiglucagon (previously referred to as ZP4207). 
(2) 
Known or suspected allergy to trial medication(s) or related products  
(3) 
History of anaphylaxis or symptoms of severe systemic allergy (such as 
angioedema)  
(4) 
Previous participation (randomization) in this trial 
(5) 
Females who are pregnant according to a positive pregnancy test, actively 
attempting to get pregnant, or are lactating 
(6) 
Patients on a closed loop artificial pancreas 
(7) 
Receipt of any investigational drug within 3 months prior to screening 
(8) 
Active malignancy within the last 5 years 
(9) 
Congestive heart failure, New York Heart Association class II-IV 

 
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(10) Inadequately treated blood pressure as defined as systolic blood pressure ≥180 
mmHg or diastolic blood pressure ≥110 mmHg at screening. 
(11) Current bleeding disorder, including use of anticoagulant treatment 
(12) Known presence or history of pheochromocytoma (i.e. adrenal gland tumor) or 
insulinoma (i.e. insulin-secreting pancreas tumor) 
(13) Known or suspected HIV infection 
(14) Use of a systemic beta-blocker drug, indomethacin, warfarin or anticholinergic 
drugs in the previous 28 days before Day 1 of this trial) 
(15) Use of systemic corticosteroids, anti-inflammatory biological agents, kinase 
inhibitors or other immune modulating agents within the last 3 months prior to 
screening 
(16) Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >2.5 X the 
upper limit of normal (ULN), bilirubin >1.5 X ULN, estimated glomerular filtration 
rate (eGFR) <30 mL/min/1.73m2 according to the Modification of Diet in Renal 
Disease (MDRD) Study definition 
(17) Clinically significant abnormal ECG at screening, as evaluated by Investigator 
(18) Donation of blood or plasma in the past month, or in excess of 500 mL within 
12 weeks prior to screening 
(19) Active substance or alcohol abuse 
(20) Patients with mental incapacity or language barriers that preclude adequate 
understanding or cooperation, who are unwilling to participate in the trial, or who in 
the opinion of the Investigator should not participate in the trial 
(21) Surgery or trauma with significant blood loss within the last 2 months prior to 
screening 
(22) Any condition interfering with trial participation or trial endpoints or that could be 
hazardous to the patient 
7.3.3 Premature removal from trial 
Participation in the trial is strictly voluntary. A patient has the right to withdraw from the trial at 
any time and for any reason. If he/she chooses to withdraw, the investigator must be informed 
immediately. The investigator has the right to terminate participation of any patient at any time if 
the investigator deems it in the patient's best interest. The reason and circumstances for 
premature discontinuation will be documented in the electronic Case Report Form (eCRF). 
7.3.3.1 Possible reasons for patient discontinuation 
A patient will be discontinued if the following applies: 
 
If a protocol deviation occurs which, in the clinical judgment of the Investigator, can 
invalidate the assessment of ADA responses to dasiglucagon or glucagon, the patient will 
be withdrawn by the Investigator 
 
AEs that are considered unacceptable by the patient or the Investigator 
If discontinuation occurs following administration of any trial medication, the patient will be 
asked to return and participate in the complete follow-up visit at trial Day 104. 
If trial participation is terminated due to an AE possibly related to the trial medication (including 
reference product) or trial examinations, the patient must be followed up by additional 
examinations according to the medical judgment of the investigator until the abnormal condition 
is resolved or the investigator deems further observations or examinations to be no longer 
medically indicated. 

 
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Patients, who meet one or more of the following dosing day exclusion criteria at a dosing visit, 
will be excluded from the dosing visit, but can be rescheduled to one of the following days 
(maximum 3 days postponement). Each dosing visit can only be rescheduled once. 
 
Strenuous exercise within 4 days prior to dosing, as judged by the Investigator. Strenuous 
exercise is not allowed during the treatment period of the trial 
 
Clinically significant illness that may interfere with trial objectives or impose a risk to 
patients, as judged by the Investigator 
 
Consumption of alcohol within 24 h prior to dosing visit, or positive results from an alcohol 
breath test 
 
Changes in medical history or concomitant medication resulting in fulfillment of clinical 
exclusion criteria, as judged by the Investigator 
A total of 90 patients must complete the trial. To qualify as completed, the patient must be 
dosed according to protocol and have blood drawn for the ADA analyses described in the 
protocol. Discontinued patients will be replaced in order to reach 90 completed patients. 
7.3.3.2 Center discontinuation 
The center can be closed and the trial terminated for the following reasons: 
 The center is unlikely to be able to recruit sufficient patients within the agreed time frame 
 The center does not respond to trial management requests 
 Repeat protocol violations 
7.3.3.3 Trial termination 
The sponsor reserves the right to modify or terminate the trial at any time. Possible reasons for 
termination are: 
 
Safety reasons – the incidence of AEs in this or any other trial using the same trial 
medication indicates a potential health risk for the patients. 
 
New scientific knowledge becomes known that makes the objectives of the trial no longer 
feasible/valid 
 
Unsatisfactory enrolment of patients 
7.3.4 Replacement of patients  
Patients prematurely withdrawn from the trial will be replaced in order to reach 90 completed 
patients. Replacement patients will receive the same treatment allocation (i.e. 3 doses of 
dasiglucagon or GlucaGen) as the patients they are replacing. 

 
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7.4 
Investigational medicinal product(s) 
7.4.1 Identity of investigational medicinal product(s)  
The identity of the investigation products is summarized in Table 7-1. 
Table 7-1: Identity of investigational products 
 
Test product 
Reference product 
Name 
Dasiglucagon 
GlucaGen® 
Active substance 
ZP4207  
Recombinant glucagon 
hydrochloride  
Formulation 
Liquid formulation, 0.6 mL  
Powder and solvent for 
reconstitution as 1 mL solution for 
injection 
Strength 
1 mg/mL 
1 mg 
Container 
Single use pre-filled syringe 
Powder and solvent for 
reconstitution packed together in a 
plastic box. A “hypo-kit”  
Manufacturer 
Zealand Pharma A/S, Glostrup 
(Copenhagen), Denmark 
Novo Nordisk A/S, Bagsværd, 
Denmark 
Storage requirements 
Store between 2 and 8°C 
Store between 2 and 8°C 
Handling, preparation and administration of trial medication will be done by unblinded trial 
personnel. All trial assessments on the trial site will be done by blinded trial personnel. 
However, exposure assessments and ADA assessments will be performed by unblinded 
personnel at the specialty laboratories, to make sure that dasiglucagon or GlucaGen 
administration is matched with the applicable bioanalytical assay.  
The test product will be packed by the sponsor. The information on the labels will be in the local 
language. The label on the product will be compliant with local laws and regulations. 
7.4.2 Treatments administered 
Dasiglucagon is a stable peptide analog of human glucagon in a ready-to-use liquid formulation 
indicated for treatment of severe hypoglycemia in insulin dependent patients with diabetes 
mellitus. Dasiglucagon is in clinical development and has no marketing authorization as yet. 
GlucaGen is approved in the EU and US and is indicated for treatment of severe hypoglycemic 
reactions, which may occur in the management of insulin-treated children and adults with 
diabetes mellitus. 
Patients in this trial have not previously been treated with dasiglucagon (ZP4207) and will be 
randomly assigned (1:1) to receive 1 of the following trial medications: 
 
0.6 mg dasiglucagon 
 
1 mg GlucaGen 
Prior to administration of trial medication at all dosing visits patients must reach a target plasma 
glucose level of 70-150 mg/dL. Plasma glucose levels may be adjusted by s.c. administration of 
a fast-acting insulin analog if blood glucose exceeds150 mg/dL or by glucose ingestion if blood 
glucose is below 70 mg/dL. 
Following the first (Visit 2) and third (Visit 4) dose administration, patients must be fasting for 90 
min after dosing. Following the 90-min blood sample draw after the administration of the first 
(Visit 2) and third (Visit 4) dose administration, patients may be treated individually in order to 

 
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alleviate any potential side effects in order to minimize withdrawals and consequently reduce 
the amount of missing data. This treatment can also be instituted immediately after the second 
dose administration (Visit 3), as pharmacodynamics will not be assessed at this visit.  
The following treatment modalities may be used, as considered appropriate by the investigator:  
 
patients will be allowed to eat and drink moderately to make them feel comfortable 
 
a moderate and individualized corrective dose of insulin to convert the induced 
hyperglycemia to euglycemia, after agreement with the investigator 
 
antiemetic treatment e.g. in the form of an 8-mg slow intravenous (i.v.) dose of 
ondansetron (Zofran®) or alternatively a 10-mg slow i.v. dose of metoclopramide 
(Primperan®)  
Patients must be monitored for at least 5 h after dosing at the clinical site for safety 
observations, including blood glucose monitoring.  
Patients will not be discharged until they are considered stable and with a blood glucose level in 
the range of 70-180 mg/dL. Before discharge, the investigator will provide instructions to the 
patients on management of their blood glucose levels. Each trial medication will be administered 
s.c. 3 times in total, with 7 days between dosing (i.e. dosing occurs at Days 0, 7, and 14; Visits 
2, 3, and 4).  
7.4.3 Selection of doses in the trial 
The selected dose of 1 mg GlucaGen is the recommended dose for treatment of severe 
hypoglycemia. Based on pre-clinical and clinical studies, it has been demonstrated that 0.6 mg 
of dasiglucagon results in an initial pharmacodynamic response (i.e. acute glucose mobilization) 
comparable to 1 mg GlucaGen. 
7.4.4 Treatment compliance 
All trial medications will be prepared and administered by unblinded trial personnel.  
7.4.5 Method of assigning patients to treatments or treatment sequences 
Patients who meet all inclusion and none of the exclusion criteria and have given written 
informed consent will be randomized in a 1:1 ratio to either dasiglucagon or GlucaGen via an 
Interactive Web Response System (IWRS) that will assign a kit number to one of the 2 
aforementioned treatment arms. 
Patients with previous exogenic glucagon exposure will not be excluded from the trial, but the 
information on previous glucagon administration will be recorded, to enable subgroup analyses.  
In the event of an emergency, e.g., when it becomes necessary for the investigator to know 
which treatment the patient is taking, the code for that patient can be broken by the investigator, 
preferably after consultation with the medical monitor. Emergency code breaks can be 
performed using the IWRS. 
7.4.6 Blinding 
This is a double-blind trial. Since dasiglucagon is available as a liquid formulation and GlucaGen 
is available as a powder for reconstitution, and they are therefore not identical in appearance, 
unblinded trial personnel will be responsible for handling, preparing, and administering the trial 
medication. To maintain double-blind conditions, all trial assessments at the trial site will be 
done by blinded trial personnel not involved in the administration of trial medications. However, 
exposure assessments and ADA assessments will be performed by unblinded personnel at the 
specialty laboratories, to make sure that dasiglucagon or GlucaGen administration is matched 
with the applicable bioanalytical assay.  

 
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7.4.7 Drug accountability and disposal 
Handling, preparation and administration of trial medication will be done by unblinded trial 
personnel. Each center will keep accurate records of the trial supplies received, stored, and 
dispensed, using appropriate forms. The trial supplies will be stored under appropriate 
conditions, locked and with restricted access.  
All unused supplies and all empty and partially empty containers of trial medication will be 
stored until the trial closure visit has been performed and then sent to the sponsor.  
7.4.8 Prior and concomitant therapy 
Prior glucagon exposure will be recorded in the eCRF at screening. All concomitant medications 
will be recorded in the eCRF at each visit.  
Patients using any new concomitant medication resulting in fulfillment of a dosing day exclusion 
criterion will be excluded from the dosing visit, but can be rescheduled to one of the following 
days. Each dosing visit can only be rescheduled once. See Section 7.3.3.1 for possible reasons 
for patient discontinuation. 
7.4.9 Treatment after end of trial  
Not applicable in this trial.  
7.5 
Assessments and schedule of measurements (overview) 
The following assessments and measurements will be carried out at the times specified in the 
trial flow chart (Table 2-1).  
Informed consent will be obtained prior to any trial-related procedures; see Section 11.3. 
7.5.1 Screening examination 
At screening (Visit 1), the following assessments will take place: 
 
Informed consent 
 
Check of patient eligibility 
 
Demographics  
 
Body measurement 
 
Medical history 
 
History of alcohol/drug abuse 
 
Concomitant illnesses 
 
Prior medications 
 
Concomitant medications 
 
Physical examination 
 
Vital signs 
 
ECG 
 
AEs  
 
Hematology, biochemistry, coagulation 
 
Pregnancy test (women only) 
 
Urinalysis  
 
Urine drug screen (trial site testing) 
 
Alcohol breath test 
 

 
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7.5.2 Instructions to patients prior to dosing 
On dosing days, patients are allowed to consume a small meal for breakfast with corresponding 
administration of rapid acting insulin to address the meal and in accordance with their normal 
management of blood glucose levels.  
Use of long-acting insulin and rate of basal continuous subcutaneous insulin infusion (CSII) will 
be continued according to normal glycemic management of the individual patients during dosing 
days.  
7.5.3 Procedures and assessments during the treatment period of the trial 
At Visit 2 (Day 0) patient eligibility is rechecked (check of changes between the screening visit 
and Visit 2) and patients eligible to participate will be randomized to treatment with dasiglucagon 
or GlucaGen.  
Additionally, during the treatment period of the trial, at Visits 2 and 4 (Days 0 and 14), the 
following assessments will take place: 
 
Concomitant medication 
 
Check of withdrawal criteria 
 
Check of dosing day exclusion criteria 
 
Vital signs (pre-dose, and at 30 and 90 min post-dosing) 
 
ECG (pre-dose, and at 30 and 90 min post-dosing) 
 
Local tolerability (at 0.5 and 2 h post-dosing) 
 
AEs  
 
Hematology and biochemistry (pre-dose, and at 30 and 90 min post-dosing) 
 
Urinalysis (pre-dose) 
 
Urine drug screen (pre-dose) at trial site 
 
Alcohol breath test (pre-dose) 
 
Dasiglucagon/glucagon plasma concentrations  
(Pre-dose, 5, 10, 30, 60, and 90 min post-dosing. The actual time of blood sampling for 
exposure should not deviate from the nominal time by more than ±1 min. Pre-dose is 
defined as within 5 min prior to dosing.) 
 
Plasma glucose concentration  
(Pre-dose, 5, 10, 30, 60, and 90 min post-dosing. The actual time for blood sampling for 
plasma glucose should not deviate from the nominal time by more than ±1 min. Pre-dose 
is defined as within 5 min prior to dosing.) 
 
Antibodies against dasiglucagon/glucagon (pre-dose) 
 
Administration of trial medication 
Prior to administration of trial medication patients must reach a target plasma glucose 
level of 70-150 mg/dL. Plasma glucose levels may be adjusted by s.c. administration of a 
fast-acting insulin analog or by glucose ingestion. Patients must be fasting for 90 min 
after administration of trial medication, and can be treated individually to alleviate any 
potential side effects. See section 7.4.2. Patients will be observed for at least 5 h post-
dose. 
At Visit 3 of the treatment period (Day 7), only the following assessments will take place 
 
Concomitant medication  
 
Check of withdrawal criteria 
 
Check of dosing day exclusion criteria 
 
Local tolerability (at 0.5 and 2 h post-dosing) 
 
AEs  

 
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 
Urine drug screen (pre-dose) at trial site 
 
Alcohol breath test (pre-dose) 
 
Antibodies against dasiglucagon/glucagon (pre-dose) 
 
Administration of trial medication 
Prior to administration of trial medication patients must reach a target plasma glucose 
level of 70-150 mg/dL. Plasma glucose levels may be adjusted by s.c. administration of a 
fast-acting insulin analog or by glucose ingestion. Patients are NOT required to be fasting 
after administration of trial medication, and can be treated individually to alleviate any 
potential side effects immediately following dosing. See section 7.4.2. Patients will be 
observed for at least 5 h post-dose. 
7.5.4 Follow-up period of the trial 
After the final dose of trial medication (at Visit 4, Day 14, described above), patients will be 
followed up until Day 104 (Visit 7). During the follow-up period, visits take place at Days 35, 60, 
and 104 (Visits 5, 6, and 7).  
At Visits 5 and 6 during the follow-up period, the following assessments will take place: 
 
Concomitant medication  
 
Check of withdrawal criteria 
 
AEs  
 
Antibodies against dasiglucagon/glucagon 
Additionally, the following assessments will take place at Visit 5 only: 
 
Vital signs 
 
ECG  
 
Hematology and biochemistry  
At Visit 7, the final visit of the follow-up period and of the trial (EoT visit), the following 
assessments will take place: 
 
Concomitant medication  
 
Physical examination 
 
Vital signs 
 
ECG 
 
AEs  
 
Hematology and biochemistry 
 
Urinalysis 
 
Antibodies against dasiglucagon/glucagon 
7.5.5 Final examination at the end of the trial  
The final visit of the trial is Visit 7 (Day 104 of the follow-up period; EoT visit). See Section 7.5.4 
for further details.  
7.5.6 Additional (safety) examinations 
If there are any unclear symptoms or observations the responsible physician in charge may 
perform further medical examinations, other than outlined in this protocol, including further 
clinical laboratory tests, in order to clarify the relevance or to diagnose symptoms.  

 
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7.5.7 Safety laboratory tests 
Samples obtained will be prepared and transferred to the appropriate laboratory by 
SynteractHCR according to Standard Operating Procedures. The parameters listed in Section 
7.6.4.1 will be determined using standard methods. 
The total volume of blood sampled per patient for safety analyses is 68 mL. 
7.6 
Immunogenicity, pharmacokinetic, pharmacodynamic, tolerability and safety 
measurements 
Details of sampling for immunogenicity testing, plasma glucose concentrations, plasma trial 
medication concentrations, and safety laboratory testing are provided in a laboratory manual 
(see the Investigator site file).  
7.6.1 Immunogenicity measurements 
Antibodies against dasiglucagon/glucagon will be measured at all visits after screening. During 
the treatment period (Visits 2, 3, and 4) samples will be collected pre-dose.  
The clinical ADA assays have been validated in accordance with existing guidelines and 
recommendations.6,7,8,9,10  
Confirmed positive anti- dasiglucagon antibody samples, (treatment-induced or treatment-
boosted) from anti-dasiglucagon antibody-positive patients will be evaluated for binding titer 
neutralizing potential and titer as well as cross-reactivity towards endogenous glucagon.  
No further serum sampling will be needed as the ADA samples can be used for Nab analysis. 
The in vitro neutralizing effect of antibodies will be measured using an assay9,12 based on 
glucagon receptor transfected human embryonic kidney cells. The calculated sensitivity in 
previous studies was about 51.8 ng/mL. The assay was also validated for recombinant glucagon 
with similar results.11,12 In case of a positive result in the Nab assay, a titer estimation will be 
performed. The cell-based Nab analyses will be performed by a special laboratory, BioAgilytix, 
Durham, NC, USA. 
In vivo neutralizing effect will be evaluated by comparing PK and PD endpoints between ADA 
positive and ADA negative patients, further investigation may be performed by correlating ADA 
titer with PK and PD endpoints. 
Residual and additional antibody serum samples may be stored until approval of market 
authorization by the health authorities. Further characterization of the antibody response may be 
requested by the health authorities. 
7.6.2 Plasma concentrations of dasiglucagon and GlucaGen  
The exposure to trial medication (dasiglucagon or GlucaGen) will be assessed based on plasma 
concentration data (AUC0-30min, AUC0-90 min, Cmax, tmax) from samples collected at Visits 2 and 4 
(after administration of the first and third doses of trial medication).  
Samples will be collected pre-dose, and at 5, 10, 30, 60, and 90 min post-dosing. The actual 
time of blood sampling for exposure should not deviate from the nominal time by more than ±1 
min. Pre-dose is defined as within 5 min prior to dosing. 
7.6.3 Pharmacodynamic measurements 
The plasma glucose profile will be assessed based on plasma concentration data (AUE0-30min, 
AUE0-90 min, CEmax, tmax) from samples collected at dosing Visits 2 and 4 (first and third dosing 
visit).  

 
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Samples will be collected pre-dose, and at 5, 10, 30, 60, and 90 min post-dosing. The actual 
time of blood sampling for evaluation of plasma glucose should not deviate from the nominal 
time by more than ±1 min. Pre-dose is defined as within 5 min prior to dosing.  
7.6.4 Safety and tolerability measurements  
7.6.4.1 Safety laboratory tests 
Routine safety laboratory tests will be performed centrally. Samples for safety laboratory 
parameters will be collected at Visits 1, 2, 4, 5, and 7. Samples for urinalysis will be collected at 
Visits 1, 2, 4, and 7. The following parameters will be determined: 
 
Clinical chemistry: sodium, potassium, calcium, glucose, urea, creatinine, total bilirubin, 
AST (SGOT), ALT (SGPT), gamma-GT, alkaline phosphatase, total protein, C-reactive 
protein, HbA1c, C-peptide  
 
Hematology: hemoglobin, red blood cell count (erythrocytes), hematocrit, platelet count 
(thrombocytes), total white blood cell count (leucocytes) 
 
Coagulation: international normalized ratio (INR), fibrinogen (at screening visit only)  
 
Urinalysis: pH, blood (leukocytes and erythrocytes), protein, glucose, ketones, nitrite 
A pregnancy test will be performed at screening (Visit 1) for women only. 
Alcohol breath tests and urine drug screen will be performed at Screening (Visit 1) and at Visits 
2, 3, and 4. 
For further details, please refer to the laboratory manual.  
7.6.4.2 Safety examinations 
Physical examination is performed at Screening (Visit 1) and EoT (Visit 7).  
AEs are assessed at all visits. Local tolerability is assessed at all dosing visits (Visits 2, 3 and 4. 
ECG and vital signs are assessed at Screening (Visit 1) Visits 2, 4, 5, and 7.  
 
Physical examination includes examination of the following body systems: head, ears, 
eyes, nose, throat (HEENT), including the thyroid gland; heart, lung, chest; abdomen; 
skin; musculoskeletal system; nervous system; lymph node 
 
Vital signs include: pulse rate and blood pressure in a sitting position after 5 min, body 
temperature 
 
Local tolerability: skin reactions will be assessed at the injection site at 0.5 and 2 h post-
dosing. Skin reactions will be reported as AEs (see Section 8). 
 
12-lead ECG. Details from ECG assessments will be recorded, including PR, QRS and 
QT intervals.   
8. Adverse events 
8.1 
Definitions 
Adverse Event (AE) 
An AE is any untoward medical occurrence in a trial patient administered an investigational 
medicinal product (IMP) and which does not necessarily have a causal relationship with the 
treatment. An AE can therefore be any unfavorable and unintended sign (for example, an 
abnormal laboratory finding), symptom, or disease temporally associated with the use of an 
IMP, whether or not considered related to the IMP.  
Note: This includes events from the first trial related activity after the patient has signed the 
informed consent.  

 
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AEs include: 
 
A clinically significant worsening of a concomitant illness. 
 
A clinical laboratory abnormality which is clinically significant, i.e. any abnormality that 
suggests a disease and/or organ toxicity and is of a severity that requires active 
management. Active management includes active treatment or further investigations, for 
example change of medicine dose or more frequent follow-up due to the abnormality. 
 
Hypoglycemic episodes (see Section 8.4) 
 
Injection site reactions 
The following should not be recorded as AEs, if recorded at screening (on Screening Form or 
CRF): 
 
Pre-planned procedure, unless the condition for which the procedure was planned has 
worsened from the first trial related activity after the patient has signed the informed 
consent. 
 
Pre-existing conditions found as a result of screening procedures (pre-existing conditions 
should be reported as medical history or concomitant illness). 
Serious adverse event (SAE) 
A SAE is any untoward medical occurrence that at any dose:  
 
results in death  
 
is life-threatening  
 
requires inpatient hospitalization or prolongation of existing hospitalization 
 
results in persistent or significant disability or incapacity 
 
is a congenital anomaly or birth defect 
 
is medically important 
Medical judgement must be exercised in deciding whether an AE is believed to be 
‘medically important’. Medically important event may not be immediately life-threatening 
or result in death or hospitalization but may jeopardize the patient or may require 
intervention to prevent one of the other outcomes listed in the definition above. 
Suspected unexpected serious adverse reactions (SUSAR) 
An AE, fulfilling one of the criteria of seriousness and being assessed as related to IMP 
application, the nature or severity of which is not consistent with the applicable reference 
document (e.g. ZP4207 IB3 or package leaflet/SmPC for an approved product such as 
GlucaGen13). 
Intensity of an adverse event 
The maximum intensity (severity) of all AEs must be assessed by the Investigator and 
documented. Severity should be graded when the AE outcome is known: 
Mild:  
A type of adverse event that is usually transient and may require only minimal 
treatment or therapeutic intervention. The event does not generally interfere with 
usual activities of daily living. 
Moderate:  A type of adverse event that is usually alleviated with additional specific therapeutic 
intervention. The event interferes with usual activities of daily living, causing 
discomfort but poses no significant or permanent risk of harm to the research 
participant. 
Severe:  
A type of adverse event that interrupts usual activities of daily living, or significantly 
affects clinical status, or may require intensive therapeutic intervention. 

 
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A ‘severe’ reaction does not necessarily deem the AE as ‘serious’ and a SAE may not be 
‘severe’ in nature. 
Causality relationship to trial medication 
The causality of each AE should be assessed by the Investigator according to the following 
classification: 
Probable: Good reason and sufficient documentation to assume a causal relationship. 
Possible: A causal relationship is conceivable and cannot be dismissed. 
Unlikely: The event is most likely related to etiology other than the trial product. 
Not related:  
No relationship to trial product 
Outcome of an adverse event 
The outcome of all AEs must be assessed by the Investigator and documented by his/her staff. 
The following definitions should be used: 
Recovered/resolved:  
The patient has fully recovered, or by medical or surgical 
treatment the condition has returned to the level observed 
at the first trial-related activity after the patient signed the 
informed consent.  
Recovering/resolving: 
The condition is improving and the patient is expected to 
recover from the event. This term is only applicable if the 
patient has completed the trial. 
Recovered/resolved with sequelae:  The patient has recovered from the condition, but with 
lasting effect due to a disease, injury, treatment or 
procedure. If a sequela meets an SAE criterion, the AE 
must be reported as an SAE. 
Not recovered/ not resolved:  
The condition of the patient has not improved and the 
symptoms are unchanged. 
Fatal:  
This term is only applicable if the patient died from a 
condition related to the reported AE. Outcomes of other 
reported AEs in a patient before he/she died should be 
assessed as "recovered/resolved", "recovering/resolving", 
"recovered/ resolved with sequelae" or "not recovered/not 
resolved". An AE with fatal outcome must be reported as 
an SAE. 
Unknown:  
This term is only applicable if the patient is lost to follow-
up. 
8.2 
Collection, recording and reporting of adverse events 
All events meeting the definition of an AE must be collected and reported from the first trial 
related activity after the patient has signed the informed consent until the end of the post-
treatment follow-up period. At each contact with the site (visit or telephone, excluding safety 
visits, where the patient is not seeing the Investigator or his staff (e.g. visits to the laboratory)) 
the patient must be asked about AEs. All AEs, either observed by the Investigator or reported by 
the patient, must be recorded by the Investigator and evaluated. 
The Investigator should record the diagnosis, if possible. If no diagnosis can be made the 
Investigator should record each sign and symptom as individual AEs. 
All AEs must be recorded by the Investigator. One single Adverse Event Form must be used per 
AE from start to resolution. For SAEs, the Serious Adverse Event Form must also be completed.  

 
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AE information should include the following: 
 
Date and time of onset and resolution 
 
Date and time of Investigator’s first information on the (S)AE 
 
Seriousness 
 
Severity 
 
Causal relationship with IMP 
 
Interruption or withdrawal of treatment with IMP and other measures taken 
 
Outcome 
All AEs are coded; details are described in the trial specific Data Management Plan.  
The Investigator must report initial information in writing (fax or email) on all SAEs to the 
responsible medical monitor of the Sponsor (Zealand) and to the Sponsor’s responsible 
pharmacovigilance unit (PharmaLex) immediately (within 24 hours) after obtaining knowledge 
about the event. 
Name:  
 
Company:  PharmaLex (formerly Lindeq) 
Address:  
Agern Allé 24, DK-2970 Hørsholm, Denmark 
Tel:  
 (8 a.m. to 4 p.m.) 
 (outside 8 a.m. to 4 p.m.)   
Fax:  
 
E-mail: 
drugsafety@lindeq.com  
In addition, and meeting the same timeline, Investigators have to report all SAEs to Zealand by 
forwarding the SAE form electronically (e.g. in PDF format) within 24 hours to the 
representatives of Zealand. 
Names:  
 and 
 
Address: 
Smedeland 36, DK-2600 Glostrup, Denmark 
Tel: 
 / 
 
E-mails: 
/ 
 
It is the responsibility of PharmaLex to report all SUSARs that occur in this trial to the 
Competent Authorities and IRBs/IECs in accordance with the local requirements in force and 
ICH guideline for GCP. The trial monitor must be informed accordingly. 
8.3 
Follow-up of adverse events 
All AEs that are ongoing at the end of the patient’s participation in the study will be followed-up 
until the event is resolved or reaches a satisfactory outcome as deemed by the Investigator.  
Follow-up actions for all SAEs will be performed according to appropriate clinical care practices 
and may depend on the nature of the event. These will be determined after internal review 
and/or sponsor review. 
The follow up information should only include new (updated and/or additional) information that 
reflects the situation at the time of the Investigator’s signature. 
Follow-up information on (S)AEs will be updated using the (S)AE Form. If a non-serious event 
becomes serious during the follow-up the AE Form and SAE Form have to be used and 
reporting timelines follow those of a SAE. 

 
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The Investigator must forward follow-up information on SAEs and if previously non-serious AEs 
become SAEs to the Sponsor immediately (within 24 hours) after obtaining knowledge about the 
new information. 
8.4 
Hypoglycemia 
Hypoglycemia will be regarded as an AE and recorded and documented on an AE Form. 
Hypoglycemia is defined as a fall of plasma glucose below 3.9 mmol/L (70 mg/dL). 
During the dosing visits, mild to moderate symptoms of hypoglycemia, or a blood glucose (BG) 
value less than a threshold of <2.8 mmol/L (50 mg/dL), corresponding to a plasma glucose (PG) 
value of <3.1 mmol/L (56 mg/dL), will be treated by i.v. glucose solution at the investigator’s 
discretion according to best available medical practice. Treatment is to be repeated until BG 
value stabilized above the threshold limit again. BG measurements will only be done due to 
safety concerns. Insulin-induced hypoglycemia should be recorded as an AE. 
8.5 
Pregnancy 
Female patients must be instructed to notify the Investigator immediately if they become 
pregnant or if they suspect to be pregnant during the trial. The Sponsor has a responsibility to 
monitor the outcome of all pregnancies reported during the clinical trial. 
Male patients must be instructed to notify the Investigator immediately if their partner becomes 
pregnant or suspects to be pregnant. The Sponsor has a responsibility to monitor the outcome 
of all pregnancies reported during the clinical trial. During an information meeting at the trial site, 
the patient’s partner will be fully informed by a physician of her participation in capturing the 
outcome data, and will be asked to provide her written consent. 
The Investigator must report all information on pregnancies on the initial pregnancy form. The 
completed initial pregnancy form must be forwarded to the Sponsor according to the procedure 
stated in Section 8.2. Any (S)AEs in the mother, as well as other pregnancy complications 
(ectopic pregnancy) fulfilling the criteria of an (S)AE, must be reported on the (S)AE form.  
The following must be collected in the initial pregnancy form:  
 
Medical history of the mother 
 
Family history 
 
Course of the pregnancy, including expected delivery date 
The Investigator must follow the pregnancy until the pregnancy outcome and the newborn 
infant(s) until the age of 1 month. The Investigator must collect information on the pregnancy 
and pregnancy complications as well as the pregnancy outcome including the health of the 
newborn infant(s) on the pregnancy outcome form. The completed pregnancy outcome form 
must be forwarded to the Sponsor according to the procedure stated in Section 8.2. Any (S)AEs 
in the newborn must be reported on the (S)AE form. 
The SAEs that must be reported including abnormal outcome - such as congenital anomalies, 
fetal death and termination of pregnancy (spontaneous or elective abortion), including any 
anomalies of the fetus observed at gross examination or during autopsy.  
The following must be collected in the pregnancy outcome form:  
 
Course of the pregnancy 
 
Outcome of the pregnancy 
 
Condition of the newborn 
 
Any AEs in the newborn infant must be followed till the age of 1 month 

 
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8.6 
Precautions 
Normal precautions taken for a human trial, including the provision of emergency equipment, 
will be taken during this trial. Qualified and well trained physicians and medical staff will instruct 
the patients. During a patient’s participation in the trial, the Investigator should ensure that 
adequate medical care is provided to the patients for any AEs, including clinically significant 
laboratory values related to the trial. The Investigator should inform the patient when medical 
care is needed for intercurrent illnesses of which the Investigator becomes aware.  
For further information on safety precautions for ZP4207 and GlucaGen, please refer to the 
current version of the Investigator’s Brochure3 and the SmPC for GlucaGen13, respectively. 
8.7 
Safety Committee 
The internal Zealand Pharma Safety Committee (SC) is constituted to perform ongoing safety 
surveillance of clinical trials with dasiglucagon, including this trial. 
If safety signals are observed, either based on reported SAEs, periodic review of laboratory 
parameters, review of all AEs reported between the SC meetings, or on notification of significant 
findings, the SC will take appropriate measures to safeguard the patients.  
The SC convenes every quarter to review relevant safety information, including AEs and 
laboratory data.  

 
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9. Data management and quality control 
9.1 
Case report forms 
All the information collected during the trial will be recorded in the eCRFs, which are identified 
by patient number. Suitable eCRFs will be designed by SynteractHCR. The investigator will 
ensure that the eCRFs are correctly completed. All key pages will be signed or initialed by the 
investigator, signifying agreement with and responsibility for the recorded data. Key pages are 
the following: end-of-visit form, AE-reporting form, medication form, concomitant medication 
form and trial-closure form.  
A trial specific list should be generated prior to the performance of the trial, which specifies 
which data fields in the Case Report Form will be used by the medical personnel for direct entry 
during the performance of the trial. This means that these data fields in the CRF are source 
documents. For the other CRF data fields, the source data will be found in other documents 
(such as patients’ files, worksheets, etc.), that is, for these CRF data fields the “other” 
documents are the source documents. Should such a list be created, it should be submitted to 
the authorities together with the protocol.  
9.2 
Quality control 
The investigator will permit trial-related monitoring, IEC review, and regulatory inspections, 
providing direct access to source data /documents. Sponsor-authorized quality assurance 
personnel may carry out audits for which the investigator must provide support. 
The trial will be supervised by a monitor from SynteractHCR. The trial monitor will contact the 
investigator regularly to discuss the progress of the trial and to check the trial documents 
including the informed consent forms for completeness and consistency.  
The trial monitor or a representative of the sponsor will cross-check the data entered in the 
eCRFs with the source data at the trial site and observe the trial procedures in order to verify 
adherence to the trial protocol. 
The eCRFs will be checked for completeness and correctness by the monitor and data 
management department of SynteractHCR according to the SynteractHCR SOPs and any queries 
will be resolved by the investigator. 
All of the clinical data will be captured via electronic data capture (EDC) using a web-based tool. 
The software Marvin from the company XClinical (www.xclinical.com/) is the preferred EDC 
software. Marvin is compliant with all legislation relevant to electronic data capture (FDA 21 
CFR Part 11, GCP). 
The investigator site staff will enter and edit the data via a secure network, with secure access 
features (username and password). A complete electronic audit trail will be maintained. The 
investigator will approve the data using an electronic signature (Ref: 21 CFR Part 11), and this 
approval is used to confirm the accuracy of the data recorded. 
eCRFs will be used for all patients. The investigator’s data will be accessible from the 
investigator’s site throughout the trial. The electronic CRFs must be kept current to reflect 
patient status at each phase during the course of the trial. The electronic CRF will not capture 
personalized data. The investigator must make a separate confidential record of personalized 
details (name and initials) on the patient identification and enrollment log. All changes to data 
are done by the investigator through the EDC system.  
It is the responsibility of the Principal Investigator of the respective site to ensure that all patient 
discontinuations or changes in trial or other medications entered on the patient’s eCRF are also 
made on the patient’s medical records. 
The eCRFs for any patient leaving the trial should be completed at the time of the final visit or 
shortly thereafter. 

 
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9.3 
Data management 
Data management will be performed according to SynteractHCR SOPs. 
 

 
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10. Statistical methods and determination of sample size 
10.1 Statistical and analysis plan 
A separate Statistical Analysis Plan (SAP) will be finalized that details the planned statistical 
analysis and may include necessary adaptations to the planned statistical analysis before 
unblinding of the data.  
Any deviations from the planned analyses will be described and justified in the final integrated 
trial report. 
10.1.1 General considerations 
All data obtained in this trial and documented in the eCRFs will be listed and summarized with 
statistics or frequency tables as appropriate. In case of termination of the trial, all data collected 
up to that time point will be included into the analysis. 
Raw data listings and summary tables will be generated using the software SAS© Version 9 or 
higher.  
Continuous variables will be summarized with means, standard deviations, medians, minimums, 
and maximums and valid cases.  
Other summaries (e.g. quartiles, 95% confidence intervals) may be used as appropriate. 
Categorical efficacy and safety variables will be summarized by counts and by percentage of 
patients in corresponding categories.  
10.1.2 Classification of patients to subsets 
For the statistical analysis the randomized patients will be divided up into the following datasets: 
The following definitions are applicable: 
Safety analysis set 
(SAS) 
all patients who were randomized and received at least one dose of 
trial medication 
Full analysis set 
(FAS) 
all patients of the SAS with at least one measurement of the ADA 
titer 
Per Protocol set 
(PPS) 
all patients of the FAS for whom no relevant protocol deviations 
were documented 
The analysis of the primary endpoint will be based on the FAS. A secondary analysis of the 
primary endpoint will be based on the PPS. Safety analysis will be based on the SAS. 
The decision whether a protocol deviation is relevant or not for the exclusion of patients from the 
PPS set will be made case-by-case in a data review meeting. 
10.1.3 Immunogenicity data 
All immunogenicity parameters will be analyzed descriptively per treatment group. No statistical 
tests are planned. Baseline ADA-positive patients will be calculated as a percentage of the total 
number of patients whose baseline samples were tested for ADA. Titer will be reported as 
median and interquartile range. 
95% confidence intervals for incidence rates and for rate differences will be given. 
Secondary immunogenicity parameters will be described with appropriate descriptive statistics 
for dichotomous, categorical or continuous variables. 

 
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10.1.4 Exposure and PD endpoints 
Plasma dasiglucagon and glucagon concentrations 0-90 min from dosing: AUC0-30min, AUC0-90 
min, Cmax, and tmax will be summarized with descriptive statistics. 
Plasma glucose profiles 0-90 min from dosing: AUE0-30min, AUE0-90 min, CEmax, and tmax will be 
summarized with descriptive statistics. 
10.1.5 Safety data 
Clinical laboratory data 
Clinical laboratory test results will be marked whether the result is below, within or above the 
respective reference range. The number of values outside of the reference range will be 
counted. 
Adverse events 
Adverse events will be tabulated by system organ class (SOC) and preferred term (PT) after 
medical coding using the Medical Dictionary for Regulatory Activities (MedDRA). AE summary 
tables will include counts and percentages of patients who experienced adverse events 
summarized by system organ class (SOC) and preferred term (PT). 
Other safety data 
Vital signs, physical examination, ECG and local tolerability data will be summarized with 
descriptive statistics. 
10.1.6 Further data 
Baseline and demographic data will be summarized using descriptive statistics. Baseline ADA-
positive patients will be calculated as a percentage of the total number of patients whose 
baseline samples were tested for ADA. 
All other data obtained in this trial and documented in the eCRF will be listed. 
10.1.7 Withdrawals, drop-outs and missing data 
In the case of drop-outs, no imputation of values for immunogenicity measurements will be 
done. Analysis is done on valid cases only i.e. no imputation technique like LOCF (last 
observation carried forward) will be applied. 
10.1.8 Baseline and center comparisons 
Demographic and other baseline characteristics will be compared. 
10.1.9 Subgroup analysis 
No subgroup analysis is currently planned. 
10.1.10 Interim analysis 
No interim analysis is currently planned. 
10.2 Determination of sample size 
The purpose of the present trial is to generate data describing the immunogenic potential of 
dasiglucagon, when used as a rescue therapy from severe hypoglycemia and with reference to 
the immunogenic potential of GlucaGen. The sample size is based on generating data to show 
that the 90% confidence of the ADA incidence is no worse than 15% as the predefined 
acceptability criterion and with a reference to similar data being generated for GlucaGen.  

 
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Currently, no ADA incidences have been detected in the completed clinical trials, where up to 5 
repeated doses of dasiglucagon have been administered to the same patients within a week. 
Across the two phase 1 clinical trials and a completed phase 2 PK/PD trial, a total of 141 
subjects have been exposed to dasiglucagon and no incidences of ADA development have 
been observed. The obtained data indicate that dasiglucagon has a low risk for induction of 
ADAs in the investigated settings and as a consequence the sample size is based on showing 
that the ADA incidence is no worse than the predefined margin of 15%. 

 
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11. Ethics and regulations 
11.1 Independent ethics committees and competent authorities 
The clinical trial authorization (CTA) granted by the competent authority (CA) and a favorable 
opinion from the relevant independent ethics committee(s) (IEC(s)) /Institutional Review Board 
(IRB) will be obtained prior to the start of the trial. The local authorities will be notified about the 
trial as required by law. 
The CA and the EC/IRB will be notified about the end of the trial and a report summarizing the 
trial results will be sent to the CA and the EC within one year after the end of the trial. If the trial 
is terminated early, the CA and the EC will be notified within 15 days. 
The IECs and/or IRBs met the requirements of the International Conference on Harmonisation 
(ICH) Harmonised Tripartite Guideline for Good Clinical Practice (GCP) and local legislation. 
They also met the requirements of 21 CFR 312.3. 
11.2 Ethical conduct of the trial  
The trial will be conducted in accordance with the ethical principles set forth in the Declaration of 
Helsinki (including amendments).  
11.3 Patient information and consent 
Written informed consent will be obtained from all patients prior to entry into the trial. The 
investigator will explain to each patient orally and in writing (patient information sheet) the 
nature, significance, risks and implications of the trial before inclusion. In particular, the patients 
will be informed about the following: 
 
the possibility of withdrawing from the clinical trial at any time by revoking the consent and 
without any resulting disadvantage 
 
how personal and health-related data will be collected and used during the trial 
 
the patient must be informed that his/ her medical records may be examined by authorized 
monitors or Clinical Quality Assurance auditors appointed by the Sponsor, by appropriate 
IEC members, and by inspectors from regulatory authorities. 
All patients will receive a copy of the patient information sheet and a copy of their signed and 
dated informed consent form.  
All patients will be insured against injury caused by their participation in the trial according to 
legal requirements. They will be informed about the insurance and the resulting obligations on 
their part. 
11.4 Legal and regulatory requirements 
This trial will be carried out in accordance with: 
 
ICH guidelines for GCP, United States investigational new drug (IND) regulations (21 CFR 
312), the regulations on electronic records and electronic signature (21 CFR 11), the most 
recent guidelines of the Declaration of Helsinki, and the relevant laws and regulations of the 
country in which the trial takes place. 
 
Standard operating procedures (SOPs for clinical investigation and documentation in force 
at SynteractHCR) 

 
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12. Trial administration 
12.1 Responsibilities 
Zealand A/S is the sponsor of this trial. SynteractHCR, a contract research organization (CRO), 
will organize the performance of this trial.  
A list with the names and addresses of the responsible institutions and persons is provided in 
Appendix 1 of this protocol. 
12.2 Protocol deviations 
The investigator agrees to conduct the trial in compliance with the protocol. Prospective protocol 
deviations or waivers will not be granted for this trial. 
Any deviation from the clinical trial protocol in the conduct of the clinical trial will be notified to 
the Monitor on an ongoing basis.  
12.3 Protocol changes  
Amendments to this trial protocol may be made following the procedures specified by local laws 
and regulations. Substantial amendments to this trial protocol may be implemented only if the 
approval of the CA(s) and a favorable opinion of the ethics committee(s) have been obtained. 
Substantial amendments to the conduct of the clinical trial may arise from changes to the 
protocol or from new information relating to the scientific documents in support of the trial. 
Amendments to the trial are regarded as “substantial” where they are likely to have a significant 
impact on: 
 
the safety, physical health and mental integrity of the patients; 
 
the scientific value of the trial; 
 
the conduct or management of the trial; or 
 
the quality or safety of any investigational medicinal product used in the trial. 
If a new event occurs related to the conduct of the trial or the development of the investigational 
product, which may affect the safety of the patients, the sponsor and the investigator will take 
appropriate safety measures to protect the patients against any immediate hazard. The sponsor 
will immediately inform the CA(s) and ethics committee(s) of the new events and the measures 
taken. 
12.4 Publication of results 
The original eCRFs and the data generated from the eCRFs or otherwise obtained during the 
trial under this trial protocol will become the property of the sponsor. Publication of the results of 
this trial by SynteractHCR or the investigator is possible only after written consent has been 
obtained from the sponsor. Any material intended for publication will be given to the sponsor at 
least 4 weeks before submission for publication. The sponsor will have the right to comment on 
the intended publication and to take any reasonable measures for patent protection. 
12.5 Clinical trial report 
After completion of the trial, the results will be tabulated, evaluated and issued as a complete 
final clinical trial report according to the ICH-E3 Note for guidance on structure and content of 
clinical trial reports.  
The sponsor will send a summary of this clinical trial report to the EC and CA within one year 
after the end of the trial.  

 
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12.6 Retention of trial records 
Records and documents pertaining to the conduct of the trial and the distribution of the 
investigational product (e.g. ICFs, laboratory slips, medication inventory records, and other 
pertinent information) must be retained by the Investigator according to local requirements. 
To meet regulatory requirements, the eCRF data will be electronically stored at sites. The 
CDISC ODM (see http://www.cdisc.org/ for details) will be used to store and archive all 
electronic data at the sites. Since CDISC ODM is also the source for the EDC-web-based 
system, no transcription of data is necessary. CDISC ODM is a platform-independent 
standardized data format including the complete trial metadata and audit trail. The data can be 
reviewed at a later stage using off-the-shelf tools. CDISC provides a complete CDISC ODM 
Viewer for these purposes. If needed, PDF-files can be created from the ODM file. 

 
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13. References  
1. 
Seaquist ER, Anderson J., Childs B, Cryer P, Dagogo-Jack S, Fish L, et al. Hypoglycemia 
and diabetes: a report of a workgroup of the American Diabetes Association and the 
Endocrine Society. Diabetes Care 2013; 36(5):1384-95. doi:10.2337/dc12-2480. 
2. 
American Diabetes Association Position Statement Standards of medical care in diabetes - 
2016. Diabetes Care 2016; 39(Suppl. 1):S1-S112. 
3. 
Dasiglucagon Investigator Brochure, Edition 3, 12 Dec 2016. Zealand Pharma A/S.  
4. 
Kedia N. Treatment of severe diabetic hypoglycemia with glucagon: an underutilized 
therapeutic approach. Diabetes Metab Syndr Obes 2011;4:337-46. 
5. 
UK Hypoglycaemia Study Group. Risk of hypoglycaemia in types 1 and 2 diabetes: effects 
of treatment modalities and their duration, Diabetologia 2007;50:1140–7. 
6. 
FDA. 
Guidance 
for 
Industry. 
Bioanalytical 
Method 
Validation. 
May 
2001. 
http://www.fda.gov/downloads/Drugs/Guidance/ucm070107.pdf. 
7. 
Viswanathan CT, Bansal S, Booth B, DeStefano AJ, Rose MJ, Saistad J, et al. 
Workshop/conference 
report—Quantitative 
bioanalytical 
methods 
validation 
and 
implementation: Best practices for chromatographic and ligand binding assays. AAPS J 
9(1): E30-42. doi:10.1208/aapsj0901004.  
8. 
Shankar G, Devanaryan V, Amaravadi L, Barrett YCBowsher R, Finco-Kent D, et al. 
Recommendations for the validation of immunoassays used for detection of host antibodies 
against biotechnology products. J Pharm Biomed Anal 2008; 48(5):1267-81. 
9. 
Commissioning and validation of a method for the validation of anti-ZP4207 antibodies in 
human serum. Zealand Pharma Report, Study 14-173 
10. 
Commissioning and validation of a method for the validation of anti-glucagon antibodies in 
human serum. Zealand Pharma Report, Study 14-174 
11. 
Bioagilytix Labs. Validation of an Assay to detect neutralizing Antibodies to ZP4207 by 
Measuring Cyclic Adenosine Monophosphate (cAMP) in Glucagon Receptor Transected 
Cell Line, study no. BAL-14-206-004-REP. Zealand Pharma, Study 15-039. 09 Aug 2016. 
12. 
Bioagilytix Labs. Validation of an Assay to Detect Neutralizing Antibodies to Glucagon by 
Measuring Cyclic Adenosine Monophosphate (cAMP) in a Glucagon Receptor Transfected 
Cell Line, BAL-14-206-005. Zealand Pharma, Study 15-040. 04 Jul 2016. 
13. 
SPC Novo Nordisk GlucaGen® HypoKit 1 mg powder and solvent for solution for injection. 
http://www.medicines.org.uk/emc/medicine/4258/SPC/GlucaGen+Hypokit+1+mg 
 

 
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APPENDIX 1: 
List of names and addresses 
 

 
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List of names and addresses 
 
 
Sponsor 
Zealand Pharma A/S 
Smedeland 36 
2600 Glostrup, Copenhagen 
Denmark 
 
Contract Research 
Organization (CRO) 
SynteractHCR Deutschland GmbH 
Albrechtstr. 14 
80636 Munich, Germany 
 
Coordinating investigator 
Linda Morrow, MD  
Prosciento  
855 Third Avenue 
91911 Chula Vista, CA, USA 
 
Trial monitor 
To be decided  
SynteractHCR Deutschland GmbH 
Albrechtstr. 14 
80636 Munich, Germany 
 
Statistician 
 
Senior Director Biometrics EMEA 
SynteractHCR Deutschland GmbH 
Albrechtstr. 14 
80636 Munich, Germany 
 
 
Sponsor representative 
 
Clinical Trial Manager  
Zealand Pharma A/S 
Smedeland 36, 2600 Glostrup, Denmark 
Tel: 
 
E-mail: 
 
Sponsor’s medical expert 
 
Medical Director  
Zealand Pharma A/S 
Smedeland 36, 2600 Glostrup, Denmark 
Tel: 
 
E-mail: 
  
 
Sponsor representative for 
pharmacovigilance 
 
PharmaLex A/S Agern Allé 24, 2970 Hørsholm, Denmark 
Tel: 
 (8 a.m. to 4 p.m.) 
 
 (outside 8 a.m. to 4 p.m.)   
Fax:  
 
E-mail: drugsafety@lindeq.com 
 
 
Clinical laboratory 
To be determined 
 
Analytical laboratory 
(ZP4207 PK, ZP4207 ADA, 
Glucagon ADA) 
 
York Bioanalytical Solutions (YBS) 
 (ZP4207 Bioanalysis)  
 (ADA analyses) 
Cedar House  

 
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(ZP4207 and Glucagon Nab) 
Northminster Business Park  
Northfield Lane  
York, YO26 6QR 
United Kingdom 
E-mail: 
 
E-mail: 
 
 
 
 
BioAgilytix Labs 
2300 Englert Drive 
Durham, NC 27713 
USA 
 
 
 

 
 
ZP4207-16136 
Amendment 01, final version 1.0, 08-May-2017 
 
 
 
CLINICAL TRIAL PROTOCOL AMENDMENT 
 
A phase 3, Randomized, Double-Blind, Parallel Group Safety Trial to Evaluate the 
Immunogenicity of Dasiglucagon and GlucaGen® Administered Subcutaneously in 
Patients with Type 1 Diabetes Mellitus (T1DM) 
Sponsor code: ZP4207-16136 
SynteractHCR: ZEA-DNK-01711 
EudraCT number: 2017-000062-30 
 
Sponsor: 
Zealand Pharma A/S, 
Smedeland 36, 
2600 Glostrup, 
DENMARK 
Clinical Research Organization: 
SynteractHCR Deutchland GmbH,  
Albrechtstr. 14, 
80636 Munich 
GERMANY 
Study Drug Name: 
Dasiglucagon  
Development Phase: 
3  
Amendment Number: 
01 
Amendment Date: 
May 8th 2017 
Type of Amendment: 
Substantial  
Amendment to protocol: 
Final version 1, dated January 18th 2017 
 
The study will be conducted according to the protocol and in compliance with Good 
Clinical Practice (GCP), with the Declaration of Helsinki [1] and with other applicable 
regulatory requirements. 

 
 
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Amendment 01, final version 1.0, 08-May-2017 
 
 
CONFIDENTIAL 
 
 
 
                          Page 3 of 26 
Declaration of the Investigator 
 
Title: A phase 3, Randomized, Double-Blind, Parallel Group Safety Trial to Evaluate the 
Immunogenicity of Dasiglucagon and GlucaGen® Administered Subcutaneously in 
Patients with Type 1 Diabetes Mellitus (T1DM) 
 
 
All documentation for this trial that is supplied to me and that has not been previously published 
will be kept in the strictest confidence. This documentation includes the protocol, and this trial 
protocol amendment number 1, Investigator's Brochure, Case Report Forms (CRFs), and other 
scientific data. 
The trial will not be commenced without the prior written approval of a properly constituted 
Institutional Review Board (IRB) or Independent Ethics Committee (IEC). No changes will be 
made to the trial protocol without the prior written approval of the Sponsor and the IRB or IEC, 
except where necessary to eliminate an immediate hazard to the patients. 
I have read and understood and agree to abide by all the conditions and instructions contained 
in this protocol amendment. 
 
Responsible Investigator of the local trial centre 
 
 
_____________________________________ 
_____________________ 
Signature  
 
 
 
 
 
Date 
 
_____________________________________ 
Name (block letters) 
 
_____________________________________ 
Title (block letters) 
 
_____________________________________ 
Institution (block letters) 
 
_____________________________________ 
Phone number 

 
 
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Amendment 01, final version 1.0, 08-May-2017 
 
 
CONFIDENTIAL 
 
 
 
                          Page 4 of 26 
Table of Contents 
1 
Amendment type ................................................................................................... 6 
2 
Rationale for amendment ...................................................................................... 6 
3 
Summary of Amendment....................................................................................... 6 
4 
Changes and rationale: ......................................................................................... 7 
4.1 Clarification on the statistical method and anti-drug antibody (ADA) 
assays ........................................................................................................ 7 
4.2 Update of exclusion criterion on blood pressure .............................................. 7 
4.3 Update of exclusion criterion on alcohol/drug abuse ....................................... 7 
4.4 Specification of prohibited concomitant medication ......................................... 7 
4.5 Additional ECG assessment added ................................................................. 7 
4.6 Monitoring of patients’ electrolyte levels .......................................................... 8 
4.7 Clinical event of interest added ........................................................................ 8 
4.8 Treatment of patients experiencing hypo- or hyperglycemia prior 
dosing ......................................................................................................... 8 
4.9 Monitoring of potential pregnancies ................................................................. 8 
4.10 
Additional visits required for patients discontinuing treatment 
prematurely ................................................................................................ 8 
4.11 
Specification on time windows and order of assessments .......................... 9 
4.12 
Specification of the requirements at the dosing visits ................................. 9 
4.13 
Responsibility of unblinded trial personnel ................................................. 9 
4.14 
Randomization of replacement patients ..................................................... 9 
4.15 
Clarification to the reporting of (Serious) Adverse Events .......................... 9 
4.16 
Clarification on case report forms ............................................................... 9 
4.17 
Subgroup analyses added to statistical section .......................................... 9 
4.18 
Administrative changes ............................................................................ 10 
5 
Amended text ...................................................................................................... 10 
5.1 Clarification on the statistical method and anti-drug antibody (ADA) 
assays ...................................................................................................... 10 
5.2 Update of exclusion criterion on blood pressure ............................................ 13 
5.3 Update of exclusion criteria on alcohol/drug abuse ....................................... 13 
5.4 Specification of prohibited concomitant medication ....................................... 14 

 
 
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CONFIDENTIAL 
 
 
 
                          Page 5 of 26 
5.5 Additional ECG assessments added ............................................................. 15 
5.6 Monitoring of patients’ electrolyte levels ........................................................ 16 
5.7 Clinical event of interest added ...................................................................... 17 
5.8 Treatment of patients experiencing hypo- or hyperglycemia prior 
dosing ....................................................................................................... 19 
5.9 Monitoring of potential pregnancies ............................................................... 20 
5.10 
Additional visits required for patients discontinuing treatment 
prematurely .............................................................................................. 21 
5.11 
Specification on time windows for assessments ....................................... 21 
5.12 
Specification of the requirements at the dosing visits ............................... 22 
5.13 
Responsibility of unblinded trial personnel ............................................... 22 
5.14 
Randomization of replacement patients ................................................... 23 
5.15 
Clarification to the reporting of (Serious) Adverse Events ........................ 23 
5.16 
Clarification on case report form ............................................................... 24 
5.17 
Subgroup analysis added to statistical section ......................................... 24 
5.18 
Administrative and editorial changes ........................................................ 24 
 
 
 

 
 
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Amendment 01, final version 1.0, 08-May-2017 
 
 
CONFIDENTIAL 
 
 
 
                          Page 6 of 26 
1 
Amendment type 
This is substantial amendment number 01 to trial protocol version 1, dated 18 January 2017. 
 
2 
Rationale for amendment 
The amendment will add precision to the description of the overall rationale of the trial. In 
addition, details pertaining to safety assessment of the patients are revised. Furthermore, the 
amendment serves to correct changes, errors or inconsistencies in the description of the 
operational set up of the trial.   
 
3 
Summary of Amendment 
With this substantial amendment number 01, the following changes are made to the original 
protocol: 
 
Clarification on the statistical method and anti-drug antibody (ADA) assays 
 
Update of exclusion criterion on blood pressure 
 
Update of exclusion criterion on alcohol/drug abuse 
 
Specification of prohibited concomitant medication 
 
Additional ECG assessment added 
 
Clinical event of interest added 
 
Treatment options for patients experiencing hypo- or hyperglycemia prior dosing 
 
Monitoring of patients’ electrolyte levels 
 
Monitoring of potential pregnancies 
 
Additional visits required for patients discontinuing treatment prematurely 
 
Specification on time windows for assessments 
 
Specification of the requirements at the dosing visits 
 
Responsibility of unblinded trial personnel 
 
Randomization of replacement patients 
 
Clarification to the reporting of (Serious) Adverse Events 
 
Clarification on case report forms 
 
Subgroup analysis added to the statistical section 
 
Administrative changes 
 
Section 4 of this amendment will describe the overall changes and rationales.  
Section 5 of this amendment will list the actual changes in the protocol text reflecting both 
superseded and new wording. 
 

 
 
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CONFIDENTIAL 
 
 
 
                          Page 7 of 26 
4 
Changes and rationale: 
4.1 
Clarification on the statistical method and anti-drug antibody (ADA) 
assays 
The primary objective has been updated to clarify that GlucaGen is considered a reference 
product and the objective of the trial is to evaluate the immunogenicity of both dasiglucagon and 
GlucaGen. It has been specified that the ADA assays to be used in this trial are both validated, 
but specific for dasiglucagon and GlucaGen, respectively. Hence, the performance of the 
assays are not directly comparable and a formal statistical comparison or non-inferiority testing 
is not performed. The rationale for the sample size calculation has been adapted accordingly. 
These clarifications have been implemented throughout the protocol including the protocol title. 
The rationale for the update is to clarify that the trial is not a non-inferiority trial and no formal 
statistical testing will be performed. 
 
4.2 
Update of exclusion criterion on blood pressure 
Exclusion criterion number 10 has been adjusted to exclude patients with a systolic blood 
pressure ≥160 mmHg or diastolic blood pressure ≥90 mmHg at screening. 
The rationale for narrowing the limit of allowed blood pressure values at screening is to only 
include patients of good health, apart from having type 1 diabetes, in the trial. 
 
4.3 
Update of exclusion criterion on alcohol/drug abuse 
Exclusion criterion number 19 has been updated to exclude patients with a significant history of 
alcohol or drug abuse or a positive alcohol or drug test at screening. Further, the limits for 
current alcohol consumption has been added.  
In addition, it has been specified in the protocol which drugs the drug test will screen for and 
that a positive drug test during the trial will be a withdrawal criteria. 
The rationale of the update is to ensure patients with a history or current abuse of alcohol 
and/or drugs are not included in the trial.  
 
4.4 
Specification of prohibited concomitant medication 
An additional exclusion criterion has been added to exclude patients using any non-prescription 
or prescription drugs known to cause QT prolongation. It has further been specified that 
metoclopramide (Primperan®) is the only allowed antiemetic treatment that can be used at the 
dosing visits; 2, 3, and 4. 
The rationale for the addition is due to the sporadic QTcB changes post 
dasiglucagon/GlucaGen administration observed in the phase 2 trial. 
 
4.5 
Additional ECG assessment added 
ECG will be measured at 20, 35, 45 and 60 minutes post dosing at all three dosing visits; 2, 3, 
and 4. 

 
 
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The rationale for the change is due to the sporadic QTcB changes post dasiglucagon/GlucaGen 
administration observed in the phase 2 trial. The updated time points for ECG assessments are 
to cover the range of tmax for dasiglucagon and GlucaGen at all three dosing visits. 
 
4.6 
Monitoring of patients’ electrolyte levels 
It has been added to exclusion criterion 16 that patients with altered electrolytes values of 
clinical relevance for cardiac conduction will be excluded from the trial. Further, the investigator 
must ensure that patients are actively treated to correct any electrolyte imbalances following 
potential events of vomiting at the dosing visits. 
The rationale for the change is to ensure that patients do not have any electrolyte imbalances 
that could potentially affect the cardiac conduction and the QT interval.  
 
4.7 
Clinical event of interest added 
Changes in blood pressure and/or pulse after dosing will be considered a clinical event of 
interest. Additional vital sign assessments have been added. 
The rationale for the addition is due to the nonclinical and clinical findings in healthy volunteers 
of hemodynamic changes with dasiglucagon. Due to these findings additional information on 
such events will be captured in a specific form in the case report form. 
 
4.8 
Treatment of patients experiencing hypo- or hyperglycemia prior dosing 
It has been specified that at all three dosing visits; 2, 3, and 4, the investigator should 
administer corrective doses of insulin if a patient has a plasma glucose >150 mg/dL before 
dosing. Likewise if a patient has a plasma glucose <70 mg/dL before dosing glucose ingestion 
should be provided to the patient. 
The rationale for this addition is to clarify how the investigator should ensure patients have a 
plasma glucose level on 70-150mg/dL before dosing.  
 
4.9 
Monitoring of potential pregnancies 
For women of childbearing potential a urine stick pregnancy test will be performed at the site 
prior dosing at all three dosing visits; 2, 3, and 4.  
If a female patient becomes pregnant in the period between the screening visit and the last 
dosing visit, she must be discontinued from trial treatment. 
The rationale for the change is to ensure that patients who have become pregnant in the period 
following the screening visit are not exposed to trial medication. 
 
4.10 Additional visits required for patients discontinuing treatment 
prematurely 
A patient prematurely discontinuing treatment will be asked to attend all three follow up visits; 5, 
6, and 7, to have all follow up assessments performed. Only in case a patient withdraw consent 
or is excluded before exposure to trial product the follow up visits can be omitted. 
The rationale for this addition is to avoid missing data for the primary and key secondary 
endpoints. 

 
 
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4.11 Specification on time windows and order of assessments 
Time window allowance has been added to collection time of safety blood samples, vital signs 
and local tolerability assessments. Further, the time for obtaining informed consent has been 
specified as well as the time of randomization. 
The rationale for the addition is to clarify the time and timing for the assessments to take place. 
 
4.12 Specification of the requirements at the dosing visits 
The requirements for fasting at the dosing visits; 2, 3, and 4, have been specified. Further, the 
instructions to patients prior dosing have been made more clear. 
The rationale for the addition is to clarify the procedures around the dosing visits. 
 
4.13 Responsibility of unblinded trial personnel 
The responsibility of the unblinded trial personnel has been clarified. 
The rationale for the addition is to clarify the procedures to maintain the double blinding.  
 
4.14 Randomization of replacement patients 
Replacement patients will not necessarily be randomized to the same treatment as the patient 
they are replacing.  
The rationale is that it is not technically possible nor needed to assign the replacement patients 
to the same treatment as the patient they are replacing. 
 
4.15 Clarification to the reporting of (Serious) Adverse Events 
It has been clarified that the investigator only needs to send the SAE form to the 
Pharmacovigilance unit (Safety CRO). Further, the text has been updated to make it more 
simple. 
The rationale for the changes is to make the process for SAE reporting more simple and to 
make the text more clear.  
 
4.16 Clarification on case report forms 
Minor clarifications have been made to the section on case report forms. E.g. it has been 
specified that no end-of-visit form will be used in the trial. 
The rational for the change is to correct minor errors and make the section more clear. 
 
4.17 Subgroup analyses added to statistical section 
It has been added that subgroup analyses by gender, age and race will be performed for the 
primary endpoint. Further details if needed will be provided in the statistical analysis plan. 
The rationale for including this in the protocol is due to regulatory requirements.  
 

 
 
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4.18 Administrative changes 
- 
IND and dasiglucagon SUB numbers have been added  
- 
Coordinating investigator and other trial personnel have been updated (changes also 
applicable for Appendix 1) 
 
5 
Amended text 
This section will list the actual changes in the protocol text reflecting both the original and the 
new wording. 
 
New wording is marked in underlined italics and deleted wording is marked with strikethrough.  
 
5.1 
Clarification on the statistical method and anti-drug antibody (ADA) 
assays 
Front page: 
Updated text: 
A phase 3, Randomized, Double-Blind, Parallel Group Safety Trial to Evaluate the 
Immunogenicity of Dasiglucagon and compared to GlucaGen® Administered Subcutaneously in 
Patients with Type 1 Diabetes Mellitus (T1DM) 
 
Section 1. Signatures and agreement with protocol 
Updated text: 
Title: A phase 3, Randomized, Double-Blind, Parallel Group Safety Trial to Evaluate the 
Immunogenicity of Dasiglucagon and compared to GlucaGen® Administered Subcutaneously in 
Patients with Type 1 Diabetes Mellitus (T1DM) 
Section 2. Trial synopsis 
Title of the trial 
Updated text: 
A phase 3, Randomized, Double-Blind, Parallel Group Safety Trial to Evaluate the 
Immunogenicity of Dasiglucagon and compared to GlucaGen® Administered Subcutaneously in 
Patients with Type 1 Diabetes Mellitus (T1DM) 
 
Objectives 
Updated text: 
The primary objective is to evaluate the immunogenicity of repeated single doses of 
dasiglucagon and GlucaGen following subcutaneous (s.c.) administration compared with s.c. 
GlucaGen in T1DM patients. 
 
Trial design 
Updated text: 
This is a randomized, double-blind, parallel group trial evaluating comparing the immunogenicity 
of either dasiglucagon or GlucaGen administered to euglycemic T1DM patients. 

 
 
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Statistical methods: 
Updated text: 
All statistical analysis will be descriptive i.e. no formal statistical testing will be performed. 
Continuous variables will be summarized with means, standard deviations, medians, minimums, 
and maximums, and valid cases. 
 
Sample size calculation: 
Updated text: 
The purpose of the present trial is to generate data describing the immunogenic potential of 
dasiglucagon and GlucaGen., when used as a rescue therapy form severe hypoglycemia and 
with reference to the immunogenic potential of GlucaGen. The sample size is based on 
generating data to show that the 90% confidence of the ADA incidence is no worse than 15% as 
the predefined acceptability criterion and with a reference to similar data being generated for 
GlucaGen.The ADA assays to be used in this trial are both validated, but specific for GlucaGen 
and dasiglucagon, respectively, and the performance of the assays are thus not directly 
comparable. As a consequence, a formal comparison or non-inferiority analysis will not be 
performed.  
Currently, no ADA incidences have been detected in the completed clinical trials, where up to 5 
repeated doses of dasiglucagon have been administered to the same patients within a week. 
Across the two phase 1 clinical trials and a completed phase 2 
pharmacokinetic/pharmacodynamic trial, a total of 141 subjects have been exposed to 
dasiglucagon and no incidences of ADA development have been observed. The obtained data 
indicate that dasiglucagon has a low risk for induction of ADAs in the investigated settings and 
as a consequence the sample size is based on showing that the ADA incidence is no worse 
than the predefined margin of 15%.a meaningful sample size to compare both treatments 
cannot be estimated. 
The sample size is therefore based on a certain precision of the confidence interval for the 
overall ADA incidence if no events are observed, respectively to ensure a certain probability for 
observing one event. 
When no events are observed, to obtain an upper bound of 0.050 on the 90.0% confidence 
interval for the probability of such a rare event, would require a sample size of 45. Respectively, 
accepting a chance of observing at least one event of 90% and an actual probability of the 
event of 5% leads to a sample size of 45 patients completing the trial. In order to account for 
drop-outs, It is expected that 112 patients in total will be randomized and treated. 
 
Section 5.2 Trial rationale 
Updated text: 
The present trial aims to evaluate that immunogenicity risk with an assessment of the 
occurrence of ADAs and neutralizing ADAs, and of cross-reactivity with native glucagon, 
following repeated single doses of dasiglucagon by s.c. administration in T1DM patients. The 
reference product comparator in this trial is GlucaGen, a recombinant human glucagon 
approved for the treatment of the severe hypoglycemic reactions that may occur in the 
management of insulin-treated children and adults with diabetes mellitus. Given the differences 
in ADA assay for dasiglucagon and GlucaGen, a formal statistical comparison or non-inferiority 
testing is not performed. 
 

 
 
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Section 6 Trial objectives 
Updated text: 
Primary objective 
 
To evaluate the immunogenicity of repeated single doses of dasiglucagon and 
GlucaGen following s.c. administration compared with s.c. GlucaGen in T1DM patients. 
 
Section 7.2 Discussion of trial design and choice of control groups 
Updated text: 
Euglycemic patients with T1DM will be randomized 1:1 in order to evaluate the immunogenicity 
of dasiglucagon and compared to GlucaGen. The randomized, double-blind, parallel group 
design, with administration of 3 fixed consecutive doses of randomized trial medication 
(dasiglucagon or GlucaGen) to the same patient will allow characterization of immunogenic 
potential for and a relative comparison of the immunogenicity between the 2 products. 
 
Section 7.3 Selection of trial population 
Updated text: 
Dasiglucagon is indicated for treatment of severe hypoglycemia in patients with T1DM. Given 
the role of the immune system in the pathogenesis of T1DM, the present trial aims to evaluate 
the immune response of patients with T1DM taking repeated single doses of s.c. dasiglucagon 
and compared to GlucaGen.  
 
Section 10.1.1 General Considerations 
New text: 
All statistical analysis will be descriptive i.e. no formal testing will be performed. 
 
Section 10.1.2 Classification of patients to subsets 
Updated text: 
The following definitions are applicable: 
Safety analysis set 
(SAS) 
all patients who were randomized and received at least one 
dose of trial medication 
Full analysis set 
(FAS) 
all patients of the SAS with at least one measurement of the 
ADA titer at baseline 
Per Protocol set 
(PPS) 
all patients of the FAS for whom no relevant protocol deviations 
were documented 
 
Section 10.2 Determination of sample size 
Updated text: 
The purpose of the present trial is to generate data describing the immunogenic potential of 
dasiglucagon and GlucaGen., when used as a rescue therapy form severe hypoglycemia and 
with reference to the immunogenic potential of GlucaGen. The sample size is based on 
generating data to show that the 90% confidence of the ADA incidence is no worse than 15% as 
the predefined acceptability criterion and with a reference to similar data being generated for 
GlucaGen.The ADA assays to be used in this trial are both validated, but specific for GlucaGen 

 
 
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and dasiglucagon, respectively, and the performance of the assays are thus not directly 
comparable. As a consequence, a formal comparison or non-inferiority analysis will not be 
performed.  
Currently, no ADA incidences have been detected in the completed clinical trials, where up to 5 
repeated doses of dasiglucagon have been administered to the same patients within a week. 
Across the two phase 1 clinical trials and a completed phase 2 
pharmacokinetic/pharmacodynamic trial, a total of 141 subjects have been exposed to 
dasiglucagon and no incidences of ADA development have been observed. The obtained data 
indicate that dasiglucagon has a low risk for induction of ADAs in the investigated settings and 
as a consequence the sample size is based on showing that the ADA incidence is no worse 
than the predefined margin of 15%.a meaningful sample size to compare both treatments 
cannot be estimated. 
The sample size is therefore based on a certain precision of the confidence interval for the 
overall ADA incidence if no events are observed, respectively to ensure a certain probability for 
observing one event. 
When no events are observed, to obtain an upper bound of 0.050 on the 90.0% confidence 
interval for the probability of such a rare event, would require a sample size of 45. Respectively, 
accepting a chance of observing at least one event of 90% and an actual probability of the 
event of 5% leads to a sample size of 45 patients completing the trial. In order to account for 
drop-outs, It is expected that 112 patients in total will be randomized and treated. 
 
5.2 
Update of exclusion criterion on blood pressure 
Section 2. Trial synopsis, Exclusion criteria 
Updated text: 
10. Inadequately treated blood pressure as defined as systolic blood pressure ≥160 180 mmHg 
or diastolic blood pressure ≥90 110 mmHg at screening 
 
Section 7.3.2 Exclusion criteria 
Updated text: 
10. Inadequately treated blood pressure as defined as systolic blood pressure ≥160 180 mmHg 
or diastolic blood pressure ≥90 110 mmHg at screening 
 
5.3 
Update of exclusion criteria on alcohol/drug abuse 
Section 2. Trial synopsis, Exclusion criteria 
Updated text: 
19. Active substance of alcohol abuse. A positive result in the alcohol and/or urine drug screen 
at the screening visit. Significant history of alcoholism or drug abuse as judged by the 
investigator or consuming more than 24 g alcohol per day for men, or more than 12 g alcohol 
per day for women.  
 
Section 7.3.2 Exclusion criteria 
Updated text: 
19. Active substance of alcohol abuse. A positive result in the alcohol and/or urine drug screen 
at the screening visit. Significant history of alcoholism or drug abuse as judged by the 

 
 
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investigator or consuming more than 24 g alcohol per day for men, or more than 12 g alcohol 
per day for women.  
 
Section 7.3.3.1 Possible reasons for patient discontinuation  
Updated text: 
A patient will be discontinued if the following applies: 
 
If a protocol deviation occurs which, in the clinical judgment of the Investigator, can 
invalidate the assessment of ADA responses to dasiglucagon or glucagon, the patient 
will be withdrawn by the Investigator 
 
AEs that are considered unacceptable by the patient or the Investigator 
 
Positive result from an urine drug screen test 
 
Section 7.6.4.1 Safety laboratory tests 
Updated text: 
Alcohol breath tests and urine drug screen (amphetamine, cocaine, MDMA, methamphetamine, 
opiate/morphine, marihuana) will be performed at Screening (Visit 1) and at Visits 2, 3, and 4. 
 
5.4 
Specification of prohibited concomitant medication 
Section 2. Trial synopsis, Exclusion criteria 
New text: 
23. Use of prescription or non-prescription medications known to cause QT prolongation 
 
Section 7.3.2. Exclusion criteria 
New text: 
23. Use of prescription or non-prescription medications known to cause QT prolongation 
 
Section 7.4.2 Treatments administered 
Updated text: 
 
antiemetic treatment e.g. in the form of an 8 mg slow intravenous (i.v.) dose of 
ondansetron (Zofran®) or alternatively a 10 mg slow i.v. dose of metoclopramide 
(Primperan®) as per local label, administered before or after dosing. 
 
 

 
 
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5.5 
Additional ECG assessments added 
Table 2-1 Flow chart  
 
 
Footnotes 
New text: 
10 On dosing days Visit, 2, 3 and 4 ECG’s are assessed pre-dose, and at 20, 35, 45 and 60 min post-
dosing. The actual time for assessment should not deviate from the nominal time by more than ±5 min. 
Pre-dose is defined as within 5 min prior to dosing. 
 
Section 7.5.3 Procedures and assessments during the treatment period of the trial 
Visit 2 and 4:  
Updated text: 
 
ECG (pre-dose, and at 20, 35, 45 30 and 90 60 min post-dosing) 
 
Visit 3: 
New text: 
 
ECG (pre-dose, and at 20, 35, 45 and 60 min post-dosing) 
 
Section 7.6.4.2 Safety examinations 
Updated text: 
ECG is assessed at Screening (Visit 1) Visits 2, 3, and 4… 
 

 
 
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5.6 
Monitoring of patients’ electrolyte levels 
Section 2. Trial synopsis, Exclusion criteria 
Updated text: 
16. Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >2.5 X the upper 
limit of normal (ULN), bilirubin >1.5 X ULN, estimated glomerular filtration rate (eGFR) 
<30 mL/min/1.73m2 according to the Modification of Diet in Renal Disease (MDRD) 
Study definition. Altered electrolytes values of clinical relevance for cardiac conduction, 
as judged by the investigator.  
 
Section 7.3.2 Exclusion criteria 
Updated text: 
16. Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >2.5 X the upper 
limit of normal (ULN), bilirubin >1.5 X ULN, estimated glomerular filtration rate (eGFR) 
<30 mL/min/1.73m2 according to the Modification of Diet in Renal Disease (MDRD) 
Study definition. Altered electrolytes values of clinical relevance for cardiac conduction, 
as judged by the investigator.  
 
Section 7.4.2 Treatments administered 
New text: 
Patients will not be discharged until they are considered stable and with a blood glucose level in 
the range of 70-180 mg/dL. Before discharge, the investigator will provide instructions to the 
patients on management of their blood glucose levels. Each trial medication will be 
administered s.c. 3 times in total, with 7 days between dosing (i.e. dosing occurs at Days 0, 7, 
and 14; Visits 2, 3, and 4). Should the patient experience vomiting following the first or second 
dasiglucagon or GlucaGen administration, the investigator must ensure normal electrolytes prior 
to the next dosing day. An electrolyte imbalance can be corrected by administration of an 
electrolyte supplement or by any other treatment modality considered appropriate by the 
investigator.   
 
 

 
 
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5.7 
Clinical event of interest added 
Table 2-1 Flow chart 
 
 
Footnotes 
New text: 
12 On dosing days Visit 2, 3, and 4 vital signs are collected pre-dose and at 30, 90 and 120 min post-
dosing. The actual time of assessment should not deviate from the nominal time by more than ±5 min. 
Pre-dose is defined as within 5 min prior to dosing. 
 
Section 5.1 Background of the trial, Safety of Dasiglucagon 
Updated text: 
Glucagon has been described to exert positive inotropic and chronotropic effects and may 
therefore cause tachycardia and hypertension. In the phase 1 clinical trials, but not the phase 2 
trial, temporary but clinically significant decreases in blood pressure were observed in a few 
healthy volunteers receiving investigational medicinal product (IMP) doses of at least 1.0 mg (4 
with dasiglucagon and 1 with GlucaGen). This is not considered a safety concern, however 
hemodynamic changes post dosing will be considered a clinical event of interest. 
ThereforeThe The phase 1 and 2 results and the safety profile described to date do not give rise 
to specific safety concerns. 
 
Section 7.5.3 Procedures and assessments during the treatment period of the trial 
Visit 2 and 4:  
Updated text: 
 
Vital signs (pre-dose, and at 30, and 90 and 120 min post-dosing) 
 

 
 
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Visit 3: 
New text: 
 
Vital signs (pre-dose, and at 30, 90 and 120 min post-dosing) 
 
Section 7.6.4.2 Safety examinations 
Updated text: 
ECG is assessed at Screening (Visit 1) Visits 2, 3, and 4 and vital signs are assessed at 
Screening (Visit 1) Visits 2, 3, 4, 5, and 7. 
 
Section 8.1 Definitions 
New text: 
Clinical event of interest 
A clinical event of interest is an event which, in the evaluation of safety, has a special focus 
(e.g. required by health authorities). 
In this trial hemodynamic changes, as defined below, are considered clinical event of interest: 
 
Post-dose clinical signs, or measured vital signs, indicating a clinical significant drop 
in blood pressure including signs of orthostatic hypotension, vasovagal responses or 
bradycardia 
 
Post-dose change in pulse or blood pressure considered an event of hypo- or 
hypertension as judged by the investigator. 
 
Section 8.2 Collection, recording and reporting of adverse events 
Updated text: 
All AEs must be recorded by the Investigator. One single Adverse Event Form must be used per 
AE from start to resolution. For SAEs, the Serious Adverse Event Form must also be completed. 
For clinical events of Interest, the Clinical Event of Interest Form must also be completed. 
AE information should include the following: 
 
Date and time of onset and resolution 
 
Date and time of Investigator’s first information on the (S)AE 
 
Seriousness 
 
Severity 
 
Causal relationship with IMP 
 
Interruption or withdrawal of treatment with IMP and other measures taken 
 
Outcome 
All AEs are coded; details are described in the trial specific Data Management Plan.  
If an event classifies as a clinical event of interest, the Investigator must tick the Clinical Event 
of Interest box on the AE form and complete the Clinical Event of Interest Form. The Clinical 
Event of Interest Form will capture if the event was associated with any signs or symptoms and 
capture the highest/lowest blood pressure and pulse measured during the event. 
 
 

 
 
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5.8 
Treatment of patients experiencing hypo- or hyperglycemia prior dosing 
Table 2-1 Flow chart, footnotes 
Updated text: 
9 Prior to administration of trial medication patients must reach a target plasma glucose level of 70-150 
mg/dL. Plasma glucose levels may be adjusted by subcutaneous (s.c.) administration of a fast-acting 
insulin analog or by glucose ingestion at the discretion of the investigator.  
 
Section 7.4.2 Treatments administered 
Updated text: 
Prior to administration of trial medication at all dosing visits patients must reach a target plasma 
glucose level of 70-150 mg/dL. If the patient presents with plasma glucose > 150 mg/dL, 
corrective amounts of fast acting insulin will be administered at the investigator’s discretion. 
Plasma glucose measured after 20 and after 40 minutes should ensure that the patient has 
reached the targeted 70-150 mg/dL. If the patient presents with plasma glucose < 70 mg/dL 
glucose ingestion will be provided in order to reach target plasma glucose of 70-150 mg/dL 
documented by plasma glucose measurements after 20 and 40 minutes, respectively. Plasma 
glucose levels may be adjuseted by s.c. administration of a fast acting insulin analog if blood 
glucose exceeds 150 mg/dL or by glucose ingestion if blood glucose is below 70 mg/dL. 
 
Section 7.5.3 
Visit 2 and 4: 
Updated text: 
 
Prior to administration of trial medication at all dosing visits patients must reach a target 
plasma glucose level of 70-150 mg/dL. If the patient presents with plasma glucose > 150 
mg/dL, corrective amounts of fast acting insulin will be administered at the investigator’s 
discretion. Plasma glucose measured after 20 and after 40 minutes should ensure that 
the patient has reached the targeted 70-150 mg/dL. If the patient present with plasma 
glucose < 70 mg/dL glucose ingestion will be provided in order to reach target plasma 
glucose of 70-150 mg/dL documented by plasma glucose measurements after 20 and 40 
minutes, respectively. Plasma glucose levels may be adjuseted by s.c. administration of 
a fast acting insulin analog or by glucose ingestion. 
 
Visit 3: 
Updated text: 
 
Prior to administration of trial medication at all dosing visits patients must reach a target 
plasma glucose level of 70-150 mg/dL. If the patient presents with plasma glucose > 150 
mg/dL, corrective amounts of fast acting insulin will be administered at the investigator’s 
discretion. Plasma glucose measured after 20 and after 40 minutes should ensure that 
the patient has reached the targeted 70-150 mg/dL. If the patient present with plasma 
glucose < 70 mg/dL glucose ingestion will be provided in order to reach target plasma 
glucose of 70-150 mg/dL documented by plasma glucose measurements after 20 and 40 
minutes, respectively. Plasma glucose levels may be adjuseted by s.c. administration of 
a fast acting insulin analog or by glucose ingestion. 
 
 

 
 
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5.9 
Monitoring of potential pregnancies 
Table 2-1 Flow chart  
 
 
Footnotes 
New text: 
11 Pregnancy test is only applicable for women of childbearing potential. At Visit 1 a serum pregnancy test 
should be performed. At Visit 2, 3 and 4 a pre-dose urine pregnancy test should be performed.  
 
Section 7.3.3.1 Possible reasons for patient discontinuation 
New Text: 
A patient will be discontinued if the following applies: 
 
Pregnancy. If a female patient becomes pregnant in the time between the screening visit 
and any one of the dosing visits 
 
Section 7.5.1 Screening examination 
Updated text: 
 
Pregnancy test (women of childbearing potential only) 
 
Section 7.5.3 Procedures and assessments during the treatment period of the trial 
Visit 2 and 4: 
New text: 
 
Urine pregnancy test (pre-dose) at trial site (women of childbearing potential only) 
 
Visit 3 
New text: 
 
Urine pregnancy test (pre-dose) at trial site (women of childbearing potential only) 
 
Section 7.6.4.1 Safety laboratory tests 
Updated text: 
A pregnancy test will be performed at screening (Visit 1) and pre-dose at the three dosing visits 
(Visit 2, 3 and 4) for women of childbearing potential only. 
 
 

 
 
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5.10 Additional visits required for patients discontinuing treatment 
prematurely 
Section 7.3.3.1 Possible reasons for patient discontinuation 
New text: 
If discontinuation occurs following administration of any trial medication, the patient will be 
asked to return and participate in the complete follow-up visits at trial Day 35, 60, and 104. 
 
Section 7.4.2 Treatments administered 
New text: 
Following the first (Visit 2) and third (Visit 4) dose administration, patients must be fasting for 90 
min after dosing. Following the 90-min blood sample draw after the administration of the first 
(Visit 2) and third (Visit 4) dose administration, patients may be treated individually in order to 
alleviate any potential side effects in order to minimize prematurely treatment discontinuation 
withdrawals and consequently reduce the amount of missing data. This treatment can also be 
instituted immediately after the second dose administration (Visit 3), as pharmacodynamics will 
not be assessed at this visit.  
 
In order to minimize the number of patients discontinuing treatment prematurely and 
consequently reduce the amount of missing data, the following treatment modalities may be 
used, as considered appropriate by the investigator:  
 
5.11 Specification on time windows for assessments 
Flowchart 2-1, footnotes 
New text: 
1 Informed consent can be obtained on the same day as screening, but prior to any trial-related 
procedures At least 1 day before the screening visit (Visit 1) 
… 
4 Coagulation parameters are measured at screening visit only. On dosing days Visit 2 and 4, vital signs, 
ECG’s and blood samples are collected pre-dose, and at 30 and 90 min post-dosing. The actual time for 
sampling/assessment should not deviate from the nominal time by more than ±5 min. Pre-dose is 
defined as within 5 min prior to dosing. 
5 Local tolerability assessed at 0.5 and 2 h post-dose. The actual time for assessment should not deviate 
from the nominal time by more than ±10 min. 
 
Section 7.5.3 Procedures and assessments during the treatment period of the trial 
Updated text: 
At Visit 2 (Day 0) patient eligibility is rechecked (check of changes between the screening visit 
and Visit 2). Withdrawal criteria and dosing day exclusion criteria are also checked and patients 
eligible to participate will be randomized to treatment with dasiglucagon or GlucaGen.  
Additionally, during the treatment period of the trial, at Visits 2 and 4 (Days 0 and 14), the 
following assessments will take place: 
 
Concomitant medication 
 
Check of withdrawal criteria (prior randomization at Visit 2) 
 
Check of dosing day exclusion criteria (prior randomization at Visit 2) 

 
 
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5.12 Specification of the requirements at the dosing visits 
Table 2-1 Flowchart, footnotes 
Updated text: 
9 Prior to administration of trial medication patients must reach a target plasma glucose level of 70-150 
mg/dL. Plasma glucose levels may be adjusted by administration if fast-acting insulin analog or by glucse 
ingestion. Patients At visit 2 and 4 patients must be fasting for 90 min after administration of trial 
medication and will be treated individually to alleciate any potential side effects. At all dosing visits 
Ppatients will be treated individually to alleviate any potential side effects and will be observed for at least 
5 h post-dose. 
 
Section 7.4.2 Treatments administered 
Updated text: 
At visit 2 and 4: 
 
90 min after dosing patients will be allowed to eat and drink moderately to make 
them feel comfortable 
 
90 min after dosing a moderate and individualized corrective dose of insulin to 
convert the induced hyperglycemia to euglycemia, after agreement with the 
investigator 
 
antiemetic treatment in the form of metoclopramide (Primperan®) as per local label, 
administered before or after dosing 
 
At visit 3:  
 
patients will be allowed to eat and drink moderately to make them feel comfortable 
 
a moderate and individualized corrective dose of insulin to convert the induced 
hyperglycemia to euglycemia, after agreement with the investigator 
    antiemetic treatment e.g. in the form of an 8 mg slow intravenous (i.v.) dose of 
ondansetron (Zofran®) or alternatively a 10 mg slow i.v. dose of metoclopramide 
(Primperan®) as per local label, administered before or after dosing. 
 
Section 7.5.2 Instructions to patients prior to dosing 
Updated text: 
On dosing days, patients are allowed to consume a small meal for breakfast with corresponding 
administration of rapid acting insulin to address the meal and in accordance with their normal 
management of blood glucose levels. At visit 2 and visit 4 the patient should aim to have a 
similar sized breakfast and corresponding rapid acting insulin dose.  
 
5.13 Responsibility of unblinded trial personnel 
Section 7.4.6 Blinding 
New text: 
This is a double-blind trial. Since dasiglucagon is available as a liquid formulation and 
GlucaGen is available as a powder for reconstitution, and they are therefore not identical in 
appearance, unblinded trial personnel will be responsible for handling, preparing according to 

 
 
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the prescription from the IWRS, and administering the trial medication and keep the records 
strictly confidential and accessible only for unblinded staff until after database lock. 
 
5.14 Randomization of replacement patients 
Section 7.3.4 Replacement of patients 
Updated text: 
Patients prematurely withdrawn from the trial will be replaced in order to reach 90 completed 
patients. Replacement patients will receive the same treatment allocation (i.e. 3 doses of 
dasiglucaon or GlucaGen) as the patients they are replacing. 
 
5.15 Clarification to the reporting of (Serious) Adverse Events 
Section 8.2 Collection recording and reporting of adverse events 
Updated text: 
At each contact with the site (visit or telephone, excluding safety visits, where the patient is not 
seeing the Investigator or his staff (e.g. visits to the laboratory)) the patient must be asked about 
AEs.  
… 
The Investigator must report initial information in writing (fax or email) on all SAEs to the 
responsible medical monitor of the Sponsor (Zealand) and to the Sponsor’s responsible 
pharmacovigilance unit (Safety CROPharmalex) immediately (within 24 hours) after obtaining 
knowledge about the event. Please refer to Appendix 1 for contact details. The Safety CRO will 
inform the medical monitor and the sponsor about the reported SAEs. 
 
Name:  
 
Company:  PharmaLex (formerly Lindeq) 
Address:  Agern Allé 24, DK 2970 Hørsholm, Denmark 
Tel:  
 (8 a.m. to 4 p.m.) 
 (outside 8 a.m. to 4 p.m.)   
Fax:  
 
E mail: 
drugsafety@lindeq.com  
 
In addition, and meeting the same timeline, Investigators have to report all SAEs to Zealand by 
forwarding the SAE form electronically (e.g. in PDF format) within 24 hours to the 
representatives of Zealand. 
 
Names:  
 and 
 
Address: Smedeland 36, DK 2600 Glostrup, Denmark 
Tel: 
 / 
 
E mails: 
 / 
 
 

 
 
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It is the responsibility of PharmaLexthe Safety CRO to report all SUSARs that occur in this trial 
to the Competent Authorities and IRBs/IECs in accordance with the local requirements in force 
and ICH guideline for GCP. The trial monitor must be informed accordingly. 
 
Section 8.7 Safety Committee 
Updated text: 
As a minimum tThe SC convenes every quarter to review relevant safety information, including 
AEs and laboratory data. 
 
5.16 Clarification on case report forms 
Section 9.1 Case report forms 
Updated text: 
All key pages will be signed or initialed by the investigator, signifying agreement with and 
responsibility for the recorded data. Key pages are the following: end of visit form, AE-reporting 
form, trial medication form, concomitant medication form and trial-closure form.  
Data directly captured in the eCRF (i.e., data assigned or calculated automatically by the EDC 
system) is called e-source. A trial specific list should be generated prior to the performance of 
the trial, which specifies which data fields in the Case Report Form will be used by the medical 
personnel for direct entry during the performance of the trial. This means that these data fields 
in the CRF are source documents. For the other CRF data fields, which are entered by medical 
personnel during the trial, the source data will be found in other documents (such as patients’ 
files, worksheets, etc.), that is i.e. for these CRF data fields the “other” documents are the 
source documents. Should such a list be created, it should be submitted to the authorities 
together with the protocol. 
 
5.17 Subgroup analysis added to statistical section 
10.1.9 Subgroup analysis 
Updated text: 
Subgroup analyses for the primariy endpoint (voerl ADA incidence) by gender, age, and race 
will be performed. No subgroup analysis is currently planned. 
 
5.18 Administrative and editorial changes 
Front page 
New text: 
Sponsor code: ZP4207-16136 
SynteractHCR: ZEA-DNK-01711 
EudraCT number: 2017-000062-30 
IND Number: 127866 
Dasiglucagon SUB code: SUB181296 
 
Coordinating Investigator 
Updated text: 

 
 
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Linda Morrow, MD 
Prosciento 
855 Third Avenue 
91911 Chula Vista 
CA, USA 
Thomas R. Pieber, MD 
Medical University of Graz  
Auenbruggerplatz 15 
A-8036 Graz, Austria 
 
Section 1. Signatures and agreement with protocol 
Updated text: 
Coordinating Investigator: 
Linda Morrow, MD 
 
 
 
 
Prosciento 
 
 
 
 
855 Third Avenue 
91911 Chula Vista 
CA, USA 
 
 
 
 
 
Thomas R. Pieber, MD 
Medical University of Graz  
Auenbruggerplatz 15 
A-8036 Graz, Austria 
 
 
Sponsor’s representative:  
 
, MSc (Pharm) 
 
 
 
 
Clinical Trial Project Manager  
Zealand Pharma A/S 
Smedeland 36, 2600 Glostrup, Denmark 
 
Section 2. Trial synopsis 
Coordinating Investigator 
Updated text: 
Linda Morrow, MD, Prosciento, 855 Third Avenue, 91911 Chula Vista,  
CA, USA 
 
Thomas R. Pieber, MD, Medical University of Graz, Auenbruggerplatz 15, A-8036 Graz, Austria 
 
Planned trial period 
Updated text: 
First Patient First Visit: May March 2017 
Last Patient First Visit: November September 2017 

 
 
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APPENDIX 1: 
 
Coordinating investigator 
Linda Morrow, MD  
Prosciento  
855 Third Avenue 
91911 Chula Vista, CA, USA 
Thomas R. Pieber, MD 
Medical University of Graz  
Auenbruggerplatz 15 
A-8036 Graz, Austria 
 
Trial Monitor 
To be decided 
SynteractHCR Deutschland GmbH 
Albrechtstr. 14 
80636 Munich, Germany 
 
Sponsor representative 
 
  
Clinical Trial Project Manager  
Zealand Pharma A/S 
Smedeland 36, 2600 Glostrup, Denmark 
Tel: 
 
 
E-mail: 
 
 
 
Clinical laboratory 
To be determined 
MLM Medical Labs GmbH 
 
Dohrweg 63, 41066 Mönchengladbach, Germany 
Tel: 
 
E-mail: 
 
 
 
 

 
 
ZP4207-16136 
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CLINICAL TRIAL PROTOCOL AMENDMENT 
 
A phase 3, Randomized, Double-Blind, Parallel Group Safety Trial to Evaluate the 
Immunogenicity of Dasiglucagon and GlucaGen® Administered Subcutaneously in 
Patients with Type 1 Diabetes Mellitus (T1DM) 
Sponsor code: ZP4207-16136 
SynteractHCR: ZEA-DNK-01711 
EudraCT number: 2017-000062-30 
 
Sponsor: 
Zealand Pharma A/S, 
Smedeland 36, 
2600 Glostrup, 
DENMARK 
Clinical Research Organization: 
SynteractHCR Deutchland GmbH,  
Albrechtstr. 14, 
80636 Munich 
GERMANY 
Study Drug Name: 
Dasiglucagon  
Development Phase: 
3  
Amendment Number: 
01 
Amendment Date: 
May 8th 2017 
Type of Amendment: 
Substantial  
Amendment to protocol: 
Final version 1, dated January 18th 2017 
 
The study will be conducted according to the protocol and in compliance with Good 
Clinical Practice (GCP), with the Declaration of Helsinki [1] and with other applicable 
regulatory requirements. 

 
 
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Declaration of the Investigator 
 
Title: A phase 3, Randomized, Double-Blind, Parallel Group Safety Trial to Evaluate the 
Immunogenicity of Dasiglucagon and GlucaGen® Administered Subcutaneously in 
Patients with Type 1 Diabetes Mellitus (T1DM) 
 
 
All documentation for this trial that is supplied to me and that has not been previously published 
will be kept in the strictest confidence. This documentation includes the protocol, and this trial 
protocol amendment number 1, Investigator's Brochure, Case Report Forms (CRFs), and other 
scientific data. 
The trial will not be commenced without the prior written approval of a properly constituted 
Institutional Review Board (IRB) or Independent Ethics Committee (IEC). No changes will be 
made to the trial protocol without the prior written approval of the Sponsor and the IRB or IEC, 
except where necessary to eliminate an immediate hazard to the patients. 
I have read and understood and agree to abide by all the conditions and instructions contained 
in this protocol amendment. 
 
Responsible Investigator of the local trial centre 
 
 
_____________________________________ 
_____________________ 
Signature  
 
 
 
 
 
Date 
 
_____________________________________ 
Name (block letters) 
 
_____________________________________ 
Title (block letters) 
 
_____________________________________ 
Institution (block letters) 
 
_____________________________________ 
Phone number 

 
 
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Table of Contents 
1 
Amendment type ................................................................................................... 6 
2 
Rationale for amendment ...................................................................................... 6 
3 
Summary of Amendment....................................................................................... 6 
4 
Changes and rationale: ......................................................................................... 7 
4.1 Clarification on the statistical method and anti-drug antibody (ADA) 
assays ........................................................................................................ 7 
4.2 Update of exclusion criterion on blood pressure .............................................. 7 
4.3 Update of exclusion criterion on alcohol/drug abuse ....................................... 7 
4.4 Specification of prohibited concomitant medication ......................................... 7 
4.5 Additional ECG assessment added ................................................................. 7 
4.6 Monitoring of patients’ electrolyte levels .......................................................... 8 
4.7 Clinical event of interest added ........................................................................ 8 
4.8 Treatment of patients experiencing hypo- or hyperglycemia prior 
dosing ......................................................................................................... 8 
4.9 Monitoring of potential pregnancies ................................................................. 8 
4.10 
Additional visits required for patients discontinuing treatment 
prematurely ................................................................................................ 8 
4.11 
Specification on time windows and order of assessments .......................... 9 
4.12 
Specification of the requirements at the dosing visits ................................. 9 
4.13 
Responsibility of unblinded trial personnel ................................................. 9 
4.14 
Randomization of replacement patients ..................................................... 9 
4.15 
Clarification to the reporting of (Serious) Adverse Events .......................... 9 
4.16 
Clarification on case report forms ............................................................... 9 
4.17 
Subgroup analyses added to statistical section .......................................... 9 
4.18 
Administrative changes ............................................................................ 10 
5 
Amended text ...................................................................................................... 10 
5.1 Clarification on the statistical method and anti-drug antibody (ADA) 
assays ...................................................................................................... 10 
5.2 Update of exclusion criterion on blood pressure ............................................ 13 
5.3 Update of exclusion criteria on alcohol/drug abuse ....................................... 13 
5.4 Specification of prohibited concomitant medication ....................................... 14 

 
 
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5.5 Additional ECG assessments added ............................................................. 15 
5.6 Monitoring of patients’ electrolyte levels ........................................................ 16 
5.7 Clinical event of interest added ...................................................................... 17 
5.8 Treatment of patients experiencing hypo- or hyperglycemia prior 
dosing ....................................................................................................... 19 
5.9 Monitoring of potential pregnancies ............................................................... 20 
5.10 
Additional visits required for patients discontinuing treatment 
prematurely .............................................................................................. 21 
5.11 
Specification on time windows for assessments ....................................... 21 
5.12 
Specification of the requirements at the dosing visits ............................... 22 
5.13 
Responsibility of unblinded trial personnel ............................................... 22 
5.14 
Randomization of replacement patients ................................................... 23 
5.15 
Clarification to the reporting of (Serious) Adverse Events ........................ 23 
5.16 
Clarification on case report form ............................................................... 24 
5.17 
Subgroup analysis added to statistical section ......................................... 24 
5.18 
Administrative and editorial changes ........................................................ 24 
 
 
 

 
 
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                          Page 6 of 26 
1 
Amendment type 
This is substantial amendment number 01 to trial protocol version 1, dated 18 January 2017. 
 
2 
Rationale for amendment 
The amendment will add precision to the description of the overall rationale of the trial. In 
addition, details pertaining to safety assessment of the patients are revised. Furthermore, the 
amendment serves to correct changes, errors or inconsistencies in the description of the 
operational set up of the trial.   
 
3 
Summary of Amendment 
With this substantial amendment number 01, the following changes are made to the original 
protocol: 
 
Clarification on the statistical method and anti-drug antibody (ADA) assays 
 
Update of exclusion criterion on blood pressure 
 
Update of exclusion criterion on alcohol/drug abuse 
 
Specification of prohibited concomitant medication 
 
Additional ECG assessment added 
 
Clinical event of interest added 
 
Treatment options for patients experiencing hypo- or hyperglycemia prior dosing 
 
Monitoring of patients’ electrolyte levels 
 
Monitoring of potential pregnancies 
 
Additional visits required for patients discontinuing treatment prematurely 
 
Specification on time windows for assessments 
 
Specification of the requirements at the dosing visits 
 
Responsibility of unblinded trial personnel 
 
Randomization of replacement patients 
 
Clarification to the reporting of (Serious) Adverse Events 
 
Clarification on case report forms 
 
Subgroup analysis added to the statistical section 
 
Administrative changes 
 
Section 4 of this amendment will describe the overall changes and rationales.  
Section 5 of this amendment will list the actual changes in the protocol text reflecting both 
superseded and new wording. 
 

 
 
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4 
Changes and rationale: 
4.1 
Clarification on the statistical method and anti-drug antibody (ADA) 
assays 
The primary objective has been updated to clarify that GlucaGen is considered a reference 
product and the objective of the trial is to evaluate the immunogenicity of both dasiglucagon and 
GlucaGen. It has been specified that the ADA assays to be used in this trial are both validated, 
but specific for dasiglucagon and GlucaGen, respectively. Hence, the performance of the 
assays are not directly comparable and a formal statistical comparison or non-inferiority testing 
is not performed. The rationale for the sample size calculation has been adapted accordingly. 
These clarifications have been implemented throughout the protocol including the protocol title. 
The rationale for the update is to clarify that the trial is not a non-inferiority trial and no formal 
statistical testing will be performed. 
 
4.2 
Update of exclusion criterion on blood pressure 
Exclusion criterion number 10 has been adjusted to exclude patients with a systolic blood 
pressure ≥160 mmHg or diastolic blood pressure ≥90 mmHg at screening. 
The rationale for narrowing the limit of allowed blood pressure values at screening is to only 
include patients of good health, apart from having type 1 diabetes, in the trial. 
 
4.3 
Update of exclusion criterion on alcohol/drug abuse 
Exclusion criterion number 19 has been updated to exclude patients with a significant history of 
alcohol or drug abuse or a positive alcohol or drug test at screening. Further, the limits for 
current alcohol consumption has been added.  
In addition, it has been specified in the protocol which drugs the drug test will screen for and 
that a positive drug test during the trial will be a withdrawal criteria. 
The rationale of the update is to ensure patients with a history or current abuse of alcohol 
and/or drugs are not included in the trial.  
 
4.4 
Specification of prohibited concomitant medication 
An additional exclusion criterion has been added to exclude patients using any non-prescription 
or prescription drugs known to cause QT prolongation. It has further been specified that 
metoclopramide (Primperan®) is the only allowed antiemetic treatment that can be used at the 
dosing visits; 2, 3, and 4. 
The rationale for the addition is due to the sporadic QTcB changes post 
dasiglucagon/GlucaGen administration observed in the phase 2 trial. 
 
4.5 
Additional ECG assessment added 
ECG will be measured at 20, 35, 45 and 60 minutes post dosing at all three dosing visits; 2, 3, 
and 4. 

 
 
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The rationale for the change is due to the sporadic QTcB changes post dasiglucagon/GlucaGen 
administration observed in the phase 2 trial. The updated time points for ECG assessments are 
to cover the range of tmax for dasiglucagon and GlucaGen at all three dosing visits. 
 
4.6 
Monitoring of patients’ electrolyte levels 
It has been added to exclusion criterion 16 that patients with altered electrolytes values of 
clinical relevance for cardiac conduction will be excluded from the trial. Further, the investigator 
must ensure that patients are actively treated to correct any electrolyte imbalances following 
potential events of vomiting at the dosing visits. 
The rationale for the change is to ensure that patients do not have any electrolyte imbalances 
that could potentially affect the cardiac conduction and the QT interval.  
 
4.7 
Clinical event of interest added 
Changes in blood pressure and/or pulse after dosing will be considered a clinical event of 
interest. Additional vital sign assessments have been added. 
The rationale for the addition is due to the nonclinical and clinical findings in healthy volunteers 
of hemodynamic changes with dasiglucagon. Due to these findings additional information on 
such events will be captured in a specific form in the case report form. 
 
4.8 
Treatment of patients experiencing hypo- or hyperglycemia prior dosing 
It has been specified that at all three dosing visits; 2, 3, and 4, the investigator should 
administer corrective doses of insulin if a patient has a plasma glucose >150 mg/dL before 
dosing. Likewise if a patient has a plasma glucose <70 mg/dL before dosing glucose ingestion 
should be provided to the patient. 
The rationale for this addition is to clarify how the investigator should ensure patients have a 
plasma glucose level on 70-150mg/dL before dosing.  
 
4.9 
Monitoring of potential pregnancies 
For women of childbearing potential a urine stick pregnancy test will be performed at the site 
prior dosing at all three dosing visits; 2, 3, and 4.  
If a female patient becomes pregnant in the period between the screening visit and the last 
dosing visit, she must be discontinued from trial treatment. 
The rationale for the change is to ensure that patients who have become pregnant in the period 
following the screening visit are not exposed to trial medication. 
 
4.10 Additional visits required for patients discontinuing treatment 
prematurely 
A patient prematurely discontinuing treatment will be asked to attend all three follow up visits; 5, 
6, and 7, to have all follow up assessments performed. Only in case a patient withdraw consent 
or is excluded before exposure to trial product the follow up visits can be omitted. 
The rationale for this addition is to avoid missing data for the primary and key secondary 
endpoints. 

 
 
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4.11 Specification on time windows and order of assessments 
Time window allowance has been added to collection time of safety blood samples, vital signs 
and local tolerability assessments. Further, the time for obtaining informed consent has been 
specified as well as the time of randomization. 
The rationale for the addition is to clarify the time and timing for the assessments to take place. 
 
4.12 Specification of the requirements at the dosing visits 
The requirements for fasting at the dosing visits; 2, 3, and 4, have been specified. Further, the 
instructions to patients prior dosing have been made more clear. 
The rationale for the addition is to clarify the procedures around the dosing visits. 
 
4.13 Responsibility of unblinded trial personnel 
The responsibility of the unblinded trial personnel has been clarified. 
The rationale for the addition is to clarify the procedures to maintain the double blinding.  
 
4.14 Randomization of replacement patients 
Replacement patients will not necessarily be randomized to the same treatment as the patient 
they are replacing.  
The rationale is that it is not technically possible nor needed to assign the replacement patients 
to the same treatment as the patient they are replacing. 
 
4.15 Clarification to the reporting of (Serious) Adverse Events 
It has been clarified that the investigator only needs to send the SAE form to the 
Pharmacovigilance unit (Safety CRO). Further, the text has been updated to make it more 
simple. 
The rationale for the changes is to make the process for SAE reporting more simple and to 
make the text more clear.  
 
4.16 Clarification on case report forms 
Minor clarifications have been made to the section on case report forms. E.g. it has been 
specified that no end-of-visit form will be used in the trial. 
The rational for the change is to correct minor errors and make the section more clear. 
 
4.17 Subgroup analyses added to statistical section 
It has been added that subgroup analyses by gender, age and race will be performed for the 
primary endpoint. Further details if needed will be provided in the statistical analysis plan. 
The rationale for including this in the protocol is due to regulatory requirements.  
 

 
 
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                          Page 10 of 26 
4.18 Administrative changes 
- 
IND and dasiglucagon SUB numbers have been added  
- 
Coordinating investigator and other trial personnel have been updated (changes also 
applicable for Appendix 1) 
 
5 
Amended text 
This section will list the actual changes in the protocol text reflecting both the original and the 
new wording. 
 
New wording is marked in underlined italics and deleted wording is marked with strikethrough.  
 
5.1 
Clarification on the statistical method and anti-drug antibody (ADA) 
assays 
Front page: 
Updated text: 
A phase 3, Randomized, Double-Blind, Parallel Group Safety Trial to Evaluate the 
Immunogenicity of Dasiglucagon and compared to GlucaGen® Administered Subcutaneously in 
Patients with Type 1 Diabetes Mellitus (T1DM) 
 
Section 1. Signatures and agreement with protocol 
Updated text: 
Title: A phase 3, Randomized, Double-Blind, Parallel Group Safety Trial to Evaluate the 
Immunogenicity of Dasiglucagon and compared to GlucaGen® Administered Subcutaneously in 
Patients with Type 1 Diabetes Mellitus (T1DM) 
Section 2. Trial synopsis 
Title of the trial 
Updated text: 
A phase 3, Randomized, Double-Blind, Parallel Group Safety Trial to Evaluate the 
Immunogenicity of Dasiglucagon and compared to GlucaGen® Administered Subcutaneously in 
Patients with Type 1 Diabetes Mellitus (T1DM) 
 
Objectives 
Updated text: 
The primary objective is to evaluate the immunogenicity of repeated single doses of 
dasiglucagon and GlucaGen following subcutaneous (s.c.) administration compared with s.c. 
GlucaGen in T1DM patients. 
 
Trial design 
Updated text: 
This is a randomized, double-blind, parallel group trial evaluating comparing the immunogenicity 
of either dasiglucagon or GlucaGen administered to euglycemic T1DM patients. 

 
 
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                          Page 11 of 26 
 
Statistical methods: 
Updated text: 
All statistical analysis will be descriptive i.e. no formal statistical testing will be performed. 
Continuous variables will be summarized with means, standard deviations, medians, minimums, 
and maximums, and valid cases. 
 
Sample size calculation: 
Updated text: 
The purpose of the present trial is to generate data describing the immunogenic potential of 
dasiglucagon and GlucaGen., when used as a rescue therapy form severe hypoglycemia and 
with reference to the immunogenic potential of GlucaGen. The sample size is based on 
generating data to show that the 90% confidence of the ADA incidence is no worse than 15% as 
the predefined acceptability criterion and with a reference to similar data being generated for 
GlucaGen.The ADA assays to be used in this trial are both validated, but specific for GlucaGen 
and dasiglucagon, respectively, and the performance of the assays are thus not directly 
comparable. As a consequence, a formal comparison or non-inferiority analysis will not be 
performed.  
Currently, no ADA incidences have been detected in the completed clinical trials, where up to 5 
repeated doses of dasiglucagon have been administered to the same patients within a week. 
Across the two phase 1 clinical trials and a completed phase 2 
pharmacokinetic/pharmacodynamic trial, a total of 141 subjects have been exposed to 
dasiglucagon and no incidences of ADA development have been observed. The obtained data 
indicate that dasiglucagon has a low risk for induction of ADAs in the investigated settings and 
as a consequence the sample size is based on showing that the ADA incidence is no worse 
than the predefined margin of 15%.a meaningful sample size to compare both treatments 
cannot be estimated. 
The sample size is therefore based on a certain precision of the confidence interval for the 
overall ADA incidence if no events are observed, respectively to ensure a certain probability for 
observing one event. 
When no events are observed, to obtain an upper bound of 0.050 on the 90.0% confidence 
interval for the probability of such a rare event, would require a sample size of 45. Respectively, 
accepting a chance of observing at least one event of 90% and an actual probability of the 
event of 5% leads to a sample size of 45 patients completing the trial. In order to account for 
drop-outs, It is expected that 112 patients in total will be randomized and treated. 
 
Section 5.2 Trial rationale 
Updated text: 
The present trial aims to evaluate that immunogenicity risk with an assessment of the 
occurrence of ADAs and neutralizing ADAs, and of cross-reactivity with native glucagon, 
following repeated single doses of dasiglucagon by s.c. administration in T1DM patients. The 
reference product comparator in this trial is GlucaGen, a recombinant human glucagon 
approved for the treatment of the severe hypoglycemic reactions that may occur in the 
management of insulin-treated children and adults with diabetes mellitus. Given the differences 
in ADA assay for dasiglucagon and GlucaGen, a formal statistical comparison or non-inferiority 
testing is not performed. 
 

 
 
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Section 6 Trial objectives 
Updated text: 
Primary objective 
 
To evaluate the immunogenicity of repeated single doses of dasiglucagon and 
GlucaGen following s.c. administration compared with s.c. GlucaGen in T1DM patients. 
 
Section 7.2 Discussion of trial design and choice of control groups 
Updated text: 
Euglycemic patients with T1DM will be randomized 1:1 in order to evaluate the immunogenicity 
of dasiglucagon and compared to GlucaGen. The randomized, double-blind, parallel group 
design, with administration of 3 fixed consecutive doses of randomized trial medication 
(dasiglucagon or GlucaGen) to the same patient will allow characterization of immunogenic 
potential for and a relative comparison of the immunogenicity between the 2 products. 
 
Section 7.3 Selection of trial population 
Updated text: 
Dasiglucagon is indicated for treatment of severe hypoglycemia in patients with T1DM. Given 
the role of the immune system in the pathogenesis of T1DM, the present trial aims to evaluate 
the immune response of patients with T1DM taking repeated single doses of s.c. dasiglucagon 
and compared to GlucaGen.  
 
Section 10.1.1 General Considerations 
New text: 
All statistical analysis will be descriptive i.e. no formal testing will be performed. 
 
Section 10.1.2 Classification of patients to subsets 
Updated text: 
The following definitions are applicable: 
Safety analysis set 
(SAS) 
all patients who were randomized and received at least one 
dose of trial medication 
Full analysis set 
(FAS) 
all patients of the SAS with at least one measurement of the 
ADA titer at baseline 
Per Protocol set 
(PPS) 
all patients of the FAS for whom no relevant protocol deviations 
were documented 
 
Section 10.2 Determination of sample size 
Updated text: 
The purpose of the present trial is to generate data describing the immunogenic potential of 
dasiglucagon and GlucaGen., when used as a rescue therapy form severe hypoglycemia and 
with reference to the immunogenic potential of GlucaGen. The sample size is based on 
generating data to show that the 90% confidence of the ADA incidence is no worse than 15% as 
the predefined acceptability criterion and with a reference to similar data being generated for 
GlucaGen.The ADA assays to be used in this trial are both validated, but specific for GlucaGen 

 
 
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                          Page 13 of 26 
and dasiglucagon, respectively, and the performance of the assays are thus not directly 
comparable. As a consequence, a formal comparison or non-inferiority analysis will not be 
performed.  
Currently, no ADA incidences have been detected in the completed clinical trials, where up to 5 
repeated doses of dasiglucagon have been administered to the same patients within a week. 
Across the two phase 1 clinical trials and a completed phase 2 
pharmacokinetic/pharmacodynamic trial, a total of 141 subjects have been exposed to 
dasiglucagon and no incidences of ADA development have been observed. The obtained data 
indicate that dasiglucagon has a low risk for induction of ADAs in the investigated settings and 
as a consequence the sample size is based on showing that the ADA incidence is no worse 
than the predefined margin of 15%.a meaningful sample size to compare both treatments 
cannot be estimated. 
The sample size is therefore based on a certain precision of the confidence interval for the 
overall ADA incidence if no events are observed, respectively to ensure a certain probability for 
observing one event. 
When no events are observed, to obtain an upper bound of 0.050 on the 90.0% confidence 
interval for the probability of such a rare event, would require a sample size of 45. Respectively, 
accepting a chance of observing at least one event of 90% and an actual probability of the 
event of 5% leads to a sample size of 45 patients completing the trial. In order to account for 
drop-outs, It is expected that 112 patients in total will be randomized and treated. 
 
5.2 
Update of exclusion criterion on blood pressure 
Section 2. Trial synopsis, Exclusion criteria 
Updated text: 
10. Inadequately treated blood pressure as defined as systolic blood pressure ≥160 180 mmHg 
or diastolic blood pressure ≥90 110 mmHg at screening 
 
Section 7.3.2 Exclusion criteria 
Updated text: 
10. Inadequately treated blood pressure as defined as systolic blood pressure ≥160 180 mmHg 
or diastolic blood pressure ≥90 110 mmHg at screening 
 
5.3 
Update of exclusion criteria on alcohol/drug abuse 
Section 2. Trial synopsis, Exclusion criteria 
Updated text: 
19. Active substance of alcohol abuse. A positive result in the alcohol and/or urine drug screen 
at the screening visit. Significant history of alcoholism or drug abuse as judged by the 
investigator or consuming more than 24 g alcohol per day for men, or more than 12 g alcohol 
per day for women.  
 
Section 7.3.2 Exclusion criteria 
Updated text: 
19. Active substance of alcohol abuse. A positive result in the alcohol and/or urine drug screen 
at the screening visit. Significant history of alcoholism or drug abuse as judged by the 

 
 
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investigator or consuming more than 24 g alcohol per day for men, or more than 12 g alcohol 
per day for women.  
 
Section 7.3.3.1 Possible reasons for patient discontinuation  
Updated text: 
A patient will be discontinued if the following applies: 
 
If a protocol deviation occurs which, in the clinical judgment of the Investigator, can 
invalidate the assessment of ADA responses to dasiglucagon or glucagon, the patient 
will be withdrawn by the Investigator 
 
AEs that are considered unacceptable by the patient or the Investigator 
 
Positive result from an urine drug screen test 
 
Section 7.6.4.1 Safety laboratory tests 
Updated text: 
Alcohol breath tests and urine drug screen (amphetamine, cocaine, MDMA, methamphetamine, 
opiate/morphine, marihuana) will be performed at Screening (Visit 1) and at Visits 2, 3, and 4. 
 
5.4 
Specification of prohibited concomitant medication 
Section 2. Trial synopsis, Exclusion criteria 
New text: 
23. Use of prescription or non-prescription medications known to cause QT prolongation 
 
Section 7.3.2. Exclusion criteria 
New text: 
23. Use of prescription or non-prescription medications known to cause QT prolongation 
 
Section 7.4.2 Treatments administered 
Updated text: 
 
antiemetic treatment e.g. in the form of an 8 mg slow intravenous (i.v.) dose of 
ondansetron (Zofran®) or alternatively a 10 mg slow i.v. dose of metoclopramide 
(Primperan®) as per local label, administered before or after dosing. 
 
 

 
 
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5.5 
Additional ECG assessments added 
Table 2-1 Flow chart  
 
 
Footnotes 
New text: 
10 On dosing days Visit, 2, 3 and 4 ECG’s are assessed pre-dose, and at 20, 35, 45 and 60 min post-
dosing. The actual time for assessment should not deviate from the nominal time by more than ±5 min. 
Pre-dose is defined as within 5 min prior to dosing. 
 
Section 7.5.3 Procedures and assessments during the treatment period of the trial 
Visit 2 and 4:  
Updated text: 
 
ECG (pre-dose, and at 20, 35, 45 30 and 90 60 min post-dosing) 
 
Visit 3: 
New text: 
 
ECG (pre-dose, and at 20, 35, 45 and 60 min post-dosing) 
 
Section 7.6.4.2 Safety examinations 
Updated text: 
ECG is assessed at Screening (Visit 1) Visits 2, 3, and 4… 
 

 
 
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5.6 
Monitoring of patients’ electrolyte levels 
Section 2. Trial synopsis, Exclusion criteria 
Updated text: 
16. Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >2.5 X the upper 
limit of normal (ULN), bilirubin >1.5 X ULN, estimated glomerular filtration rate (eGFR) 
<30 mL/min/1.73m2 according to the Modification of Diet in Renal Disease (MDRD) 
Study definition. Altered electrolytes values of clinical relevance for cardiac conduction, 
as judged by the investigator.  
 
Section 7.3.2 Exclusion criteria 
Updated text: 
16. Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >2.5 X the upper 
limit of normal (ULN), bilirubin >1.5 X ULN, estimated glomerular filtration rate (eGFR) 
<30 mL/min/1.73m2 according to the Modification of Diet in Renal Disease (MDRD) 
Study definition. Altered electrolytes values of clinical relevance for cardiac conduction, 
as judged by the investigator.  
 
Section 7.4.2 Treatments administered 
New text: 
Patients will not be discharged until they are considered stable and with a blood glucose level in 
the range of 70-180 mg/dL. Before discharge, the investigator will provide instructions to the 
patients on management of their blood glucose levels. Each trial medication will be 
administered s.c. 3 times in total, with 7 days between dosing (i.e. dosing occurs at Days 0, 7, 
and 14; Visits 2, 3, and 4). Should the patient experience vomiting following the first or second 
dasiglucagon or GlucaGen administration, the investigator must ensure normal electrolytes prior 
to the next dosing day. An electrolyte imbalance can be corrected by administration of an 
electrolyte supplement or by any other treatment modality considered appropriate by the 
investigator.   
 
 

 
 
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5.7 
Clinical event of interest added 
Table 2-1 Flow chart 
 
 
Footnotes 
New text: 
12 On dosing days Visit 2, 3, and 4 vital signs are collected pre-dose and at 30, 90 and 120 min post-
dosing. The actual time of assessment should not deviate from the nominal time by more than ±5 min. 
Pre-dose is defined as within 5 min prior to dosing. 
 
Section 5.1 Background of the trial, Safety of Dasiglucagon 
Updated text: 
Glucagon has been described to exert positive inotropic and chronotropic effects and may 
therefore cause tachycardia and hypertension. In the phase 1 clinical trials, but not the phase 2 
trial, temporary but clinically significant decreases in blood pressure were observed in a few 
healthy volunteers receiving investigational medicinal product (IMP) doses of at least 1.0 mg (4 
with dasiglucagon and 1 with GlucaGen). This is not considered a safety concern, however 
hemodynamic changes post dosing will be considered a clinical event of interest. 
ThereforeThe The phase 1 and 2 results and the safety profile described to date do not give rise 
to specific safety concerns. 
 
Section 7.5.3 Procedures and assessments during the treatment period of the trial 
Visit 2 and 4:  
Updated text: 
 
Vital signs (pre-dose, and at 30, and 90 and 120 min post-dosing) 
 

 
 
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Visit 3: 
New text: 
 
Vital signs (pre-dose, and at 30, 90 and 120 min post-dosing) 
 
Section 7.6.4.2 Safety examinations 
Updated text: 
ECG is assessed at Screening (Visit 1) Visits 2, 3, and 4 and vital signs are assessed at 
Screening (Visit 1) Visits 2, 3, 4, 5, and 7. 
 
Section 8.1 Definitions 
New text: 
Clinical event of interest 
A clinical event of interest is an event which, in the evaluation of safety, has a special focus 
(e.g. required by health authorities). 
In this trial hemodynamic changes, as defined below, are considered clinical event of interest: 
 
Post-dose clinical signs, or measured vital signs, indicating a clinical significant drop 
in blood pressure including signs of orthostatic hypotension, vasovagal responses or 
bradycardia 
 
Post-dose change in pulse or blood pressure considered an event of hypo- or 
hypertension as judged by the investigator. 
 
Section 8.2 Collection, recording and reporting of adverse events 
Updated text: 
All AEs must be recorded by the Investigator. One single Adverse Event Form must be used per 
AE from start to resolution. For SAEs, the Serious Adverse Event Form must also be completed. 
For clinical events of Interest, the Clinical Event of Interest Form must also be completed. 
AE information should include the following: 
 
Date and time of onset and resolution 
 
Date and time of Investigator’s first information on the (S)AE 
 
Seriousness 
 
Severity 
 
Causal relationship with IMP 
 
Interruption or withdrawal of treatment with IMP and other measures taken 
 
Outcome 
All AEs are coded; details are described in the trial specific Data Management Plan.  
If an event classifies as a clinical event of interest, the Investigator must tick the Clinical Event 
of Interest box on the AE form and complete the Clinical Event of Interest Form. The Clinical 
Event of Interest Form will capture if the event was associated with any signs or symptoms and 
capture the highest/lowest blood pressure and pulse measured during the event. 
 
 

 
 
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5.8 
Treatment of patients experiencing hypo- or hyperglycemia prior dosing 
Table 2-1 Flow chart, footnotes 
Updated text: 
9 Prior to administration of trial medication patients must reach a target plasma glucose level of 70-150 
mg/dL. Plasma glucose levels may be adjusted by subcutaneous (s.c.) administration of a fast-acting 
insulin analog or by glucose ingestion at the discretion of the investigator.  
 
Section 7.4.2 Treatments administered 
Updated text: 
Prior to administration of trial medication at all dosing visits patients must reach a target plasma 
glucose level of 70-150 mg/dL. If the patient presents with plasma glucose > 150 mg/dL, 
corrective amounts of fast acting insulin will be administered at the investigator’s discretion. 
Plasma glucose measured after 20 and after 40 minutes should ensure that the patient has 
reached the targeted 70-150 mg/dL. If the patient presents with plasma glucose < 70 mg/dL 
glucose ingestion will be provided in order to reach target plasma glucose of 70-150 mg/dL 
documented by plasma glucose measurements after 20 and 40 minutes, respectively. Plasma 
glucose levels may be adjuseted by s.c. administration of a fast acting insulin analog if blood 
glucose exceeds 150 mg/dL or by glucose ingestion if blood glucose is below 70 mg/dL. 
 
Section 7.5.3 
Visit 2 and 4: 
Updated text: 
 
Prior to administration of trial medication at all dosing visits patients must reach a target 
plasma glucose level of 70-150 mg/dL. If the patient presents with plasma glucose > 150 
mg/dL, corrective amounts of fast acting insulin will be administered at the investigator’s 
discretion. Plasma glucose measured after 20 and after 40 minutes should ensure that 
the patient has reached the targeted 70-150 mg/dL. If the patient present with plasma 
glucose < 70 mg/dL glucose ingestion will be provided in order to reach target plasma 
glucose of 70-150 mg/dL documented by plasma glucose measurements after 20 and 40 
minutes, respectively. Plasma glucose levels may be adjuseted by s.c. administration of 
a fast acting insulin analog or by glucose ingestion. 
 
Visit 3: 
Updated text: 
 
Prior to administration of trial medication at all dosing visits patients must reach a target 
plasma glucose level of 70-150 mg/dL. If the patient presents with plasma glucose > 150 
mg/dL, corrective amounts of fast acting insulin will be administered at the investigator’s 
discretion. Plasma glucose measured after 20 and after 40 minutes should ensure that 
the patient has reached the targeted 70-150 mg/dL. If the patient present with plasma 
glucose < 70 mg/dL glucose ingestion will be provided in order to reach target plasma 
glucose of 70-150 mg/dL documented by plasma glucose measurements after 20 and 40 
minutes, respectively. Plasma glucose levels may be adjuseted by s.c. administration of 
a fast acting insulin analog or by glucose ingestion. 
 
 

 
 
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5.9 
Monitoring of potential pregnancies 
Table 2-1 Flow chart  
 
 
Footnotes 
New text: 
11 Pregnancy test is only applicable for women of childbearing potential. At Visit 1 a serum pregnancy test 
should be performed. At Visit 2, 3 and 4 a pre-dose urine pregnancy test should be performed.  
 
Section 7.3.3.1 Possible reasons for patient discontinuation 
New Text: 
A patient will be discontinued if the following applies: 
 
Pregnancy. If a female patient becomes pregnant in the time between the screening visit 
and any one of the dosing visits 
 
Section 7.5.1 Screening examination 
Updated text: 
 
Pregnancy test (women of childbearing potential only) 
 
Section 7.5.3 Procedures and assessments during the treatment period of the trial 
Visit 2 and 4: 
New text: 
 
Urine pregnancy test (pre-dose) at trial site (women of childbearing potential only) 
 
Visit 3 
New text: 
 
Urine pregnancy test (pre-dose) at trial site (women of childbearing potential only) 
 
Section 7.6.4.1 Safety laboratory tests 
Updated text: 
A pregnancy test will be performed at screening (Visit 1) and pre-dose at the three dosing visits 
(Visit 2, 3 and 4) for women of childbearing potential only. 
 
 

 
 
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5.10 Additional visits required for patients discontinuing treatment 
prematurely 
Section 7.3.3.1 Possible reasons for patient discontinuation 
New text: 
If discontinuation occurs following administration of any trial medication, the patient will be 
asked to return and participate in the complete follow-up visits at trial Day 35, 60, and 104. 
 
Section 7.4.2 Treatments administered 
New text: 
Following the first (Visit 2) and third (Visit 4) dose administration, patients must be fasting for 90 
min after dosing. Following the 90-min blood sample draw after the administration of the first 
(Visit 2) and third (Visit 4) dose administration, patients may be treated individually in order to 
alleviate any potential side effects in order to minimize prematurely treatment discontinuation 
withdrawals and consequently reduce the amount of missing data. This treatment can also be 
instituted immediately after the second dose administration (Visit 3), as pharmacodynamics will 
not be assessed at this visit.  
 
In order to minimize the number of patients discontinuing treatment prematurely and 
consequently reduce the amount of missing data, the following treatment modalities may be 
used, as considered appropriate by the investigator:  
 
5.11 Specification on time windows for assessments 
Flowchart 2-1, footnotes 
New text: 
1 Informed consent can be obtained on the same day as screening, but prior to any trial-related 
procedures At least 1 day before the screening visit (Visit 1) 
… 
4 Coagulation parameters are measured at screening visit only. On dosing days Visit 2 and 4, vital signs, 
ECG’s and blood samples are collected pre-dose, and at 30 and 90 min post-dosing. The actual time for 
sampling/assessment should not deviate from the nominal time by more than ±5 min. Pre-dose is 
defined as within 5 min prior to dosing. 
5 Local tolerability assessed at 0.5 and 2 h post-dose. The actual time for assessment should not deviate 
from the nominal time by more than ±10 min. 
 
Section 7.5.3 Procedures and assessments during the treatment period of the trial 
Updated text: 
At Visit 2 (Day 0) patient eligibility is rechecked (check of changes between the screening visit 
and Visit 2). Withdrawal criteria and dosing day exclusion criteria are also checked and patients 
eligible to participate will be randomized to treatment with dasiglucagon or GlucaGen.  
Additionally, during the treatment period of the trial, at Visits 2 and 4 (Days 0 and 14), the 
following assessments will take place: 
 
Concomitant medication 
 
Check of withdrawal criteria (prior randomization at Visit 2) 
 
Check of dosing day exclusion criteria (prior randomization at Visit 2) 

 
 
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5.12 Specification of the requirements at the dosing visits 
Table 2-1 Flowchart, footnotes 
Updated text: 
9 Prior to administration of trial medication patients must reach a target plasma glucose level of 70-150 
mg/dL. Plasma glucose levels may be adjusted by administration if fast-acting insulin analog or by glucse 
ingestion. Patients At visit 2 and 4 patients must be fasting for 90 min after administration of trial 
medication and will be treated individually to alleciate any potential side effects. At all dosing visits 
Ppatients will be treated individually to alleviate any potential side effects and will be observed for at least 
5 h post-dose. 
 
Section 7.4.2 Treatments administered 
Updated text: 
At visit 2 and 4: 
 
90 min after dosing patients will be allowed to eat and drink moderately to make 
them feel comfortable 
 
90 min after dosing a moderate and individualized corrective dose of insulin to 
convert the induced hyperglycemia to euglycemia, after agreement with the 
investigator 
 
antiemetic treatment in the form of metoclopramide (Primperan®) as per local label, 
administered before or after dosing 
 
At visit 3:  
 
patients will be allowed to eat and drink moderately to make them feel comfortable 
 
a moderate and individualized corrective dose of insulin to convert the induced 
hyperglycemia to euglycemia, after agreement with the investigator 
    antiemetic treatment e.g. in the form of an 8 mg slow intravenous (i.v.) dose of 
ondansetron (Zofran®) or alternatively a 10 mg slow i.v. dose of metoclopramide 
(Primperan®) as per local label, administered before or after dosing. 
 
Section 7.5.2 Instructions to patients prior to dosing 
Updated text: 
On dosing days, patients are allowed to consume a small meal for breakfast with corresponding 
administration of rapid acting insulin to address the meal and in accordance with their normal 
management of blood glucose levels. At visit 2 and visit 4 the patient should aim to have a 
similar sized breakfast and corresponding rapid acting insulin dose.  
 
5.13 Responsibility of unblinded trial personnel 
Section 7.4.6 Blinding 
New text: 
This is a double-blind trial. Since dasiglucagon is available as a liquid formulation and 
GlucaGen is available as a powder for reconstitution, and they are therefore not identical in 
appearance, unblinded trial personnel will be responsible for handling, preparing according to 

 
 
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the prescription from the IWRS, and administering the trial medication and keep the records 
strictly confidential and accessible only for unblinded staff until after database lock. 
 
5.14 Randomization of replacement patients 
Section 7.3.4 Replacement of patients 
Updated text: 
Patients prematurely withdrawn from the trial will be replaced in order to reach 90 completed 
patients. Replacement patients will receive the same treatment allocation (i.e. 3 doses of 
dasiglucaon or GlucaGen) as the patients they are replacing. 
 
5.15 Clarification to the reporting of (Serious) Adverse Events 
Section 8.2 Collection recording and reporting of adverse events 
Updated text: 
At each contact with the site (visit or telephone, excluding safety visits, where the patient is not 
seeing the Investigator or his staff (e.g. visits to the laboratory)) the patient must be asked about 
AEs.  
… 
The Investigator must report initial information in writing (fax or email) on all SAEs to the 
responsible medical monitor of the Sponsor (Zealand) and to the Sponsor’s responsible 
pharmacovigilance unit (Safety CROPharmalex) immediately (within 24 hours) after obtaining 
knowledge about the event. Please refer to Appendix 1 for contact details. The Safety CRO will 
inform the medical monitor and the sponsor about the reported SAEs. 
 
Name:  
 
Company:  PharmaLex (formerly Lindeq) 
Address:  Agern Allé 24, DK 2970 Hørsholm, Denmark 
Tel:  
 (8 a.m. to 4 p.m.) 
 (outside 8 a.m. to 4 p.m.)   
Fax:  
 
E mail: 
drugsafety@lindeq.com  
 
In addition, and meeting the same timeline, Investigators have to report all SAEs to Zealand by 
forwarding the SAE form electronically (e.g. in PDF format) within 24 hours to the 
representatives of Zealand. 
 
Names:  
 and 
 
Address: Smedeland 36, DK 2600 Glostrup, Denmark 
Tel: 
 / 
 
E mails: 
 / 
 
 

 
 
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It is the responsibility of PharmaLexthe Safety CRO to report all SUSARs that occur in this trial 
to the Competent Authorities and IRBs/IECs in accordance with the local requirements in force 
and ICH guideline for GCP. The trial monitor must be informed accordingly. 
 
Section 8.7 Safety Committee 
Updated text: 
As a minimum tThe SC convenes every quarter to review relevant safety information, including 
AEs and laboratory data. 
 
5.16 Clarification on case report forms 
Section 9.1 Case report forms 
Updated text: 
All key pages will be signed or initialed by the investigator, signifying agreement with and 
responsibility for the recorded data. Key pages are the following: end of visit form, AE-reporting 
form, trial medication form, concomitant medication form and trial-closure form.  
Data directly captured in the eCRF (i.e., data assigned or calculated automatically by the EDC 
system) is called e-source. A trial specific list should be generated prior to the performance of 
the trial, which specifies which data fields in the Case Report Form will be used by the medical 
personnel for direct entry during the performance of the trial. This means that these data fields 
in the CRF are source documents. For the other CRF data fields, which are entered by medical 
personnel during the trial, the source data will be found in other documents (such as patients’ 
files, worksheets, etc.), that is i.e. for these CRF data fields the “other” documents are the 
source documents. Should such a list be created, it should be submitted to the authorities 
together with the protocol. 
 
5.17 Subgroup analysis added to statistical section 
10.1.9 Subgroup analysis 
Updated text: 
Subgroup analyses for the primariy endpoint (voerl ADA incidence) by gender, age, and race 
will be performed. No subgroup analysis is currently planned. 
 
5.18 Administrative and editorial changes 
Front page 
New text: 
Sponsor code: ZP4207-16136 
SynteractHCR: ZEA-DNK-01711 
EudraCT number: 2017-000062-30 
IND Number: 127866 
Dasiglucagon SUB code: SUB181296 
 
Coordinating Investigator 
Updated text: 

 
 
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Linda Morrow, MD 
Prosciento 
855 Third Avenue 
91911 Chula Vista 
CA, USA 
Thomas R. Pieber, MD 
Medical University of Graz  
Auenbruggerplatz 15 
A-8036 Graz, Austria 
 
Section 1. Signatures and agreement with protocol 
Updated text: 
Coordinating Investigator: 
Linda Morrow, MD 
 
 
 
 
Prosciento 
 
 
 
 
855 Third Avenue 
91911 Chula Vista 
CA, USA 
 
 
 
 
 
Thomas R. Pieber, MD 
Medical University of Graz  
Auenbruggerplatz 15 
A-8036 Graz, Austria 
 
 
Sponsor’s representative:  
 
, MSc (Pharm) 
 
 
 
 
Clinical Trial Project Manager  
Zealand Pharma A/S 
Smedeland 36, 2600 Glostrup, Denmark 
 
Section 2. Trial synopsis 
Coordinating Investigator 
Updated text: 
Linda Morrow, MD, Prosciento, 855 Third Avenue, 91911 Chula Vista,  
CA, USA 
 
Thomas R. Pieber, MD, Medical University of Graz, Auenbruggerplatz 15, A-8036 Graz, Austria 
 
Planned trial period 
Updated text: 
First Patient First Visit: May March 2017 
Last Patient First Visit: November September 2017 

 
 
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APPENDIX 1: 
 
Coordinating investigator 
Linda Morrow, MD  
Prosciento  
855 Third Avenue 
91911 Chula Vista, CA, USA 
Thomas R. Pieber, MD 
Medical University of Graz  
Auenbruggerplatz 15 
A-8036 Graz, Austria 
 
Trial Monitor 
To be decided 
SynteractHCR Deutschland GmbH 
Albrechtstr. 14 
80636 Munich, Germany 
 
Sponsor representative 
 
  
Clinical Trial Project Manager  
Zealand Pharma A/S 
Smedeland 36, 2600 Glostrup, Denmark 
Tel: 
 
 
E-mail: 
 
 
 
Clinical laboratory 
To be determined 
MLM Medical Labs GmbH 
 
Dohrweg 63, 41066 Mönchengladbach, Germany 
Tel: 
 
E-mail: 
 
 
 
 

 
 
 
Clinical Trial Protocol, final version 2 
ZP4207-16136 (ZEA-DNK-01711) 
 
08 May 2017  
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Page 1/49 
 
 
 
 
Clinical Trial Protocol 
A phase 3, Randomized, Double-Blind, Parallel Group Safety Trial to Evaluate the 
Immunogenicity of Dasiglucagon and GlucaGen® Administered Subcutaneously in 
Patients with Type 1 Diabetes Mellitus (T1DM) 
Sponsor code: ZP4207-16136 
SynteractHCR: ZEA-DNK-01711 
EudraCT number: 2017-000062-30 
IND Number: 127866 
Dasiglucagon SUB code: SUB181296 
 
 
Coordinating investigator:  
Thomas R. Pieber, MD 
Medical University of Graz  
Auenbruggerplatz 15 
A-8036 Graz, Austria 
 
 
Sponsor:  
Zealand Pharma A/S 
 
Smedeland 36 
 
2600 Glostrup, Copenhagen 
 
Denmark 
 
 
Version: final version 2. This version includes Protocol version 1, dated 18 January 2017 and 
Protocol Amendment 1, dated 08 May 2017 
Date: 08 May 2017 
 
 
 
 
 
GCP statement 
This trial will be performed in compliance with Good Clinical Practice (GCP),  
the Declaration of Helsinki (with amendments) and local legal and regulatory requirements.

 
Clinical Trial Protocol, final version 2 
ZP4207-16136 (ZEA-DNK-01711) 
 
08 May 2017  
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Title: A phase 3, randomized, double-blind, parallel group safety trial to evaluate the 
immunogenicity of dasiglucagon and GlucaGen® administered subcutaneously in patients with 
type 1 diabetes mellitus (T1DM) 
I agree to conduct this trial according to the Trial Protocol.  
I agree that the trial will be carried out in accordance with Good Clinical Practice (GCP), with the 
Declaration of Helsinki (with amendments) and with the laws and regulations of the countries in 
which the trial takes place. 
 
 
 
Investigator 
  
 
 
 
 
 
 
Date 
 
Signature 
 
 
 
 
 
Name and 
address 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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2. Trial synopsis 
Title of the trial: 
A phase 3, randomized, double-blind, parallel group safety trial to evaluate the immunogenicity of 
dasiglucagon* and GlucaGen® administered subcutaneously in patients with type 1 diabetes mellitus 
(T1DM) 
* Dasiglucagon is the proposed international nonproprietary name 
EudraCT number: 
2017-000062-30 
 
Protocol codes: 
Sponsor: ZP4207-16136 
SynteractHCR: ZEA-DNK-01711 
Sponsor or sponsor's representative in the European Union: 
Zealand Pharma A/S, Smedeland 36, 2600 Glostrup (Copenhagen), Denmark 
Coordinating investigator: 
Thomas R. Pieber, MD, Medical University of Graz, Auenbruggerplatz 15,A-8036 Graz, Austria 
Trial center(s): 
2 centers in the EU, 2 centers in the US, and 3 centers in Canada 
Planned trial period: 
First Patient First Visit: May 2017 
Last Patient First Visit: November 2017 
Phase of Development:  
Phase 3 
Objectives: 
The primary objective is to evaluate the immunogenicity of repeated single doses of dasiglucagon and 
GlucaGen following subcutaneous (s.c.) administration in T1DM patients. 
The secondary objective is to evaluate the safety and tolerability of repeated single doses of 
dasiglucagon following s.c. administration compared with s.c. GlucaGen in T1DM patients. 
Trial design: 
This is a randomized, double-blind, parallel group trial evaluating the immunogenicity of either 
dasiglucagon or GlucaGen administered to euglycemic T1DM patients. Patients will be randomized 
1:1 to receive 3 s.c. injections of dasiglucagon or GlucaGen with 1 week between doses. Patients will 
be followed for at least 3 months from the day of the first dose to assess any immune response. A 
total of 90 patients are expected to complete the trial. Handling, preparation and administration of trial 
medication will be done by unblinded trial personnel. All trial assessments will be done by blinded trial 
personnel. However, exposure assessments and anti-drug antibody (ADA) assessments will be 
performed by unblinded personnel at the specialty laboratories, to make sure that dasiglucagon or 
GlucaGen administration is matched with the applicable bioanalytical assay. 
Planned number of patients: 
90 completed patients (45 completed patients per treatment group). Prematurely discontinued 
patients will be replaced in order to reach 90 completed patients. It is expected that 112 patients in 
total will be randomized and treated. 
To qualify as completed, the patient must be dosed according to protocol and have blood drawn for 
the planned anti-drug antibody (ADA) analyses. 
Medical condition or disease under investigation: 
Given the role of the immune system in the pathogenesis of T1DM, the present trial is conducted in 
patients with T1DM. There are no data indicating an altered immune response with varying blood 
glucose levels. Therefore, for the safety and well-being of the patients, they will not be brought into 
hypoglycemia prior to dosing. Patients with previous exogenic glucagon exposure will not be excluded 
from the trial, but the information on previous glucagon administration will be recorded. 
Inclusion criteria: 
To be included in the trial, patients have to fulfill all of the following criteria: 
1. Informed consent obtained before any trial-related activities (trial-related activities are any 
procedure that would not have been performed during normal management of the patient) 
2. Availability for the entire trial period 
3. Age between 18 and 70 years, both inclusive 
4. Male or female patients with T1DM for at least 1 year. Diagnostic criteria as defined by the 

 
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American Diabetes Association 
5. Hemoglobin A1c (HbA1c) <10% 
6. Stable anti-diabetic treatment for at least 1 month (e.g. within 10% insulin dose adjustment) 
7. A female participant must meet one of the following criteria 
a. Participant is of childbearing potential and agrees to use one of the accepted contraceptive 
regimens throughout the entire duration of the trial from screening until last follow-up visit. An 
acceptable method of contraception includes at least one of the following: 
i. Abstinence from heterosexual intercourse 
ii. Systemic contraceptives (birth control pills, injectable/implant/ insertable hormonal birth 
control products, transdermal patch); if the participant is using systemic contraceptives, 
she must use an additional form of acceptable contraception (iii or iv, below) 
iii. Intrauterine device (with and without hormones) 
iv. Condom with spermicide  
or 
b. Participant is of non-childbearing potential, defined as surgically sterile (i.e. has undergone 
complete hysterectomy, bilateral oophorectomy, or tubal ligation), or in a menopausal state (at 
least 1 year without menses) 
8. A male must be surgically sterilized or willing to refrain from sexual intercourse from screening 
and until last follow-up visit or, if sexually active, uses a condom and partner practices 
contraception during the trial from screening and until the last follow-up visit 
 
Exclusion criteria: 
Patients meeting any of the following criteria during screening evaluations will be excluded from trial 
participation: 
1. Previous administration of dasiglucagon (previously referred to as ZP4207) 
2. Known or suspected allergy to trial medication(s) or related products  
3. History of anaphylaxis or symptoms of severe systemic allergy (such as angioedema)  
4. Previous participation (randomization) in this trial 
5. Females who are pregnant according to a positive pregnancy test, actively attempting to get 
pregnant, or are lactating 
6. Patients on a closed loop artificial pancreas 
7. Receipt of any investigational drug within 3 months prior to screening 
8. Active malignancy within the last 5 years 
9. Congestive heart failure, New York Heart Association class II-IV 
10. Inadequately treated blood pressure as defined as systolic blood pressure ≥160 mmHg or diastolic 
blood pressure ≥90 mmHg at screening 
11. Current bleeding disorder, including use of anticoagulant treatment 
12. Known presence or history of pheochromocytoma (i.e. adrenal gland tumor) or insulinoma 
(i.e. insulin-secreting pancreas tumor) 
13. Known or suspected HIV infection 
14. Use of a systemic beta-blocker drug, indomethacin, warfarin or anticholinergic drugs in the 
previous 28 days before Day 1 of this trial 
15. Use of systemic corticosteroids, anti-inflammatory biological agents, kinase inhibitors or other 
immune modulating agents within the last 3 months prior to screening 
16. Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >2.5 X the upper limit of 
normal (ULN), bilirubin >1.5 X ULN, estimated glomerular filtration rate (eGFR) 
<30 mL/min/1.73m2 according to the Modification of Diet in Renal Disease (MDRD) Study 
definition. Altered electrolytes values of clinical relevance for cardiac conduction, as judged by the 
investigator. 
17. Clinically significant abnormal ECG at screening as evaluated by Investigator 
18. Donation of blood or plasma in the past month, or in excess of 500 mL within 12 weeks prior to 
screening 
19. A positive result in the alcohol and/or urine drug screen at the screening visit. Significant history of 
alcoholism or drug abuse as judged by the investigator or consuming more than 24 g alcohol per 
day for men, or more than 12 g alcohol per day for women.  

 
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20. Patients with mental incapacity or language barriers that preclude adequate understanding or 
cooperation, who are unwilling to participate in the trial, or who in the opinion of the Investigator 
should not participate in the trial 
21. Surgery or trauma with significant blood loss within the last 2 months prior to screening 
22. Any condition interfering with trial participation or trial endpoints or that could be hazardous to the 
patient 
23.Use of prescription or non-prescription medications known to cause QT prolongation 
Test product, dose and mode of administration: 
Dasiglucagon: 0.6 mg; liquid formulation, 1 mg/mL in prefilled syringes containing 0.6 mL 
Reference product, dose and mode of administration: 
GlucaGen, 1 mg; powder and solvent for reconstitution as 1 mL solution for injection (recombinant 
glucagon hydrochloride, Novo Nordisk) 
Duration of treatment: 
Patients will receive 3 s.c. injections of trial medication (dasiglucagon or GlucaGen) with 1 week 
between each dosing. 
Prior to administration of trial medication patients must reach a target plasma glucose level of 
70-150 mg/dL. Plasma glucose levels may be adjusted by s.c. administration of a fast-acting insulin 
analog or by glucose ingestion. 
Criteria for evaluation: 
Immunogenicity: 
Primary endpoint:  
• 
Overall ADA incidence 
This will be calculated as a percentage of the combined results of treatment-induced ADA-
positive patients and treatment-boosted ADA-positive patients and the total number of 
evaluable patients, excluding baseline-positive patients without any samples available after 
drug administration.  
Key secondary endpoints: 
 
Treatment-induced ADA 
Incidence calculated as a percentage of the total number of evaluable patients that were ADA 
negative at baseline and ADA positive after drug administration and the total number of 
evaluable patients, excluding baseline positive patients without any samples available after 
drug administration.  
 
Treatment-boosted ADA 
Incidence calculated as percentage of baseline ADA-positive patients with significant increases 
(≥5-fold) in ADA titer after drug administration and the total number of evaluable patients, 
excluding baseline-positive patients without any samples available after drug administration.  
Secondary endpoints: 
Characterization of ADA response:  
 
Incidence and titer of neutralizing activity of ADA positive patients 
 
Incidence of cross-reactivity of ADA positive patients towards endogenous glucagon 
 
Kinetics of ADA: 
The timing and duration of detected ADA response  
Safety: 
 
The incidence, type and severity of AEs 
 
Changes from baseline in clinical laboratory parameters 
 
Changes from baseline in vital signs 
 
Clinically 
meaningful 
changes 
from 
baseline 
in 
physical 
examination 
and 
electrocardiogram (ECG)  

 
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Exposure endpoints, after administration of first and third doses of trial medication:  
 
Plasma dasiglucagon and glucagon concentrations from 0-90 min after dosing will be 
evaluated based on the following endpoints: AUC0-30min, AUC0-90 min, Cmax, tmax 
Pharmacodynamics, after administration of first and third doses of trial medication: 
 
Plasma glucose profiles over the period from 0-90 min after dosing will be evaluated 
based on the following endpoints: AUE0-30min, AUE0-90 min, CEmax, tmax 
Statistical methods: 
All statistical analysis will be descriptive i.e. no formal statistical testing will be performed. Continuous 
variables will be summarized with means, standard deviations, medians, minimums, and maximums, 
and valid cases. Other summaries (e.g. quartiles, 95% confidence intervals) may be used as 
appropriate. Categorical variables will be summarized by counts and by percentage of patients in 
corresponding categories. 
 
Sample size calculation: 
The purpose of the present trial is to generate data describing the immunogenic potential of 
dasiglucagon and GlucaGen. The ADA assays to be used in this trial are both validated, but specific 
for GlucaGen and dasiglucagon, respectively,  and the performance of the assays are thus not 
directly comparable. As a consequence, a formal comparison or non-inferiority analysis will not be 
performed. 
Currently, no ADA incidences have been detected in the completed clinical trials, where up to 5 
repeated doses of dasiglucagon have been administered to the same patients within a week. Across 
the two phase 1 clinical trials and a completed phase 2 pharmacokinetic/pharmacodynamic trial, a 
total of 141 subjects have been exposed to dasiglucagon and no incidences of ADA development 
have been observed. The obtained data indicate that dasiglucagon has a low risk for induction of 
ADAs in the investigated settings and as a consequence a meaningful sample size to compare both 
treatments cannot be estimated. 
The sample size is therefore based on a certain precision of the confidence interval for the overall 
ADA incidence if no events are observed, respectively to ensure a certain probability for observing 
one event. 
When no events are observed, to obtain an upper bound of 0.050 on the 90.0% confidence interval 
for the probability of such a rare event, would require a sample size of 45. Respectively, accepting a 
chance of observing at least one event of 90% and an actual probability of the event of 5% leads to a 
sample size of 45 patients completing the trial. In order to account for drop-outs, It is expected that 
112 patients in total will be randomized and treated. 

 
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Table 2-1: Flow chart 
Trial period 
Screening 
Treatment 
Follow-up 
Visit number 
V1 
V2 
V3 
V4 
V5 
V6 
V7 (EoT) 
Trial day 
-3 
0 
7 
14 
35 
60 
104 
Visit window (days) 
-30 to - -3 
 
±1 
±1 
±2 
±5 
±10 
Patient related info/assessments 
Informed consent 
X1 
 
 
 
 
 
 
Inclusion/exclusion criteria 
X 
X2,3 
 
 
 
 
 
Demography 
X 
 
 
 
 
 
 
Body measurements 
X 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
Concomitant illness 
X 
 
 
 
 
 
 
Prior medications 
X 
 
 
 
 
 
 
Concomitant medication 
X 
X 
X 
X 
X 
X 
X 
History of alcohol/drug abuse 
X 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
Withdrawal criteria 
 
X 
X 
X 
X 
X 
 
Dosing day exclusion criteria 
 
X 
X 
X 
 
 
 
Safety assessments 
Physical examination 
X 
 
 
 
 
 
X 
Vital signs 
X 
X12 
X12 
X12 
X 
 
X 
ECG 
X 
X10 
X10 
X10 
X 
 
X 
Local tolerability  
 
X5 
X5 
X5 
 
 
 
Adverse events 
X 
X 
X 
X 
X 
X 
X 

 
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Trial period 
Screening 
Treatment 
Follow-up 
Visit number 
V1 
V2 
V3 
V4 
V5 
V6 
V7 (EoT) 
Trial day 
-3 
0 
7 
14 
35 
60 
104 
Visit window (days) 
-30 to - -3 
 
±1 
±1 
±2 
±5 
±10 
Laboratory 
Hematology, biochemistry, coagulation 
X4 
X4 
 
X4 
X 
 
X 
Pregnancy test 
X11 
X11 
X11 
X11 
 
 
 
Urinalysis 
X 
X2 
 
X2 
 
 
X 
Urine drug screen 
X6 
X2,6 
X2,6 
X2,6 
 
 
 
Alcohol breath test 
X 
X2 
X2 
X2 
 
 
 
Exposure and pharmacodynamics (PD) 
Dasiglucagon /glucagon 
 
X7 
 
X7 
 
 
 
Plasma glucose 
 
X8 
 
X8 
 
 
 
Other assessments 
Antibodies against dasiglucagon /glucagon 
 
X2 
X2 
X2 
X 
X 
X 
Trial material 
Administration of trial medication 
 
X9 
X9 
X9 
 
 
 
ECG = electrocardiogram; EoT = End of Trial; ; PD = pharmacodynamics; V = visit 
1 Informed consent can be obtained on the same day as screening, but prior to any trial-related procedures 2 Pre-dose 
3 Only check of changes between the screening visit and V2.  
4 Coagulation parameters are measured at screening visit only. On dosing days Visit 2 and 4,  blood samples are collected pre-dose, and at 30 and 90 min post-dosing. The 
actual time for sampling should not deviate from the nominal time by more than ±5 min. Pre-dose is defined as within 5 min prior to dosing. 
5 Local tolerability assessed at 0.5 and 2 h post-dose. The actual time for assessment should not deviate from the nominal time by more than ±10 min. 
6 Urine drug screen will be performed at trial site for visits 1-4 
7 Pre-dose, 5, 10, 30, 60, and 90 min post-dosing. The actual time of blood sampling for exposure should not deviate from the nominal time by more than ±1 min. Pre-dose is 
defined as within 5 min prior to dosing. 
8 Pre-dose, 5, 10, 30, 60, and 90 min post-dosing. The actual time for blood sampling for plasma glucose should not deviate from the nominal time by more than ±1 min. Pre-
dose is defined as within 5 min prior to dosing. 
9 Prior to administration of trial medication patients must reach a target plasma glucose level of 70-150 mg/dL. Plasma glucose levels may be adjusted by administration of a 
fast-acting insulin analog or by glucose ingestion at the discretion of the investigator. At visit 2 and 4 patients must be fasting for 90 min after administration of trial medication. 
At all dosing visits, patients will be treated individually to alleviate any potential side effects and will be observed for at least 5 h post-dose. 
10 On dosing days Visit 2, 3 and 4 ECG’s are assessed pre-dose, and at 20, 35, 45 and 60 min post-dosing. The actual time of assessment should not deviate from the nominal 
time by more than ±5 min. Pre-dose is defined as within 5 min prior to dosing. 

 
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11 Pregnancy test is only applicable for women of childbearing potential. At Visit 1 a serum pregnancy test should be performed. At Visit 2, 3 and 4 a pre-dose urine pregnancy 
test should be performed.  
12 On dosing days Visit 2, 3, and 4 vitals signs are collected pre-dose and at 30, 90 and 120 min post-dosing. The actual time of assessment should not deviate from the 
nominal time by more than ±5 min. Pre-dose is defined as within 5 min prior to dosing. 
 
 
 

 
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3. Table of contents 
1. 
SIGNATURES AND AGREEMENT WITH PROTOCOL ..................................................... 2 
2. 
TRIAL SYNOPSIS ............................................................................................................... 4 
3. 
TABLE OF CONTENTS .................................................................................................... 11 
4. 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ............................................ 14 
4.1 
Abbreviations ..................................................................................................................... 14 
4.2 
Definitions of terms ............................................................................................................ 15 
5. 
INTRODUCTION................................................................................................................ 16 
5.1 
Background of the trial ....................................................................................................... 16 
5.2 
Trial rationale ..................................................................................................................... 18 
5.3 
Assessment of anticipated benefits and risks .................................................................... 18 
6. 
TRIAL OBJECTIVES ......................................................................................................... 20 
7. 
INVESTIGATIONAL PLAN ............................................................................................... 21 
7.1 
Overall trial design and plan .............................................................................................. 21 
7.2 
Discussion of trial design and choice of control groups ..................................................... 21 
7.3 
Selection of trial population ................................................................................................ 22 
7.3.1 
Inclusion criteria ................................................................................................................. 23 
7.3.2 
Exclusion criteria ................................................................................................................ 23 
7.3.3 
Premature removal from trial ............................................................................................. 24 
7.3.3.1 
Possible reasons for patient discontinuation ............................................................ 24 
7.3.3.2 
Center discontinuation .............................................................................................. 25 
7.3.3.3 
Trial termination ........................................................................................................ 25 
7.3.4 
Replacement of patients .................................................................................................... 25 
7.4 
Investigational medicinal product(s)................................................................................... 26 
7.4.1 
Identity of investigational medicinal product(s) .................................................................. 26 
7.4.2 
Treatments administered ................................................................................................... 26 
7.4.3 
Selection of doses in the trial ............................................................................................. 27 
7.4.4 
Treatment compliance ....................................................................................................... 27 
7.4.5 
Method of assigning patients to treatments or treatment sequences ................................ 28 
7.4.6 
Blinding .............................................................................................................................. 28 
7.4.7 
Drug accountability and disposal ....................................................................................... 28 
7.4.8 
Prior and concomitant therapy ........................................................................................... 28 
7.4.9 
Treatment after end of trial ................................................................................................. 28 
7.5 
Assessments and schedule of measurements (overview) ................................................ 28 
7.5.1 
Screening examination ...................................................................................................... 29 
7.5.2 
Instructions to patients prior to dosing ............................................................................... 29 
7.5.3 
Procedures and assessments during the treatment period of the trial .............................. 29 
7.5.4 
Follow-up period of the trial ................................................................................................ 31 
7.5.5 
Final examination at the end of the trial ............................................................................. 31 
7.5.6 
Additional (safety) examinations ........................................................................................ 31 
7.5.7 
Safety laboratory tests ....................................................................................................... 31 
7.6 
Immunogenicity, pharmacokinetic, pharmacodynamic, tolerability and safety 
measurements ................................................................................................................... 31 
7.6.1 
Immunogenicity measurements ......................................................................................... 32 
7.6.2 
Plasma concentrations of dasiglucagon and GlucaGen .................................................... 32 
7.6.3 
Pharmacodynamic measurements .................................................................................... 32 
7.6.4 
Safety and tolerability measurements ................................................................................ 32 
7.6.4.1 
Safety laboratory tests .............................................................................................. 32 
7.6.4.2 
Safety examinations ................................................................................................. 33 

 
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8. 
ADVERSE EVENTS .......................................................................................................... 33 
8.1 
Definitions .......................................................................................................................... 33 
8.2 
Collection, recording and reporting of adverse events ...................................................... 35 
8.3 
Follow-up of adverse events .............................................................................................. 36 
8.4 
Hypoglycemia ..................................................................................................................... 36 
8.5 
Pregnancy .......................................................................................................................... 37 
8.6 
Precautions ........................................................................................................................ 37 
8.7 
Safety Committee............................................................................................................... 38 
9. 
DATA MANAGEMENT AND QUALITY CONTROL ......................................................... 39 
9.1 
Case report forms .............................................................................................................. 39 
9.2 
Quality control .................................................................................................................... 39 
9.3 
Data management ............................................................................................................. 40 
10. 
STATISTICAL METHODS AND DETERMINATION OF SAMPLE SIZE ......................... 41 
10.1 
Statistical and analysis plan ............................................................................................... 41 
10.1.1 
General considerations .................................................................................................... 41 
10.1.2 
Classification of patients to subsets................................................................................. 41 
10.1.3 
Immunogenicity data ........................................................................................................ 41 
10.1.4 
Exposure and PD endpoints ............................................................................................ 42 
10.1.5 
Safety data ....................................................................................................................... 42 
10.1.6 
Further data ..................................................................................................................... 42 
10.1.7 
Withdrawals, drop-outs and missing data ........................................................................ 42 
10.1.8 
Baseline and center comparisons.................................................................................... 42 
10.1.9 
Subgroup analysis ........................................................................................................... 42 
10.1.10 
Interim analysis ............................................................................................................ 42 
10.2 
Determination of sample size ............................................................................................. 42 
11. 
ETHICS AND REGULATIONS .......................................................................................... 44 
11.1 
Independent ethics committees and competent authorities .............................................. 44 
11.2 
Ethical conduct of the trial .................................................................................................. 44 
11.3 
Patient information and consent ........................................................................................ 44 
11.4 
Legal and regulatory requirements .................................................................................... 44 
12. 
TRIAL ADMINISTRATION ................................................................................................ 45 
12.1 
Responsibilities .................................................................................................................. 45 
12.2 
Protocol deviations ............................................................................................................. 45 
12.3 
Protocol changes ............................................................................................................... 45 
12.4 
Publication of results .......................................................................................................... 45 
12.5 
Clinical trial report .............................................................................................................. 45 
12.6 
Retention of trial records .................................................................................................... 46 
13. 
REFERENCES................................................................................................................... 47 
 
Appendices: 
(1) 
List of names and addresses 
 
 

 
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Index of in-text tables 
Table 2-1: Flow chart ............................................................................................................................. 1 
Table 7-1: Identity of investigational products ................................................................................. 26 
 
Index of in-text figures 
Figure 7-1 Overview of the trial design ............................................................................................. 21 
 

 
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4. List of abbreviations and definition of terms 
4.1 
Abbreviations 
 
 
ADA 
Anti-drug Antibody 
AE 
Adverse Event 
ALT (SGPT) 
Alanine Aminotransferase (Serum Glutamic Pyruvic Transaminase) 
AST (SGOT) 
Aspartate Aminotransferase (Serum Glutamic Oxaloacetic Transaminase) 
BG 
Blood Glucose 
CA 
Competent Authority (Directive 2001/20/EC) 
CFR 
Code of Federal Regulations 
CRF/eCRF 
Case Report Form/Electronic Case Report Form 
CI 
Confidence Interval 
CRO 
Contract Research Organization 
CSII 
Continuous Subcutaneous Insulin Infusion 
CTA 
Clinical Trial Authorization (Directive 2001/20/EC) 
EC 
Ethics Committee 
ECG 
Electrocardiogram 
EDC 
Electronic Data Capture 
eGFR 
Estimated Glomerular Filtration Rate 
EoT 
End of Trial 
EudraCT 
European Clinical Trials Database 
FAS 
Full Analysis Set 
FDA 
Food and Drug Administration 
gamma-GT 
gamma-Glutamyltransferase 
GCP 
Good Clinical Practice 
HbA1c  
Hemoglobin A1c 
HEENT 
Head, Ears, Eyes, Nose, Throat 
HIV 
Human Immunodeficiency Virus 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonization  
IEC 
Independent Ethics Committee 
IM 
Intramuscular(ly) 
IMP 
Investigational Medicinal Product 
IND 
Investigational New Drug 
INR 
International Normalized Ratio 
IRB  
Institutional Review Board 
i.v. 
Intravenous(ly) 
IWRS 
Interactive Web Response System 
LOCF 
Last Observation Carried Forward 
MDRD 
Modification of Diet in Renal Disease 
MedDRA 
Medical Dictionary for Regulatory Activities  
Nab 
Neutralizing Antibody 
PG 
Plasma Glucose 
ODM 
Operational Data Model 
PD 
Pharmacodynamic(s) 

 
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PK 
Pharmacokinetic(s)  
PPS 
Per Protocol Set 
PT 
Preferred Term 
SAP 
Statistical Analysis Plan 
SAS 
Safety Analysis Set 
SAE 
Serious Adverse Event 
SC 
Safety Committee 
s.c. 
Subcutaneous(ly) 
SOC 
System Organ Class 
SOP 
Standard Operating Procedure 
T1DM 
Type 1 Diabetes Mellitus 
T2DM 
Type 2 Diabetes Mellitus 
ULN 
Upper Limit of Normal 
V 
Visit 
ZP4207 
Dasiglucagon  
 
 
Plasma concentrations of dasiglucagon/GlucaGen  
AUC0-30min 
Area under the plasma concentration curve from administration to observed 
concentration 30 min 
AUC0-90 min  
Area under the plasma concentration curve from administration to observed 
concentration at 90 min 
Cmax 
Maximum plasma concentration 
tmax 
Time until Cmax is reached  
 
 
Plasma glucose concentrations 
AUE0-30min 
Area under the effect curve from administration to 30 min 
AUE0-90 min 
Area under the effect curve from administration to 90 min 
CEmax 
Change from baseline plasma glucose to maximum plasma glucose 
measured post dose 
tmax 
Time to maximum effect 
 
4.2 
Definitions of terms 
 
Definition of the end of the trial: The trial ends with the last visit of the last patient participating in 
the trial. 

 
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5. Introduction  
5.1 
Background of the trial 
Hypoglycemia  
Hypoglycemia in patients with diabetes is defined as episodes of an abnormally low plasma 
glucose concentration.1 This is a common, unpredictable, and potentially dangerous side effect 
of treatment of diabetes mellitus with especially insulin or sulfonylureas. It is more frequent in 
patients with profound endogenous insulin deficiency, such as occurs in type 1 diabetes mellitus 
(T1DM) and advanced type 2 diabetes mellitus (T2DM). Treatment of T2DM with insulin causes 
hypoglycemia progressively and more frequently over time, whereas in T1DM, hypoglycemia is 
experienced throughout the course of established disease. 
Symptoms and signs of hypoglycemia are not specific. Patients undergoing a hypoglycemic 
episode experience unpleasant symptoms such as anxiety, sweating, hunger, tremors, 
palpitations, paresthesia, nausea and pallor. Depending on its severity, the hypoglycemia may 
lead to mild confusion, behavioral changes, loss of consciousness, seizures, coma, and death.2  
The incidence of hypoglycemic events or even the fear of hypoglycemia influences patients’ 
adherence to prescribed treatment regimens for diabetes mellitus. This leads to inadequate 
glycemic control, which in turn may lead to an increased risk of diabetic complications. 
Glucagon 
Glucagon is a naturally occurring hormone, secreted from the alpha cells of the pancreatic 
islets. Glucagon plays a central role in the regulation of glucose homeostasis and is the 
counterpart of insulin for controlling blood glucose levels (i.e. it acts in opposition to insulin in 
terms of effects on blood glucose levels). Glucagon stimulates hepatic glycogenolysis and 
gluconeogenesis in hypoglycemic states, thereby restoring glucose homeostasis. Glucagon 
receptor agonism has also been shown to exert effects on lipid metabolism, energy balance, 
body adipose tissue mass and food intake. Insulin decreases blood glucose levels and cases of 
hypoglycemia can be reversed by glucagon. Therefore, glucagon is indicated for the treatment 
of severe hypoglycemia.  
Antibodies against therapeutic peptides like glucagon and analogues hereof may develop when 
injected subcutaneously. Although important, glucagon is not considered to have a critical 
endogenous function since other counter regulatory hormones are also induced during 
hypoglycemia (e.g. growth hormone, cortisol, and epinephrine). In addition, results from 3 
mouse models defective in various pathways of the glucagon signaling have conﬁrmed that 
glucagon action is dispensable for their development and survival. Also, in non-clinical toxicity 
studies performed with dasiglucagon (see below), no consequences of ADA formation have 
currently been observed. In summary, glucagon appears to have a partly redundant 
endogenous function. These non-clinical data are of importance when evaluating the 
consequences of ADA formation. 
Dasiglucagon  
Dasiglucagon (ZP4207) is a stable peptide analog of human glucagon, available in a ready-to-
use liquid formulation and is in development for the treatment of severe hypoglycemia in insulin 
dependent patients with diabetes mellitus. Dasiglucagon is a specific and full glucagon receptor 
agonist designed to mimic the effects of glucagon, having a fast absorption and elimination 
(minutes). It is a peptide of 29 amino acids, with 7 amino acid substitutions compared to native 
glucagon. The main purpose of the substitutions is to increase the physical and chemical 
stability of the glucagon analog compared to marketed glucagon products such as Lilly 
Glucagon or GlucaGen®. Dasiglucagon exhibits improved physical and chemical stability and is 
available in an aqueous solution at neutral pH.3 

 
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Three clinical trials have been completed with dasiglucagon, a first human dose trial (ZP4207-
14013), a multiple-dose dose-escalation trial (ZP4207-15007) to evaluate the safety, tolerability, 
pharmacokinetics (PK) and pharmacodynamics (PD) of dasiglucagon, and a phase 2 crossover 
trial to assess the pharmacokinetics and pharmacodynamics of a single dose of an optimized 
formulation of dasiglucagon administered subcutaneously (s.c.) in patients with T1DM (ZP4207-
15126).3 
Pharmacokinetics and pharmacodynamics of dasiglucagon  
The results of the phase 1 and 2 clinical trials confirm dose-proportionality for dasiglucagon 
pharmacokinetics, which is characterized by a fast absorption with a peak plasma concentration 
obtained after 35 minutes. Thereafter, the plasma concentration rapidly declines with an 
average half-life of 28 minutes. The median time to the maximum plasma concentration (Cmax) 
was later for dasiglucagon than for GlucaGen (35 versus 20 minutes). Doses of 0.3 mg 
dasiglucagon and 0.5 mg GlucaGen and also 0.6 mg dasiglucagon and 1.0 mg GlucaGen were 
similar with regard to Cmax. For Cmax, the results indicated that 0.3 mg dasiglucagon was 
comparable to 0.5 mg GlucaGen (90% confidence interval (CI): 0.8167; 1.0068) and 0.6 mg 
dasiglucagon was comparable to 1.0 mg GlucaGen (90% CI: 0.8850; 1.1991).3 At these dose 
levels, the total exposures (AUC0-inf) were higher for dasiglucagon compared to GlucaGen. 
At all dose levels in the phase 2 trial, all patients achieved a plasma glucose level of at least 
70 mg/dL as well as an increase in plasma glucose by at least 20 mg/dL within 30 min post-
dose. The maximal observed time to reach the 20 mg/dL plasma glucose increase ranged from 
15 to 27 minutes across doses and decreased as the dose increased. The pharmacodynamic 
responses of 0.6 mg of dasiglucagon and 1.0 mg of GlucaGen were comparable.3 
Safety of dasiglucagon  
The safety data for dasiglucagon did not give rise to any relevant safety concerns for 
dasiglucagon beyond those related to the pharmacological effect of glucagon agonism. All 
adverse events (AEs) recorded in the trials were of mild or moderate severity. The most 
frequently reported systemic AE was nausea, which is a known side effect following 
administration of glucagon. Headache was the next most frequently reported event, occurring in 
all dose groups in the phase 2 trial. Injection site reactions were observed only sporadically after 
administration with either dasiglucagon or GlucaGen® and all were mild and transient. The most 
frequent injection site reaction was erythema, occurring in all treatment groups, including the 
placebo group, irrespective of dose. Glucagon has been described to exert positive inotropic 
and chronotropic effects and may therefore cause tachycardia and hypertension. In the phase 1 
clinical trials, but not the phase 2 trial, temporary but clinically significant decreases in blood 
pressure were observed in a few healthy volunteers receiving investigational medicinal product 
(IMP) doses of at least 1.0 mg (4 with dasiglucagon and 1 with GlucaGen). This is not 
considered a safety concern, however hemodynamic changes post dosing will be considered a 
clinical event of interest. 
The phase 1 and 2 results and the safety profile described to date do not give rise to specific 
safety concerns. For further information, please refer to the Investigator Brochure.3  
Immunogenicity of dasiglucagon  
To date, in the 3 clinical trials performed with dasiglucagon (described above), there have not 
been any anti-drug antibody (ADA) occurrences in a total of 141 subjects exposed to 1 or more 
doses. Data from the non-clinical toxicology program (7 non-clinical toxicity studies) showed that 
ADAs were detected in mice, rats, and dogs, and were most frequent in animals in the highest 
dasiglucagon dose groups. A fraction of the ADAs from rats and dogs were able to cross-react 
with native glucagon. However, the ADAs did not appear to be associated with changes in the 
safety or toxicity profiles compared to ADA-negative animals. In rats, the average exposure 
(AUC) was increased following 13 and 26 weeks of treatment in dose groups with higher ADA 
frequency (8 mg/kg/day). The ADA frequency and titers of consistently ADA-positive rats were 
reduced from 13 to 26 weeks of treatment, indicating a transient response in most animals. It 

 
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therefore appears that dasiglucagon has a low risk for induction of ADAs. A fraction of the 
antibodies detected in the non-clinical toxicity studies was found to cross-react with glucagon 
without advert clinical or toxicity findings. These data suggest that dasiglucagon and glucagon 
share epitopes and potential ADAs induced by dasiglucagon in humans may have the ability to 
cross-react with glucagon.3  
Although glucagon is an important hormone for controlling blood glucose levels it is considered 
to have a partially redundant endogenous function since hypoglycemia can also be corrected by 
other means. The overall immunogenicity risk of dasiglucagon in a clinical context is therefore 
considered to be low and the potential effects of induced ADAs judged to be of limited clinical 
consequence.  
As dasiglucagon contains 7 amino acid substitutions compared to native glucagon and historic 
data indicate that the immune system’s tolerance to glucagon can be impaired in the intended 
target population, there is an inherent risk for the induction of an ADA response against 
dasiglucagon. However, other product specific characteristics, i.e. dasiglucagon being a 
chemical synthetized product without host cell contaminants, a reduced potential for 
aggregation, a physiological compatible formulation, and a high bioavailability with a short half-
life, are all in favor of reducing the risk of dasiglucagon to induce an unwanted immune 
response. Considering the intended indication, in which dasiglucagon is administered as a 
single-dose rescue treatment on an infrequent basis (0.21 to 1.6 episodes per patient per 
year),4,5 the induction of a high titer ADA response with effects on clinical safety seems unlikely. 
Overall, the risk of dasiglucagon to induce an ADA response is considered low. The present trial 
aims to evaluate that immunogenicity risk in patients with T1DM administered multiple s.c. 
doses of dasiglucagon.  
5.2 
Trial rationale 
Dasiglucagon is in clinical development as a rescue treatment for severe hypoglycemia in 
patients with insulin-dependent diabetes mellitus. Immune responses to therapeutic peptides 
and proteins may develop after subcutaneous administration and could potentially adversely 
affect their safety and efficacy. The potential formation of high titer ADAs to dasiglucagon, 
although considered unlikely in a rescue indication, could influence the efficacy of dasiglucagon, 
either indirectly by interacting with the pharmacokinetics of dasiglucagon or directly by 
neutralizing the glucagon response.  
In recent years, regulatory agencies have outlined and recommended the use of a risk-based 
approach in the evaluation and mitigation of immune responses to therapeutic compounds that 
may adversely affect their safety and/or efficacy. Both transient and persistent antibody 
response should be combined to determine the overall immunogenicity of a product. Persistent 
antibodies are of importance since patients with persistent antibodies could experience clinical 
adverse reactions affecting safety and efficacy, while a transient antibody response can resolve 
without further consequence. 
The present trial aims to evaluate that immunogenicity risk with an assessment of the 
occurrence of ADAs and neutralizing ADAs, and of cross-reactivity with native glucagon, 
following repeated single doses of dasiglucagon by s.c. administration in T1DM patients. The 
reference product in this trial is GlucaGen, a recombinant human glucagon approved for the 
treatment of the severe hypoglycemic reactions that may occur in the management of insulin-
treated children and adults with diabetes mellitus. Given the differences in ADA assay for 
dasiglucagon and GlucaGen, a formal statistical comparison or non-inferiority testing is not 
performed. 
5.3 
Assessment of anticipated benefits and risks 
As glucagon and its analogs belong to a well-known drug class with a known mode of action, 
dasiglucagon is not expected to be a high-risk molecule.  

 
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Treatment with an investigational medicinal product may result in undesired effects or 
complaints. Undesired effects and complaints such as nausea, vomiting, and diarrhea are 
known AEs occurring with glucagon administration. Similar AEs have also been observed to a 
limited degree in the 3 clinical studies conducted with dasiglucagon. As with every novel drug 
substance, new and as yet unknown side effects also may occur.  
There are limited data available to assess the immunogenic potential of glucagon products 
available on the market, but the data available indicate that marketed glucagon only has a small 
immunogenic potential. Based on the 3 clinical studies conducted with dasiglucagon to date 
(see Section 5.2), no anti-dasiglucagon or anti-glucagon antibodies have been detected.  
In relation to diabetes therapy, development of insulin-antibodies is documented more 
substantially and the route of administration has been shown to influence the immunogenic 
potential of insulins. However, antibodies against insulin do not generally have an impact on 
insulin action and are thus not clinically relevant. In terms of consequence, development of high 
titer antibodies against dasiglucagon could, in theory reduce the activity of endogenous 
glucagon, which, in theory, could influence hypoglycemic episodes. Limited suppression of 
glucagon would, however, not be considered critical, since low glucose levels can also be 
corrected by other means, including oral intake of glucose and the action of other endogenous 
hormones such as oxyntomodulin and epinephrine. 
Overall, dasiglucagon is judged to be a low-risk molecule, based upon the available clinical data 
as well as the outcome of the risk-based approach to the immunogenicity assessment. In line 
with the primary objective of this trial to assess the immunogenicity of dasiglucagon, sampling 
for measurement of antibodies against dasiglucagon will take place prior to first dosing (Visit 2), 
pre-dose at subsequent visits during the treatment period (Visits 3 and 4), and at all Follow-up 
visits (at 35, 60, and 104 days after the first dose of trial medication; i.e. at Visits 5, 6, and 7 
(End of Trial [EoT] visit), respectively).  
Administration of dasiglucagon may be associated with a risk of allergic reactions similar to 
those observed for other therapeutic peptides or proteins. Patients with known or suspected 
allergies to the trial medications or related products will be excluded from the trial. Mild or 
moderate allergic reactions may include symptoms of rash, fever, flu-like symptoms, nausea, 
headache, and myalgia. Acute generalized hypersensitivity reactions are usually very rare but 
may include symptoms of flushing, sweating, dizziness, change in blood pressure and 
difficulties in breathing. No severe acute hypersensitivity reactions have been observed in the 3 
clinical trials conducted with dasiglucagon. Direct access to resuscitation equipment is ensured 
at the clinical trial sites. 
With the exception of medical examinations, a patient participating in this trial is not likely to 
derive any personal health-related benefits. The results of the trial may contribute to the future 
use of dasiglucagon in patients with diabetes mellitus experiencing severe hypoglycemic 
reactions. 
Overall, the benefit to risk ratio for patients entering the ZP4207-16136 trial is considered 
acceptable. 

 
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6. Trial objectives  
Primary objective 
 
To evaluate the immunogenicity of repeated single doses of dasiglucagon and GlucaGen 
following s.c. administration in T1DM patients. 
Secondary objective 
 
To evaluate the safety and tolerability of repeated single doses of dasiglucagon following 
s.c. administration compared with s.c. GlucaGen in T1DM patients. 
Primary endpoint: 
 
Overall ADA incidence 
This will be calculated as a percentage of the combined results of treatment-induced 
ADA-positive patients and treatment-boosted ADA-positive patients and the total number 
of evaluable patients, excluding baseline-positive patients without any samples available 
after drug administration.  
Key secondary endpoints: 
 
Treatment-induced ADA 
Incidence calculated as a percentage of the total number of evaluable patients that were 
ADA negative at baseline and ADA positive after drug administration and the total number 
of evaluable patients, excluding baseline positive patients without any samples available 
after drug administration.  
 
Treatment-boosted ADA 
Incidence calculated as percentage of baseline ADA-positive patients with significant 
increases (≥5-fold) in ADA titer after drug administration and the total number of 
evaluable patients, excluding baseline-positive patients without any samples available 
after drug administration.  
Secondary endpoints: 
Characterization of ADA response:  
 
Incidence and titer of neutralizing activity of ADA positive patients 
 
Incidence of cross-reactivity of ADA positive patients towards endogenous glucagon 
 
Kinetics of ADA: 
The timing and duration of detected ADA response  
Safety: 
 
The incidence, type and severity of AEs 
 
Changes from baseline in clinical laboratory parameters 
 
Changes from baseline in vital signs 
 
Clinically 
meaningful 
changes 
from 
baseline 
in 
physical 
examination 
and 
electrocardiogram (ECG) 
Exposure endpoints, after administration of first and third doses of trial medication:  
 
Plasma dasiglucagon and glucagon concentrations from 0-90 min after dosing will be 
evaluated based on the following endpoints: AUC0-30min, AUC0-90 min, Cmax, tmax 
Pharmacodynamics after administration of first and third doses of trial medication: 
 
Plasma glucose profiles over the period from 0-90 min after dosing will be evaluated 
based on the following endpoints: AUE0-30min, AUE0-90 min, CEmax, tmax 

 
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7. Investigational plan 
7.1 
Overall trial design and plan 
This is a randomized, double-blind, parallel group trial comparing the immunogenicity of 3 fixed 
doses of either dasiglucagon or GlucaGen administered to euglycemic T1DM patients.  
Patients with T1DM will be randomized 1:1 to receive 3 s.c. injections of either dasiglucagon 
(0.6 mg) or GlucaGen (1 mg), with 1 week between each dose. Patients will be followed for at 
least 3 months from the day of the first dose to assess any immune response. Patients with 
previous exogenic glucagon exposure will not be excluded from the trial, but the information on 
previous glucagon administration will be recorded to enable subgroup analyses. A total of 
90 patients are expected to participate in and complete the trial (45 in each treatment arm). To 
qualify as completed, the patient must be dosed according to protocol and have blood drawn for 
the ADA analyses (as scheduled in Table 2-1). Prematurely discontinued patients will be 
replaced in order to reach 90 completed patients. It is expected 112 patients in total will be 
randomized and treated. 
For the safety and well-being of the patients, they will not be brought into hypoglycemia prior to 
dosing. Prior to administration of trial product patients must reach a target plasma glucose level 
of 70-150 mg/dL.  
The trial will include the following periods (as illustrated in Figure 7-1, below). 
 
A screening period from Day -30 to Day -3 
 
A treatment period, from Day 0 (day of randomization) to Day 14 (day of third and final 
dosing with trial medication), with s.c. trial medication administered on Day 0, Day 7, and 
Day 14. Handling, preparation and administration of trial medication will be done by 
unblinded trial personnel. All trial assessments will be done by blinded trial personnel.  
 
A follow-up period, from the end of the Treatment Period, with follow-up visits at Day 35, 
Day 60, and Day 104 (the EoT visit) 
Time windows for each trial visit are given in Table 2-1. 
Figure 7-1 Overview of the trial design 
 
An overview on the trial procedures is given in the flow chart (Table 2-1). Patients should be 
seen for all visits on the designated day or as close to it as possible.  
7.2 
Discussion of trial design and choice of control groups 
The trial will be randomized and double-blind to increase trial validity and to reduce bias during 
evaluation of assessments with the two treatments. Since the 2 trial medications are not 
identical in appearance (dasiglucagon is a liquid formulation and GlucaGen is available as a 

 
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powder for reconstitution), the handling, preparation and administration of trial medication will be 
done by unblinded trial personnel who will not be involved in other trial procedures and 
assessments. All trial assessments performed at the trial site will be done by blinded trial 
personnel. However, exposure assessments and ADA assessments will be performed by 
unblinded personnel at the specialty laboratories, to make sure that dasiglucagon or GlucaGen 
administration is matched with the applicable bioanalytical assay.    
Euglycemic patients with T1DM will be randomized 1:1 in order to evaluate the immunogenicity 
of dasiglucagon and GlucaGen. The randomized, double-blind, parallel group design, with 
administration of 3 fixed consecutive doses of randomized trial medication (dasiglucagon or 
GlucaGen) to the same patient will allow characterization of immunogenic potential for the 2 
products. Treatment with the 3 repeated doses (each separated by 1 week), with follow-up visits 
at Days 35 (where potential immune responses are known to be most pronounced), and at 60 
and 104 days after the first dose (following the patient for 2-3 antibody half-lives after expected 
peak titer), is deemed relevant and sufficient for evaluating any immunogenic response to 
treatment. Patients that test positive for ADA will be monitored until the ADA levels return to 
baseline, and samples from the ADA positive patients will be tested for neutralizing potential in 
an Nab (neutralizing antibody) assay. 
Dasiglucagon and GlucaGen will be administered at fixed doses independent of body weight 
because this is the intended therapeutic dosing regimen in the emergency treatment of 
hypoglycemia. The selected dose of 1 mg GlucaGen is the recommended dose for treatment of 
severe hypoglycemia. Based on pre-clinical and clinical studies, it has been demonstrated that 
0.6 mg of dasiglucagon results in an initial pharmacodynamic response (i.e. acute glucose 
mobilization) comparable to 1 mg GlucaGen (see also Section 5.1).  
For the safety and well-being of the patients, they will not be brought into hypoglycemia prior to 
dosing. However, very high blood glucose levels at dosing will potentially impact the reporting of 
nausea and other associated AE’s. Therefore, to enable a more precise safety assessment, 
patients are required to be dosed while at a normal blood glucose level, and a pre-treatment 
plasma glucose level of 70-150 mg/dL will be targeted. Plasma glucose levels may be adjusted 
by s.c. administration of a fast-acting insulin analog or by glucose ingestion. Even with this 
precaution, it cannot be excluded that a higher frequency of nausea may be anticipated, if this 
AE is caused by hyperglycaemia. 
The safety profile described to date does not give rise to specific safety concerns. In previous 
studies, dasiglucagon was associated with the AE’s nausea, a known side effect following 
administration of glucagon, headache, and injection site reactions (erythema).  
7.3 
Selection of trial population 
Dasiglucagon is indicated for treatment of severe hypoglycemia in patients with T1DM. Given 
the role of the immune system in the pathogenesis of T1DM, the present trial aims to evaluate 
the immune response of patients with T1DM taking repeated single doses of s.c. dasiglucagon 
and GlucaGen.  
There are no data indicating an altered immune response with varying blood glucose levels, 
therefore, for the safety and well-being of the patients, they will not be brought into a 
hypoglycemic state prior to dosing. Patients with previous exogenic glucagon exposure will not 
be excluded from the trial, but the information on previous glucagon administration will be 
recorded to enable subgroup analyses. 
The trial will enroll patients in centers in the EU, in the US, and in Canada.  

 
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7.3.1 Inclusion criteria 
To be included in the trial, patients have to fulfill all of the following criteria: 
(1) 
Informed consent obtained before any trial-related activities (trial-related activities 
are any procedure that would not have been performed during normal management 
of the patient) 
(2) 
Availability for the entire trial period 
(3) 
Age between 18 and 70 years, both inclusive 
(4) 
Male or female patients with T1DM for at least 1 year. Diagnostic criteria as defined 
by the American Diabetes Association 
(5) 
Hemoglobin A1c (HbA1c) <10% 
(6) 
Stable antidiabetic treatment for at least 1 month (e.g. within 10% insulin dose 
adjustment) 
(7) 
A female participant must meet 1 of the following criteria 
a. Participant is of childbearing potential and agrees to use one of the accepted 
contraceptive regimens throughout the entire duration of the trial from screening 
until last follow-up visit. An acceptable method of contraception includes at least 
one of the following: 
i. Abstinence from heterosexual intercourse 
ii. Systemic contraceptives (birth control pills, injectable/implant/ insertable 
hormonal birth control products, transdermal patch); if the participant is 
using systemic contraceptives, she must use an additional form of 
acceptable contraception (iii or iv, below) 
iii. Intrauterine device (with and without hormones) 
iv. condom with spermicide 
or 
b. Participant is of non-childbearing potential, defined as surgically sterile (i.e. has 
undergone complete hysterectomy, bilateral oophorectomy, or tubal ligation), or 
in a menopausal state (at least 1 year without menses). 
(8) 
A male must be surgically sterilized or willing to refrain from sexual intercourse from 
screening and until last follow-up visit or, if sexually active, uses a condom and 
partner practices contraception during the trial from screening and until the last 
follow-up visit. 
7.3.2 Exclusion criteria 
Patients meeting any of the following criteria during screening evaluations will be excluded from 
trial participation: 
(1) 
Previous administration of dasiglucagon (previously referred to as ZP4207). 
(2) 
Known or suspected allergy to trial medication(s) or related products  
(3) 
History of anaphylaxis or symptoms of severe systemic allergy (such as 
angioedema)  
(4) 
Previous participation (randomization) in this trial 
(5) 
Females who are pregnant according to a positive pregnancy test, actively 
attempting to get pregnant, or are lactating 
(6) 
Patients on a closed loop artificial pancreas 
(7) 
Receipt of any investigational drug within 3 months prior to screening 
(8) 
Active malignancy within the last 5 years 
(9) 
Congestive heart failure, New York Heart Association class II-IV 

 
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(10) Inadequately treated blood pressure as defined as systolic blood pressure ≥160 
mmHg or diastolic blood pressure ≥90 mmHg at screening. 
(11) Current bleeding disorder, including use of anticoagulant treatment 
(12) Known presence or history of pheochromocytoma (i.e. adrenal gland tumor) or 
insulinoma (i.e. insulin-secreting pancreas tumor) 
(13) Known or suspected HIV infection 
(14) Use of a systemic beta-blocker drug, indomethacin, warfarin or anticholinergic 
drugs in the previous 28 days before Day 1 of this trial) 
(15) Use of systemic corticosteroids, anti-inflammatory biological agents, kinase 
inhibitors or other immune modulating agents within the last 3 months prior to 
screening 
(16) Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >2.5 X the 
upper limit of normal (ULN), bilirubin >1.5 X ULN, estimated glomerular filtration 
rate (eGFR) <30 mL/min/1.73m2 according to the Modification of Diet in Renal 
Disease (MDRD) Study definition. Altered electrolytes values of clinical relevance 
for cardiac conduction, as judged by the investigator. 
(17) Clinically significant abnormal ECG at screening, as evaluated by Investigator 
(18) Donation of blood or plasma in the past month, or in excess of 500 mL within 
12 weeks prior to screening 
(19) A positive result in the alcohol and/or urine drug screen at the screening visit. 
Significant history of alcoholism or drug abuse as judged by the investigator or 
consuming more than 24 g alcohol per day for men, or more than 12 g alcohol per 
day for women. 
(20) Patients with mental incapacity or language barriers that preclude adequate 
understanding or cooperation, who are unwilling to participate in the trial, or who in 
the opinion of the Investigator should not participate in the trial 
(21) Surgery or trauma with significant blood loss within the last 2 months prior to 
screening 
(22) Any condition interfering with trial participation or trial endpoints or that could be 
hazardous to the patient 
(23) Use of prescription or non-prescription medications known to cause QT 
prolongation 
7.3.3 Premature removal from trial 
Participation in the trial is strictly voluntary. A patient has the right to withdraw from the trial at 
any time and for any reason. If he/she chooses to withdraw, the investigator must be informed 
immediately. The investigator has the right to terminate participation of any patient at any time if 
the investigator deems it in the patient's best interest. The reason and circumstances for 
premature discontinuation will be documented in the electronic Case Report Form (eCRF). 
7.3.3.1 Possible reasons for patient discontinuation 
A patient will be discontinued if the following applies: 
 
If a protocol deviation occurs which, in the clinical judgment of the Investigator, can 
invalidate the assessment of ADA responses to dasiglucagon or glucagon, the patient will 
be withdrawn by the Investigator 
 
AEs that are considered unacceptable by the patient or the Investigator 
 
Positive result from an urine drug screen test 
 
Pregnancy. If a female patient becomes pregnant in the time between the screening visit 
and any one of the dosing visits 

 
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If discontinuation occurs following administration of any trial medication, the patient will be 
asked to return and participate in the complete follow-up visits at trial Day 35, 60, and 104. 
If trial participation is terminated due to an AE possibly related to the trial medication (including 
reference product) or trial examinations, the patient must be followed up by additional 
examinations according to the medical judgment of the investigator until the abnormal condition 
is resolved or the investigator deems further observations or examinations to be no longer 
medically indicated. 
Patients, who meet one or more of the following dosing day exclusion criteria at a dosing visit, 
will be excluded from the dosing visit, but can be rescheduled to one of the following days 
(maximum 3 days postponement). Each dosing visit can only be rescheduled once. 
 
Strenuous exercise within 4 days prior to dosing, as judged by the Investigator. Strenuous 
exercise is not allowed during the treatment period of the trial 
 
Clinically significant illness that may interfere with trial objectives or impose a risk to 
patients, as judged by the Investigator 
 
Consumption of alcohol within 24 h prior to dosing visit, or positive results from an alcohol 
breath test 
 
Changes in medical history or concomitant medication resulting in fulfillment of clinical 
exclusion criteria, as judged by the Investigator 
A total of 90 patients must complete the trial. To qualify as completed, the patient must be 
dosed according to protocol and have blood drawn for the ADA analyses described in the 
protocol. Discontinued patients will be replaced in order to reach 90 completed patients. 
7.3.3.2 Center discontinuation 
The center can be closed and the trial terminated for the following reasons: 
 The center is unlikely to be able to recruit sufficient patients within the agreed time frame 
 The center does not respond to trial management requests 
 Repeat protocol violations 
7.3.3.3 Trial termination 
The sponsor reserves the right to modify or terminate the trial at any time. Possible reasons for 
termination are: 
 
Safety reasons – the incidence of AEs in this or any other trial using the same trial 
medication indicates a potential health risk for the patients. 
 
New scientific knowledge becomes known that makes the objectives of the trial no longer 
feasible/valid 
 
Unsatisfactory enrolment of patients 
7.3.4 Replacement of patients  
Patients prematurely withdrawn from the trial will be replaced in order to reach 90 completed 
patients.  

 
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7.4 
Investigational medicinal product(s) 
7.4.1 Identity of investigational medicinal product(s)  
The identity of the investigation products is summarized in Table 7-1. 
Table 7-1: Identity of investigational products 
 
Test product 
Reference product 
Name 
Dasiglucagon 
GlucaGen® 
Active substance 
ZP4207  
Recombinant glucagon 
hydrochloride  
Formulation 
Liquid formulation, 0.6 mL  
Powder and solvent for 
reconstitution as 1 mL solution for 
injection 
Strength 
1 mg/mL 
1 mg 
Container 
Single use pre-filled syringe 
Powder and solvent for 
reconstitution packed together in a 
plastic box. A “hypo-kit”  
Manufacturer 
Zealand Pharma A/S, Glostrup 
(Copenhagen), Denmark 
Novo Nordisk A/S, Bagsværd, 
Denmark 
Storage requirements 
Store between 2 and 8°C 
Store between 2 and 8°C 
Handling, preparation and administration of trial medication will be done by unblinded trial 
personnel. All trial assessments on the trial site will be done by blinded trial personnel. 
However, exposure assessments and ADA assessments will be performed by unblinded 
personnel at the specialty laboratories, to make sure that dasiglucagon or GlucaGen 
administration is matched with the applicable bioanalytical assay.  
The test product will be packed by the sponsor. The information on the labels will be in the local 
language. The label on the product will be compliant with local laws and regulations. 
7.4.2 Treatments administered 
Dasiglucagon is a stable peptide analog of human glucagon in a ready-to-use liquid formulation 
indicated for treatment of severe hypoglycemia in insulin dependent patients with diabetes 
mellitus. Dasiglucagon is in clinical development and has no marketing authorization as yet. 
GlucaGen is approved in the EU and US and is indicated for treatment of severe hypoglycemic 
reactions, which may occur in the management of insulin-treated children and adults with 
diabetes mellitus. 
Patients in this trial have not previously been treated with dasiglucagon (ZP4207) and will be 
randomly assigned (1:1) to receive 1 of the following trial medications: 
 
0.6 mg dasiglucagon 
 
1 mg GlucaGen 
Prior to administration of trial medication at all dosing visits patients must reach a target plasma 
glucose level of 70-150 mg/dL. If the patient presents with plasma glucose > 150 mg/dL, 
corrective amounts of fast acting insulin will be administered at the investigator’s discretion. 
Plasma glucose measured after 20 and after 40 minutes should ensure that the patient has 
reached the targeted 70-150 mg/dL. If the patient presents with plasma glucose < 70 mg/dL 
glucose ingestion will be provided in order to reach target plasma glucose of 70-150 mg/dL 
documented by plasma glucose measurements after 20 and 40 minutes, respectively. 

 
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Following the first (Visit 2) and third (Visit 4) dose administration, patients must be fasting for 90 
min after dosing. Following the 90-min blood sample draw after the administration of the first 
(Visit 2) and third (Visit 4) dose administration, patients may be treated individually in order to 
alleviate any potential side effects in order to minimize prematurely treatment discontinuation 
and consequently reduce the amount of missing data. This treatment can also be instituted 
immediately after the second dose administration (Visit 3), as pharmacodynamics will not be 
assessed at this visit.  
In order to minimize the number of patients discontinuing treatment prematurely and 
consequently reduce the amount of missing data, the following treatment modalities may be 
used, as considered appropriate by the investigator:  
At visit 2 and 4: 
 
90 min after dosing patients will be allowed to eat and drink moderately to make them 
feel comfortable 
 
90 min after dosing a moderate and individualized corrective dose of insulin to convert 
the induced hyperglycemia to euglycemia, after agreement with the investigator 
 
antiemetic treatment in the form of metoclopramide (Primperan®) as per local label, 
administered before or after dosing 
 
At visit 3:  
 
patients will be allowed to eat and drink moderately to make them feel comfortable 
 
a moderate and individualized corrective dose of insulin to convert the induced 
hyperglycemia to euglycemia, after agreement with the investigator 
 
antiemetic treatment in the form of metoclopramide (Primperan®)  as per local label, 
administered before or after dosing 
 
Patients must be monitored for at least 5 h after dosing at the clinical site for safety 
observations, including blood glucose monitoring.  
Patients will not be discharged until they are considered stable and with a blood glucose level in 
the range of 70-180 mg/dL. Before discharge, the investigator will provide instructions to the 
patients on management of their blood glucose levels. Each trial medication will be administered 
s.c. 3 times in total, with 7 days between dosing (i.e. dosing occurs at Days 0, 7, and 14; Visits 
2, 3, and 4). Should the patient experience vomiting following the first or second dasiglucagon 
or GlucaGen administration, the investigator must ensure normal electrolytes prior to the next 
dosing day. An electrolyte imbalance can be corrected by administration of an electrolyte 
supplement or by any other treatment modality considered appropriate by the investigator.   
7.4.3 Selection of doses in the trial 
The selected dose of 1 mg GlucaGen is the recommended dose for treatment of severe 
hypoglycemia. Based on pre-clinical and clinical studies, it has been demonstrated that 0.6 mg 
of dasiglucagon results in an initial pharmacodynamic response (i.e. acute glucose mobilization) 
comparable to 1 mg GlucaGen. 
7.4.4 Treatment compliance 
All trial medications will be prepared and administered by unblinded trial personnel.  

 
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7.4.5 Method of assigning patients to treatments or treatment sequences 
Patients who meet all inclusion and none of the exclusion criteria and have given written 
informed consent will be randomized in a 1:1 ratio to either dasiglucagon or GlucaGen via an 
Interactive Web Response System (IWRS) that will assign a kit number to one of the 2 
aforementioned treatment arms. 
Patients with previous exogenic glucagon exposure will not be excluded from the trial, but the 
information on previous glucagon administration will be recorded, to enable subgroup analyses.  
In the event of an emergency, e.g., when it becomes necessary for the investigator to know 
which treatment the patient is taking, the code for that patient can be broken by the investigator, 
preferably after consultation with the medical monitor. Emergency code breaks can be 
performed using the IWRS. 
7.4.6 Blinding 
This is a double-blind trial. Since dasiglucagon is available as a liquid formulation and GlucaGen 
is available as a powder for reconstitution, and they are therefore not identical in appearance, 
unblinded trial personnel will be responsible for handling, preparing according to the prescription 
from the IWRS, administering the trial medication and keep the records strictly confidential and 
accessible only for unblinded staff until after database lock. To maintain double-blind conditions, 
all trial assessments at the trial site will be done by blinded trial personnel not involved in the 
administration of trial medications. However, exposure assessments and ADA assessments will 
be performed by unblinded personnel at the specialty laboratories, to make sure that 
dasiglucagon or GlucaGen administration is matched with the applicable bioanalytical assay.  
7.4.7 Drug accountability and disposal 
Handling, preparation and administration of trial medication will be done by unblinded trial 
personnel. Each center will keep accurate records of the trial supplies received, stored, and 
dispensed, using appropriate forms. The trial supplies will be stored under appropriate 
conditions, locked and with restricted access.  
All unused supplies and all empty and partially empty containers of trial medication will be 
stored until the trial closure visit has been performed and then sent to the sponsor.  
7.4.8 Prior and concomitant therapy 
Prior glucagon exposure will be recorded in the eCRF at screening. All concomitant medications 
will be recorded in the eCRF at each visit.  
Patients using any new concomitant medication resulting in fulfillment of a dosing day exclusion 
criterion will be excluded from the dosing visit, but can be rescheduled to one of the following 
days. Each dosing visit can only be rescheduled once. See Section 7.3.3.1 for possible reasons 
for patient discontinuation. 
7.4.9 Treatment after end of trial  
Not applicable in this trial.  
7.5 
Assessments and schedule of measurements (overview) 
The following assessments and measurements will be carried out at the times specified in the 
trial flow chart (Table 2-1).  
Informed consent will be obtained prior to any trial-related procedures; see Section 11.3. 

 
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7.5.1 Screening examination 
At screening (Visit 1), the following assessments will take place: 
 
Informed consent 
 
Check of patient eligibility 
 
Demographics  
 
Body measurement 
 
Medical history 
 
History of alcohol/drug abuse 
 
Concomitant illnesses 
 
Prior medications 
 
Concomitant medications 
 
Physical examination 
 
Vital signs 
 
ECG 
 
AEs  
 
Hematology, biochemistry, coagulation 
 
Pregnancy test (women of childbearing potential only) 
 
Urinalysis  
 
Urine drug screen (trial site testing) 
 
Alcohol breath test 
7.5.2 Instructions to patients prior to dosing 
On dosing days, patients are allowed to consume a small meal for breakfast with corresponding 
administration of rapid acting insulin to address the meal and in accordance with their normal 
management of blood glucose levels. At visit 2 and visit 4 the patient should aim to have a 
similar sized breakfast and corresponding rapid acting insulin dose.  
Use of long-acting insulin and rate of basal continuous subcutaneous insulin infusion (CSII) will 
be continued according to normal glycemic management of the individual patients during dosing 
days.  
7.5.3 Procedures and assessments during the treatment period of the trial 
At Visit 2 (Day 0) patient eligibility is rechecked (check of changes between the screening visit 
and Visit 2) and patients eligible to participate will be randomized to treatment with dasiglucagon 
or GlucaGen.  
Additionally, during the treatment period of the trial, at Visits 2 and 4 (Days 0 and 14), the 
following assessments will take place: 
 
Concomitant medication 
 
Check of withdrawal criteria 
 
Check of dosing day exclusion criteria 
 
Vital signs (pre-dose, and at 30, 90 and 120 min post-dosing) 
 
ECG (pre-dose, and at 20, 35, 45 and 60 min post-dosing) 
 
Local tolerability (at 0.5 and 2 h post-dosing) 
 
AEs  
 
Hematology and biochemistry (pre-dose, and at 30 and 90 min post-dosing) 
 
Urinalysis (pre-dose) 

 
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 
Urine drug screen (pre-dose) at trial site 
 
Urine pregnancy test (pre-dose) at trial site (women of childbearing potential only) 
 
Alcohol breath test (pre-dose) 
 
Dasiglucagon/glucagon plasma concentrations  
(Pre-dose, 5, 10, 30, 60, and 90 min post-dosing. The actual time of blood sampling for 
exposure should not deviate from the nominal time by more than ±1 min. Pre-dose is 
defined as within 5 min prior to dosing.) 
 
Plasma glucose concentration  
(Pre-dose, 5, 10, 30, 60, and 90 min post-dosing. The actual time for blood sampling for 
plasma glucose should not deviate from the nominal time by more than ±1 min. Pre-dose 
is defined as within 5 min prior to dosing.) 
 
Antibodies against dasiglucagon/glucagon (pre-dose) 
 
Administration of trial medication 
Prior to administration of trial medication patients must reach a target plasma glucose 
level of 70-150 mg/dL. If the patient presents with plasma glucose > 150 mg/dL, 
corrective amounts of fast acting insulin will be administered at the investigator’s 
discretion. Plasma glucose measured after 20 and after 40 minutes should ensure that 
the patient has reached the targeted 70-150 mg/dL. If the patient presents with plasma 
glucose < 70 mg/dL glucose ingestion will be provided in order to reach target plasma 
glucose of 70-150 mg/dL documented by plasma glucose measurements after 20 and 40 
minutes, respectively . Patients must be fasting for 90 min after administration of trial 
medication, and can be treated individually to alleviate any potential side effects. See 
section 7.4.2. Patients will be observed for at least 5 h post-dose. 
At Visit 3 of the treatment period (Day 7), only the following assessments will take place 
 
Concomitant medication  
 
Check of withdrawal criteria 
 
Check of dosing day exclusion criteria 
 
Vital signs (pre-dose, and at 30, 90 and 120 min post-dosing) 
 
ECG (pre-dose, and at 20, 35, 45 and 60 min post-dosing) 
 
Local tolerability (at 0.5 and 2 h post-dosing) 
 
AEs  
 
Urine drug screen (pre-dose) at trial site 
 
Urine pregnancy test (pre-dose) at trial site (women of childbearing potential only)Alcohol 
breath test (pre-dose) 
 
Antibodies against dasiglucagon/glucagon (pre-dose) 
 
Administration of trial medication 
Prior to administration of trial medication patients must reach a target plasma glucose 
level of 70-150 mg/dL. If the patient presents with plasma glucose > 150 mg/dL, 
corrective amounts of fast acting insulin will be administered at the investigator’s 
discretion. Plasma glucose measured after 20 and after 40 minutes should ensure that 
the patient has reached the targeted 70-150 mg/dL. If the patient presents with plasma 
glucose < 70 mg/dL glucose ingestion will be provided in order to reach target plasma 
glucose of 70-150 mg/dL documented by plasma glucose measurements after 20 and 40 
minutes, respectively.  Patients are NOT required to be fasting after administration of trial 
medication, and can be treated individually to alleviate any potential side effects 
immediately following dosing. See section 7.4.2. Patients will be observed for at least 5 h 
post-dose. 

 
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7.5.4 Follow-up period of the trial 
After the final dose of trial medication (at Visit 4, Day 14, described above), patients will be 
followed up until Day 104 (Visit 7). During the follow-up period, visits take place at Days 35, 60, 
and 104 (Visits 5, 6, and 7).  
At Visits 5 and 6 during the follow-up period, the following assessments will take place: 
 
Concomitant medication  
 
Check of withdrawal criteria 
 
AEs  
 
Antibodies against dasiglucagon/glucagon 
Additionally, the following assessments will take place at Visit 5 only: 
 
Vital signs 
 
ECG  
 
Hematology and biochemistry  
At Visit 7, the final visit of the follow-up period and of the trial (EoT visit), the following 
assessments will take place: 
 
Concomitant medication  
 
Physical examination 
 
Vital signs 
 
ECG 
 
AEs  
 
Hematology and biochemistry 
 
Urinalysis 
 
Antibodies against dasiglucagon/glucagon 
7.5.5 Final examination at the end of the trial  
The final visit of the trial is Visit 7 (Day 104 of the follow-up period; EoT visit). See Section 7.5.4 
for further details.  
7.5.6 Additional (safety) examinations 
If there are any unclear symptoms or observations the responsible physician in charge may 
perform further medical examinations, other than outlined in this protocol, including further 
clinical laboratory tests, in order to clarify the relevance or to diagnose symptoms.  
7.5.7 Safety laboratory tests 
Samples obtained will be prepared and transferred to the appropriate laboratory by 
SynteractHCR according to Standard Operating Procedures. The parameters listed in Section 
7.6.4.1 will be determined using standard methods. 
The total volume of blood sampled per patient for safety analyses is 68 mL. 
7.6 
Immunogenicity, pharmacokinetic, pharmacodynamic, tolerability and safety 
measurements 
Details of sampling for immunogenicity testing, plasma glucose concentrations, plasma trial 
medication concentrations, and safety laboratory testing are provided in a laboratory manual 
(see the Investigator site file).  

 
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7.6.1 Immunogenicity measurements 
Antibodies against dasiglucagon/glucagon will be measured at all visits after screening. During 
the treatment period (Visits 2, 3, and 4) samples will be collected pre-dose.  
The clinical ADA assays have been validated in accordance with existing guidelines and 
recommendations.6,7,8,9,10  
Confirmed positive anti- dasiglucagon antibody samples, (treatment-induced or treatment-
boosted) from anti-dasiglucagon antibody-positive patients will be evaluated for binding titer 
neutralizing potential and titer as well as cross-reactivity towards endogenous glucagon.  
No further serum sampling will be needed as the ADA samples can be used for Nab analysis. 
The in vitro neutralizing effect of antibodies will be measured using an assay9,12 based on 
glucagon receptor transfected human embryonic kidney cells. The calculated sensitivity in 
previous studies was about 51.8 ng/mL. The assay was also validated for recombinant glucagon 
with similar results.11,12 In case of a positive result in the Nab assay, a titer estimation will be 
performed. The cell-based Nab analyses will be performed by a special laboratory, BioAgilytix, 
Durham, NC, USA. 
In vivo neutralizing effect will be evaluated by comparing PK and PD endpoints between ADA 
positive and ADA negative patients, further investigation may be performed by correlating ADA 
titer with PK and PD endpoints. 
Residual and additional antibody serum samples may be stored until approval of market 
authorization by the health authorities. Further characterization of the antibody response may be 
requested by the health authorities. 
7.6.2 Plasma concentrations of dasiglucagon and GlucaGen  
The exposure to trial medication (dasiglucagon or GlucaGen) will be assessed based on plasma 
concentration data (AUC0-30min, AUC0-90 min, Cmax, tmax) from samples collected at Visits 2 and 4 
(after administration of the first and third doses of trial medication).  
Samples will be collected pre-dose, and at 5, 10, 30, 60, and 90 min post-dosing. The actual 
time of blood sampling for exposure should not deviate from the nominal time by more than ±1 
min. Pre-dose is defined as within 5 min prior to dosing. 
7.6.3 Pharmacodynamic measurements 
The plasma glucose profile will be assessed based on plasma concentration data (AUE0-30min, 
AUE0-90 min, CEmax, tmax) from samples collected at dosing Visits 2 and 4 (first and third dosing 
visit).  
Samples will be collected pre-dose, and at 5, 10, 30, 60, and 90 min post-dosing. The actual 
time of blood sampling for evaluation of plasma glucose should not deviate from the nominal 
time by more than ±1 min. Pre-dose is defined as within 5 min prior to dosing.  
7.6.4 Safety and tolerability measurements  
7.6.4.1 Safety laboratory tests 
Routine safety laboratory tests will be performed centrally. Samples for safety laboratory 
parameters will be collected at Visits 1, 2, 4, 5, and 7. Samples for urinalysis will be collected at 
Visits 1, 2, 4, and 7. The following parameters will be determined: 
 
Clinical chemistry: sodium, potassium, calcium, glucose, urea, creatinine, total bilirubin, 
AST (SGOT), ALT (SGPT), gamma-GT, alkaline phosphatase, total protein, C-reactive 
protein, HbA1c, C-peptide  

 
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 
Hematology: hemoglobin, red blood cell count (erythrocytes), hematocrit, platelet count 
(thrombocytes), total white blood cell count (leucocytes) 
 
Coagulation: international normalized ratio (INR), fibrinogen (at screening visit only)  
 
Urinalysis: pH, blood (leukocytes and erythrocytes), protein, glucose, ketones, nitrite 
A pregnancy test will be performed at screening (Visit 1) and pre-dose at the three dosing visits 
(Visit 2, 3 and 4) for women of childbearing potential only. 
Alcohol breath tests and urine drug screen (amphetamine, cocaine, MDMA, methamphetamine, 
opiate/morphine, marihuana) will be performed at Screening (Visit 1) and at Visits 2, 3, and 4. 
For further details, please refer to the laboratory manual.  
7.6.4.2 Safety examinations 
Physical examination is performed at Screening (Visit 1) and EoT (Visit 7).  
AEs are assessed at all visits. Local tolerability is assessed at all dosing visits (Visits 2, 3, and 
4). ECG is assessed at Screening (Visit 1) Visits 2, 3, and 4 and vital signs are assessed at 
Screening (Visit 1) Visits 2, 3, 4, 5, and 7.  
 
Physical examination includes examination of the following body systems: head, ears, 
eyes, nose, throat (HEENT), including the thyroid gland; heart, lung, chest; abdomen; 
skin; musculoskeletal system; nervous system; lymph node 
 
Vital signs include: pulse rate and blood pressure in a sitting position after 5 min, body 
temperature 
 
Local tolerability: skin reactions will be assessed at the injection site at 0.5 and 2 h post-
dosing. Skin reactions will be reported as AEs (see Section 8). 
 
12-lead ECG. Details from ECG assessments will be recorded, including PR, QRS and 
QT intervals.   
8. Adverse events 
8.1 
Definitions 
Adverse Event (AE) 
An AE is any untoward medical occurrence in a trial patient administered an investigational 
medicinal product (IMP) and which does not necessarily have a causal relationship with the 
treatment. An AE can therefore be any unfavorable and unintended sign (for example, an 
abnormal laboratory finding), symptom, or disease temporally associated with the use of an 
IMP, whether or not considered related to the IMP.  
Note: This includes events from the first trial related activity after the patient has signed the 
informed consent.  
AEs include: 
 
A clinically significant worsening of a concomitant illness. 
 
A clinical laboratory abnormality which is clinically significant, i.e. any abnormality that 
suggests a disease and/or organ toxicity and is of a severity that requires active 
management. Active management includes active treatment or further investigations, for 
example change of medicine dose or more frequent follow-up due to the abnormality. 
 
Hypoglycemic episodes (see Section 8.4) 
 
Injection site reactions 

 
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The following should not be recorded as AEs, if recorded at screening (on Screening Form or 
CRF): 
 
Pre-planned procedure, unless the condition for which the procedure was planned has 
worsened from the first trial related activity after the patient has signed the informed 
consent. 
 
Pre-existing conditions found as a result of screening procedures (pre-existing conditions 
should be reported as medical history or concomitant illness). 
Serious adverse event (SAE) 
A SAE is any untoward medical occurrence that at any dose:  
 
results in death  
 
is life-threatening  
 
requires inpatient hospitalization or prolongation of existing hospitalization 
 
results in persistent or significant disability or incapacity 
 
is a congenital anomaly or birth defect 
 
is medically important 
Medical judgement must be exercised in deciding whether an AE is believed to be 
‘medically important’. Medically important event may not be immediately life-threatening 
or result in death or hospitalization but may jeopardize the patient or may require 
intervention to prevent one of the other outcomes listed in the definition above. 
Suspected unexpected serious adverse reactions (SUSAR) 
An AE, fulfilling one of the criteria of seriousness and being assessed as related to IMP 
application, the nature or severity of which is not consistent with the applicable reference 
document (e.g. ZP4207 IB3 or package leaflet/SmPC for an approved product such as 
GlucaGen13).  
Clinical event of interest 
A clinical event of interest is an event which, in the evaluation of safety, has a special focus (e.g. 
required by health authorities). 
In this trial hemodynamic changes, as defined below, are considered clinical events of interest: 
 
Post-dose clinical signs or measured vital signs indicating a clinical significant drop in 
blood pressure including signs of orthostatic hypotension, vasovagal responses or 
bradycardia. 
 
Post-dose change in pulse or blood pressure considered an event of hypo- or 
hypertension as judged by the investigator. 
Intensity of an adverse event 
The maximum intensity (severity) of all AEs must be assessed by the Investigator and 
documented. Severity should be graded when the AE outcome is known: 
Mild:  
A type of adverse event that is usually transient and may require only minimal 
treatment or therapeutic intervention. The event does not generally interfere with 
usual activities of daily living. 
Moderate:  A type of adverse event that is usually alleviated with additional specific therapeutic 
intervention. The event interferes with usual activities of daily living, causing 
discomfort but poses no significant or permanent risk of harm to the research 
participant. 
Severe:  
A type of adverse event that interrupts usual activities of daily living, or significantly 
affects clinical status, or may require intensive therapeutic intervention. 

 
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A ‘severe’ reaction does not necessarily deem the AE as ‘serious’ and a SAE may not be 
‘severe’ in nature. 
Causality relationship to trial medication 
The causality of each AE should be assessed by the Investigator according to the following 
classification: 
Probable: Good reason and sufficient documentation to assume a causal relationship. 
Possible: A causal relationship is conceivable and cannot be dismissed. 
Unlikely: The event is most likely related to etiology other than the trial product. 
Not related:  
No relationship to trial product 
Outcome of an adverse event 
The outcome of all AEs must be assessed by the Investigator and documented by his/her staff. 
The following definitions should be used: 
Recovered/resolved:  
The patient has fully recovered, or by medical or surgical 
treatment the condition has returned to the level observed 
at the first trial-related activity after the patient signed the 
informed consent.  
Recovering/resolving: 
The condition is improving and the patient is expected to 
recover from the event. This term is only applicable if the 
patient has completed the trial. 
Recovered/resolved with sequelae:  The patient has recovered from the condition, but with 
lasting effect due to a disease, injury, treatment or 
procedure. If a sequela meets an SAE criterion, the AE 
must be reported as an SAE. 
Not recovered/ not resolved:  
The condition of the patient has not improved and the 
symptoms are unchanged. 
Fatal:  
This term is only applicable if the patient died from a 
condition related to the reported AE. Outcomes of other 
reported AEs in a patient before he/she died should be 
assessed as "recovered/resolved", "recovering/resolving", 
"recovered/ resolved with sequelae" or "not recovered/not 
resolved". An AE with fatal outcome must be reported as 
an SAE. 
Unknown:  
This term is only applicable if the patient is lost to follow-
up. 
8.2 
Collection, recording and reporting of adverse events 
All events meeting the definition of an AE must be collected and reported from the first trial 
related activity after the patient has signed the informed consent until the end of the post-
treatment follow-up period. At each contact with the site (visit or telephone, excluding visits, 
where the patient is not seeing the Investigator or his staff (e.g. visits to the laboratory)) the 
patient must be asked about AEs. All AEs, either observed by the Investigator or reported by the 
patient, must be recorded by the Investigator and evaluated. 
The Investigator should record the diagnosis, if possible. If no diagnosis can be made the 
Investigator should record each sign and symptom as individual AEs. 

 
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All AEs must be recorded by the Investigator. One single Adverse Event Form must be used per 
AE from start to resolution. For SAEs, the Serious Adverse Event Form must also be completed. 
For clinical events of interest, the Clinical Event of Interest Form must also be completed. 
AE information should include the following: 
 
Date and time of onset and resolution 
 
Date and time of Investigator’s first information on the (S)AE 
 
Seriousness 
 
Severity 
 
Causal relationship with IMP 
 
Interruption or withdrawal of treatment with IMP and other measures taken 
 
Outcome 
All AEs are coded; details are described in the trial specific Data Management Plan.  
If an event classifies as a clinical event of interest, the Investigator must tick the Clinical Event 
of Interest box on the AE form and complete the Clinical Event of Interest Form. The Clinical 
Event of Interest form will capture if the event was associated with any signs or symptoms and 
capture the highest/lowest blood pressure and pulse measured during the event. 
The Investigator must report initial information in writing (fax or email) on all SAEs to the 
Sponsor’s responsible pharmacovigilance unit (Safety CRO) immediately (within 24 hours) after 
obtaining knowledge about the event. Please refer to Appendix 1 for contact details. The Safety 
CRO will inform the medical monitor and the sponsor about the reported SAEs. 
It is the responsibility of the Safety CRO to report all SUSARs that occur in this trial to the 
Competent Authorities and IRBs/IECs in accordance with the local requirements in force and 
ICH guideline for GCP. The trial monitor must be informed accordingly. 
8.3 
Follow-up of adverse events 
All AEs that are ongoing at the end of the patient’s participation in the study will be followed-up 
until the event is resolved or reaches a satisfactory outcome as deemed by the Investigator.  
Follow-up actions for all SAEs will be performed according to appropriate clinical care practices 
and may depend on the nature of the event. These will be determined after internal review 
and/or sponsor review. 
The follow up information should only include new (updated and/or additional) information that 
reflects the situation at the time of the Investigator’s signature. 
Follow-up information on (S)AEs will be updated using the (S)AE Form. If a non-serious event 
becomes serious during the follow-up the AE Form and SAE Form have to be used and 
reporting timelines follow those of a SAE. 
The Investigator must forward follow-up information on SAEs and if previously non-serious AEs 
become SAEs to the Sponsor immediately (within 24 hours) after obtaining knowledge about the 
new information. 
8.4 
Hypoglycemia 
Hypoglycemia will be regarded as an AE and recorded and documented on an AE Form. 
Hypoglycemia is defined as a fall of plasma glucose below 3.9 mmol/L (70 mg/dL). 
During the dosing visits, mild to moderate symptoms of hypoglycemia, or a blood glucose (BG) 
value less than a threshold of <2.8 mmol/L (50 mg/dL), corresponding to a plasma glucose (PG) 
value of <3.1 mmol/L (56 mg/dL), will be treated by i.v. glucose solution at the investigator’s 
discretion according to best available medical practice. Treatment is to be repeated until BG 

 
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value stabilized above the threshold limit again. BG measurements will only be done due to 
safety concerns. Insulin-induced hypoglycemia should be recorded as an AE. 
8.5 
Pregnancy 
Female patients must be instructed to notify the Investigator immediately if they become 
pregnant or if they suspect to be pregnant during the trial. The Sponsor has a responsibility to 
monitor the outcome of all pregnancies reported during the clinical trial. 
Male patients must be instructed to notify the Investigator immediately if their partner becomes 
pregnant or suspects to be pregnant. The Sponsor has a responsibility to monitor the outcome 
of all pregnancies reported during the clinical trial. During an information meeting at the trial site, 
the patient’s partner will be fully informed by a physician of her participation in capturing the 
outcome data, and will be asked to provide her written consent. 
The Investigator must report all information on pregnancies on the initial pregnancy form. The 
completed initial pregnancy form must be forwarded to the Sponsor according to the procedure 
stated in Section 8.2. Any (S)AEs in the mother, as well as other pregnancy complications 
(ectopic pregnancy) fulfilling the criteria of an (S)AE, must be reported on the (S)AE form.  
The following must be collected in the initial pregnancy form:  
 
Medical history of the mother 
 
Family history 
 
Course of the pregnancy, including expected delivery date 
The Investigator must follow the pregnancy until the pregnancy outcome and the newborn 
infant(s) until the age of 1 month. The Investigator must collect information on the pregnancy 
and pregnancy complications as well as the pregnancy outcome including the health of the 
newborn infant(s) on the pregnancy outcome form. The completed pregnancy outcome form 
must be forwarded to the Sponsor according to the procedure stated in Section 8.2. Any (S)AEs 
in the newborn must be reported on the (S)AE form. 
The SAEs that must be reported including abnormal outcome - such as congenital anomalies, 
fetal death and termination of pregnancy (spontaneous or elective abortion), including any 
anomalies of the fetus observed at gross examination or during autopsy.  
The following must be collected in the pregnancy outcome form:  
 
Course of the pregnancy 
 
Outcome of the pregnancy 
 
Condition of the newborn 
 
Any AEs in the newborn infant must be followed till the age of 1 month 
8.6 
Precautions 
Normal precautions taken for a human trial, including the provision of emergency equipment, 
will be taken during this trial. Qualified and well trained physicians and medical staff will instruct 
the patients. During a patient’s participation in the trial, the Investigator should ensure that 
adequate medical care is provided to the patients for any AEs, including clinically significant 
laboratory values related to the trial. The Investigator should inform the patient when medical 
care is needed for intercurrent illnesses of which the Investigator becomes aware.  
For further information on safety precautions for ZP4207 and GlucaGen, please refer to the 
current version of the Investigator’s Brochure3 and the SmPC for GlucaGen13, respectively. 

 
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8.7 
Safety Committee 
The internal Zealand Pharma Safety Committee (SC) is constituted to perform ongoing safety 
surveillance of clinical trials with dasiglucagon, including this trial. 
If safety signals are observed, either based on reported SAEs, periodic review of laboratory 
parameters, review of all AEs reported between the SC meetings, or on notification of significant 
findings, the SC will take appropriate measures to safeguard the patients.  
As a minimum the SC convenes every quarter to review relevant safety information, including 
AEs and laboratory data.  

 
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9. Data management and quality control 
9.1 
Case report forms 
All the information collected during the trial will be recorded in the eCRFs, which are identified 
by patient number. Suitable eCRFs will be designed by SynteractHCR. The investigator will 
ensure that the eCRFs are correctly completed. All key pages will be signed or initialed by the 
investigator, signifying agreement with and responsibility for the recorded data. Key pages are 
the following: AE-reporting form, trial medication form, concomitant medication form and trial-
closure form.  
Data directly captured in the eCRF (i.e., data assigned or calculated automatically by the EDC 
system) is called e-source. This means that these data fields in the CRF are source documents. 
For the other CRF data fields, which are entered by medical personnel during the trial, the 
source data will be found in other documents (such as patients’ files, worksheets, etc.), i.e. for 
these CRF data fields the “other” documents are the source documents.  
9.2 
Quality control 
The investigator will permit trial-related monitoring, IEC review, and regulatory inspections, 
providing direct access to source data /documents. Sponsor-authorized quality assurance 
personnel may carry out audits for which the investigator must provide support. 
The trial will be supervised by a monitor from SynteractHCR. The trial monitor will contact the 
investigator regularly to discuss the progress of the trial and to check the trial documents 
including the informed consent forms for completeness and consistency.  
The trial monitor or a representative of the sponsor will cross-check the data entered in the 
eCRFs with the source data at the trial site and observe the trial procedures in order to verify 
adherence to the trial protocol. 
The eCRFs will be checked for completeness and correctness by the monitor and data 
management department of SynteractHCR according to the SynteractHCR SOPs and any queries 
will be resolved by the investigator. 
All of the clinical data will be captured via electronic data capture (EDC) using a web-based tool. 
The software Marvin from the company XClinical (www.xclinical.com/) is the preferred EDC 
software. Marvin is compliant with all legislation relevant to electronic data capture (FDA 21 
CFR Part 11, GCP). 
The investigator site staff will enter and edit the data via a secure network, with secure access 
features (username and password). A complete electronic audit trail will be maintained. The 
investigator will approve the data using an electronic signature (Ref: 21 CFR Part 11), and this 
approval is used to confirm the accuracy of the data recorded. 
eCRFs will be used for all patients. The investigator’s data will be accessible from the 
investigator’s site throughout the trial. The electronic CRFs must be kept current to reflect 
patient status at each phase during the course of the trial. The electronic CRF will not capture 
personalized data. The investigator must make a separate confidential record of personalized 
details (name and initials) on the patient identification and enrollment log. All changes to data 
are done by the investigator through the EDC system.  
It is the responsibility of the Principal Investigator of the respective site to ensure that all patient 
discontinuations or changes in trial or other medications entered on the patient’s eCRF are also 
made on the patient’s medical records. 
The eCRFs for any patient leaving the trial should be completed at the time of the final visit or 
shortly thereafter. 

 
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9.3 
Data management 
Data management will be performed according to SynteractHCR SOPs. 
 

 
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10. Statistical methods and determination of sample size 
10.1 Statistical and analysis plan 
A separate Statistical Analysis Plan (SAP) will be finalized that details the planned statistical 
analysis and may include necessary adaptations to the planned statistical analysis before 
unblinding of the data.  
Any deviations from the planned analyses will be described and justified in the final integrated 
trial report. 
10.1.1 General considerations 
All data obtained in this trial and documented in the eCRFs will be listed and summarized with 
statistics or frequency tables as appropriate. In case of termination of the trial, all data collected 
up to that time point will be included into the analysis. 
Raw data listings and summary tables will be generated using the software SAS© Version 9 or 
higher.  
All statistical analysis will be descriptive i.e. no formal testing will be performed. 
Continuous variables will be summarized with means, standard deviations, medians, minimums, 
and maximums and valid cases.  
Other summaries (e.g. quartiles, 95% confidence intervals) may be used as appropriate. 
Categorical efficacy and safety variables will be summarized by counts and by percentage of 
patients in corresponding categories.  
10.1.2 Classification of patients to subsets 
For the statistical analysis the randomized patients will be divided up into the following datasets: 
The following definitions are applicable: 
Safety analysis set 
(SAS) 
all patients who were randomized and received at least one dose of 
trial medication 
Full analysis set 
(FAS) 
all patients of the SAS with at least one measurement of the ADA 
titer at baseline 
Per Protocol set 
(PPS) 
all patients of the FAS for whom no relevant protocol deviations 
were documented 
The analysis of the primary endpoint will be based on the FAS. A secondary analysis of the 
primary endpoint will be based on the PPS. Safety analysis will be based on the SAS. 
The decision whether a protocol deviation is relevant or not for the exclusion of patients from the 
PPS set will be made case-by-case in a data review meeting. 
10.1.3 Immunogenicity data 
All immunogenicity parameters will be analyzed descriptively per treatment group. No statistical 
tests are planned. Baseline ADA-positive patients will be calculated as a percentage of the total 
number of patients whose baseline samples were tested for ADA. Titer will be reported as 
median and interquartile range. 
95% confidence intervals for incidence rates and for rate differences will be given. 
Secondary immunogenicity parameters will be described with appropriate descriptive statistics 
for dichotomous, categorical or continuous variables. 

 
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10.1.4 Exposure and PD endpoints 
Plasma dasiglucagon and glucagon concentrations 0-90 min from dosing: AUC0-30min, AUC0-90 
min, Cmax, and tmax will be summarized with descriptive statistics. 
Plasma glucose profiles 0-90 min from dosing: AUE0-30min, AUE0-90 min, CEmax, and tmax will be 
summarized with descriptive statistics. 
10.1.5 Safety data 
Clinical laboratory data 
Clinical laboratory test results will be marked whether the result is below, within or above the 
respective reference range. The number of values outside of the reference range will be 
counted. 
Adverse events 
Adverse events will be tabulated by system organ class (SOC) and preferred term (PT) after 
medical coding using the Medical Dictionary for Regulatory Activities (MedDRA). AE summary 
tables will include counts and percentages of patients who experienced adverse events 
summarized by system organ class (SOC) and preferred term (PT). 
Other safety data 
Vital signs, physical examination, ECG and local tolerability data will be summarized with 
descriptive statistics. 
10.1.6 Further data 
Baseline and demographic data will be summarized using descriptive statistics. Baseline ADA-
positive patients will be calculated as a percentage of the total number of patients whose 
baseline samples were tested for ADA. 
All other data obtained in this trial and documented in the eCRF will be listed. 
10.1.7 Withdrawals, drop-outs and missing data 
In the case of drop-outs, no imputation of values for immunogenicity measurements will be 
done. Analysis is done on valid cases only i.e. no imputation technique like LOCF (last 
observation carried forward) will be applied. 
10.1.8 Baseline and center comparisons 
Demographic and other baseline characteristics will be compared. 
10.1.9 Subgroup analysis 
Subgroup analyses for the primariy endpoint (voerl ADA incidence) by gender, age, and race 
will be performed. 
10.1.10 Interim analysis 
No interim analysis is currently planned. 
10.2 Determination of sample size 
The purpose of the present trial is to generate data describing the immunogenic potential of 
dasiglucagon and GlucaGen. The ADA assays to be used in this trial are both validated, but 
specific for GlucaGen and dasiglucagon, respectively,  and the performance of the assays are 
thus not directly comparable. As a consequence, a formal comparison or non-inferiority analysis 
will not be performed 

 
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Currently, no ADA incidences have been detected in the completed clinical trials, where up to 5 
repeated doses of dasiglucagon have been administered to the same patients within a week. 
Across the two phase 1 clinical trials and a completed phase 2 PK/PD trial, a total of 141 
subjects have been exposed to dasiglucagon and no incidences of ADA development have 
been observed. The obtained data indicate that dasiglucagon has a low risk for induction of 
ADAs in the investigated settings and as a consequence  a meaningful sample size to compare 
both treatments cannot be estimated. 
The sample size is therefore based on a certain precision of the confidence interval for the 
overall ADA incidence if no events are observed, respectively to ensure a certain probability for 
observing one event. 
When no events are observed, to obtain an upper bound of 0.050 on the 90.0% confidence 
interval for the probability of such a rare event, would require a sample size of 45. Respectively, 
accepting a chance of observing at least one event of 90% and an actual probability of the event 
of 5% leads to a sample size of 45 patients completing the trial. In order to account for drop-
outs, It is expected that 112 patients in total will be randomized and treated. 

 
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11. Ethics and regulations 
11.1 Independent ethics committees and competent authorities 
The clinical trial authorization (CTA) granted by the competent authority (CA) and a favorable 
opinion from the relevant independent ethics committee(s) (IEC(s)) /Institutional Review Board 
(IRB) will be obtained prior to the start of the trial. The local authorities will be notified about the 
trial as required by law. 
The CA and the EC/IRB will be notified about the end of the trial and a report summarizing the 
trial results will be sent to the CA and the EC within one year after the end of the trial. If the trial 
is terminated early, the CA and the EC will be notified within 15 days. 
The IECs and/or IRBs met the requirements of the International Conference on Harmonisation 
(ICH) Harmonised Tripartite Guideline for Good Clinical Practice (GCP) and local legislation. 
They also met the requirements of 21 CFR 312.3. 
11.2 Ethical conduct of the trial  
The trial will be conducted in accordance with the ethical principles set forth in the Declaration of 
Helsinki (including amendments).  
11.3 Patient information and consent 
Written informed consent will be obtained from all patients prior to entry into the trial. The 
investigator will explain to each patient orally and in writing (patient information sheet) the 
nature, significance, risks and implications of the trial before inclusion. In particular, the patients 
will be informed about the following: 
 
the possibility of withdrawing from the clinical trial at any time by revoking the consent and 
without any resulting disadvantage 
 
how personal and health-related data will be collected and used during the trial 
 
the patient must be informed that his/ her medical records may be examined by authorized 
monitors or Clinical Quality Assurance auditors appointed by the Sponsor, by appropriate 
IEC members, and by inspectors from regulatory authorities. 
All patients will receive a copy of the patient information sheet and a copy of their signed and 
dated informed consent form.  
All patients will be insured against injury caused by their participation in the trial according to 
legal requirements. They will be informed about the insurance and the resulting obligations on 
their part. 
11.4 Legal and regulatory requirements 
This trial will be carried out in accordance with: 
 
ICH guidelines for GCP, United States investigational new drug (IND) regulations (21 CFR 
312), the regulations on electronic records and electronic signature (21 CFR 11), the most 
recent guidelines of the Declaration of Helsinki, and the relevant laws and regulations of the 
country in which the trial takes place. 
 
Standard operating procedures (SOPs for clinical investigation and documentation in force 
at SynteractHCR) 

 
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12. Trial administration 
12.1 Responsibilities 
Zealand A/S is the sponsor of this trial. SynteractHCR, a contract research organization (CRO), 
will organize the performance of this trial.  
A list with the names and addresses of the responsible institutions and persons is provided in 
Appendix 1 of this protocol. 
12.2 Protocol deviations 
The investigator agrees to conduct the trial in compliance with the protocol. Prospective protocol 
deviations or waivers will not be granted for this trial. 
Any deviation from the clinical trial protocol in the conduct of the clinical trial will be notified to 
the Monitor on an ongoing basis.  
12.3 Protocol changes  
Amendments to this trial protocol may be made following the procedures specified by local laws 
and regulations. Substantial amendments to this trial protocol may be implemented only if the 
approval of the CA(s) and a favorable opinion of the ethics committee(s) have been obtained. 
Substantial amendments to the conduct of the clinical trial may arise from changes to the 
protocol or from new information relating to the scientific documents in support of the trial. 
Amendments to the trial are regarded as “substantial” where they are likely to have a significant 
impact on: 
 
the safety, physical health and mental integrity of the patients; 
 
the scientific value of the trial; 
 
the conduct or management of the trial; or 
 
the quality or safety of any investigational medicinal product used in the trial. 
If a new event occurs related to the conduct of the trial or the development of the investigational 
product, which may affect the safety of the patients, the sponsor and the investigator will take 
appropriate safety measures to protect the patients against any immediate hazard. The sponsor 
will immediately inform the CA(s) and ethics committee(s) of the new events and the measures 
taken. 
12.4 Publication of results 
The original eCRFs and the data generated from the eCRFs or otherwise obtained during the 
trial under this trial protocol will become the property of the sponsor. Publication of the results of 
this trial by SynteractHCR or the investigator is possible only after written consent has been 
obtained from the sponsor. Any material intended for publication will be given to the sponsor at 
least 4 weeks before submission for publication. The sponsor will have the right to comment on 
the intended publication and to take any reasonable measures for patent protection. 
12.5 Clinical trial report 
After completion of the trial, the results will be tabulated, evaluated and issued as a complete 
final clinical trial report according to the ICH-E3 Note for guidance on structure and content of 
clinical trial reports.  
The sponsor will send a summary of this clinical trial report to the EC and CA within one year 
after the end of the trial.  

 
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12.6 Retention of trial records 
Records and documents pertaining to the conduct of the trial and the distribution of the 
investigational product (e.g. ICFs, laboratory slips, medication inventory records, and other 
pertinent information) must be retained by the Investigator according to local requirements. 
To meet regulatory requirements, the eCRF data will be electronically stored at sites. The 
CDISC ODM (see http://www.cdisc.org/ for details) will be used to store and archive all 
electronic data at the sites. Since CDISC ODM is also the source for the EDC-web-based 
system, no transcription of data is necessary. CDISC ODM is a platform-independent 
standardized data format including the complete trial metadata and audit trail. The data can be 
reviewed at a later stage using off-the-shelf tools. CDISC provides a complete CDISC ODM 
Viewer for these purposes. If needed, PDF-files can be created from the ODM file. 

 
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13. References  
1. 
Seaquist ER, Anderson J., Childs B, Cryer P, Dagogo-Jack S, Fish L, et al. Hypoglycemia 
and diabetes: a report of a workgroup of the American Diabetes Association and the 
Endocrine Society. Diabetes Care 2013; 36(5):1384-95. doi:10.2337/dc12-2480. 
2. 
American Diabetes Association Position Statement Standards of medical care in diabetes - 
2016. Diabetes Care 2016; 39(Suppl. 1):S1-S112. 
3. 
Dasiglucagon Investigator Brochure, Edition 3, 12 Dec 2016. Zealand Pharma A/S.  
4. 
Kedia N. Treatment of severe diabetic hypoglycemia with glucagon: an underutilized 
therapeutic approach. Diabetes Metab Syndr Obes 2011;4:337-46. 
5. 
UK Hypoglycaemia Study Group. Risk of hypoglycaemia in types 1 and 2 diabetes: effects 
of treatment modalities and their duration, Diabetologia 2007;50:1140–7. 
6. 
FDA. 
Guidance 
for 
Industry. 
Bioanalytical 
Method 
Validation. 
May 
2001. 
http://www.fda.gov/downloads/Drugs/Guidance/ucm070107.pdf. 
7. 
Viswanathan CT, Bansal S, Booth B, DeStefano AJ, Rose MJ, Saistad J, et al. 
Workshop/conference 
report—Quantitative 
bioanalytical 
methods 
validation 
and 
implementation: Best practices for chromatographic and ligand binding assays. AAPS J 
9(1): E30-42. doi:10.1208/aapsj0901004.  
8. 
Shankar G, Devanaryan V, Amaravadi L, Barrett YCBowsher R, Finco-Kent D, et al. 
Recommendations for the validation of immunoassays used for detection of host antibodies 
against biotechnology products. J Pharm Biomed Anal 2008; 48(5):1267-81. 
9. 
Commissioning and validation of a method for the validation of anti-ZP4207 antibodies in 
human serum. Zealand Pharma Report, Study 14-173 
10. 
Commissioning and validation of a method for the validation of anti-glucagon antibodies in 
human serum. Zealand Pharma Report, Study 14-174 
11. 
Bioagilytix Labs. Validation of an Assay to detect neutralizing Antibodies to ZP4207 by 
Measuring Cyclic Adenosine Monophosphate (cAMP) in Glucagon Receptor Transected 
Cell Line, study no. BAL-14-206-004-REP. Zealand Pharma, Study 15-039. 09 Aug 2016. 
12. 
Bioagilytix Labs. Validation of an Assay to Detect Neutralizing Antibodies to Glucagon by 
Measuring Cyclic Adenosine Monophosphate (cAMP) in a Glucagon Receptor Transfected 
Cell Line, BAL-14-206-005. Zealand Pharma, Study 15-040. 04 Jul 2016. 
13. 
SPC Novo Nordisk GlucaGen® HypoKit 1 mg powder and solvent for solution for injection. 
http://www.medicines.org.uk/emc/medicine/4258/SPC/GlucaGen+Hypokit+1+mg 
 

 
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APPENDIX 1: 
List of names and addresses 
 
Sponsor 
Zealand Pharma A/S 
Smedeland 36 
2600 Glostrup, Copenhagen 
Denmark 
 
Contract Research 
Organization (CRO) 
SynteractHCR Deutschland GmbH 
Albrechtstr. 14 
80636 Munich, Germany 
 
Coordinating investigator 
Thomas R. Pieber, MD 
Medical University of Graz  
Auenbruggerplatz 15 
A-8036 Graz, Austria 
 
Trial monitor 
SynteractHCR Deutschland GmbH 
Albrechtstr. 14 
80636 Munich, Germany 
 
Statistician 
 
Senior Director Biometrics EMEA 
SynteractHCR Deutschland GmbH 
Albrechtstr. 14 
80636 Munich, Germany 
 
 
Sponsor representative 
 
Clinical Project Manager  
Zealand Pharma A/S 
Smedeland 36, 2600 Glostrup, Denmark 
Tel: 
 
E-mail: 
 
Sponsor’s medical expert 
 
Medical Director  
Zealand Pharma A/S 
Smedeland 36, 2600 Glostrup, Denmark 
Tel: 
 
E-mail: 
  
 
Sponsor representative for 
pharmacovigilance 
 
PharmaLex A/S Agern Allé 24, 2970 Hørsholm, Denmark 
Tel: 
 (8 a.m. to 4 p.m.) 
 
 (outside 8 a.m. to 4 p.m.)   
Fax:  
 
E-mail: drugsafety@lindeq.com 
 
 
Clinical laboratory 
MLM Medical Labs Gmbh 

 
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Dohrweg 63, 41066 Mönchengladbach, Germany 
Tel: 
 
E-mail: 
 
 
 
Analytical laboratory 
(ZP4207 PK, ZP4207 ADA, 
Glucagon ADA) 
 
 
 
 
 
 
 
 
 
(ZP4207 and Glucagon Nab) 
York Bioanalytical Solutions (YBS) 
 (ZP4207 Bioanalysis)  
 (ADA analyses) 
Cedar House  
Northminster Business Park  
Northfield Lane  
York, YO26 6QR 
United Kingdom 
E-mail: 
 
E-mail: 
 
 
 
 
BioAgilytix Labs 
2300 Englert Drive 
Durham, NC 27713 
USA 
 
 
 

 
 
 
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Clinical Trial Protocol 
A phase 3, Randomized, Double-Blind, Parallel Group Safety Trial to Evaluate the 
Immunogenicity of Dasiglucagon and GlucaGen® Administered Subcutaneously in 
Patients with Type 1 Diabetes Mellitus (T1DM) 
Sponsor code: ZP4207-16136 
SynteractHCR: ZEA-DNK-01711 
EudraCT number: 2017-000062-30 
IND Number: 127866 
Dasiglucagon SUB code: SUB181296 
 
 
Coordinating investigator:  
Thomas R. Pieber, MD 
Medical University of Graz  
Auenbruggerplatz 15 
A-8036 Graz, Austria 
 
 
Sponsor:  
Zealand Pharma A/S 
 
Smedeland 36 
 
2600 Glostrup, Copenhagen 
 
Denmark 
 
 
Version: final version 3. This version includes Protocol version 1, dated 18 January 2017, 
Protocol Amendment 1, dated 08 May 2017 and Protocol Amendment 2, dated 21 August 2017. 
Date: 21 August 2017 
 
 
 
 
 
GCP statement 
This trial will be performed in compliance with Good Clinical Practice (GCP),  
the Declaration of Helsinki (with amendments) and local legal and regulatory requirements.

 
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1. Signatures and agreement with protocol 
 
Title: A phase 3, randomized, double-blind, parallel group safety trial to evaluate the 
immunogenicity of dasiglucagon and GlucaGen® administered subcutaneously in patients with 
type 1 diabetes mellitus (T1DM)  
We, the undersigned, agree to conduct this trial according to the Trial Protocol.  
We agree that the trial will be carried out in accordance with Good Clinical Practice (GCP), with 
the Declaration of Helsinki (with amendments) and with the laws and regulations of the 
countries in which the trial takes place. 
 
Coordinating 
investigator 
  
Thomas R. Pieber, MD 
Medical University of Graz  
Auenbruggerplatz 15 
A-8036 Graz, Austria 
 
 
 
 
 
 
Date 
 
Signature 
Statistician 
 
Senior Director Biometrics EMEA 
SynteractHCR Deutschland 
GmbH 
Albrechtstr. 14 
80636 Munich, Germany 
 
 
 
 
 
Date 
 
Signature 
 
 
 
 
 
Sponsor’s 
representative
 
Clinical Project Manager 
Zealand Pharma 
Smedeland 36 
2600 Glostrup, Denmark 
 
 
 
 
 
Date 
Signature 
 
 
 
 
 
 
, MD, PhD 
Medical OfficerZealand Pharma 
Smedeland 36 
2600 Glostrup, Denmark 
 
 
 
 
 
Date 
Signature 
 
 
 

 
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Title: A phase 3, randomized, double-blind, parallel group safety trial to evaluate the 
immunogenicity of dasiglucagon and GlucaGen® administered subcutaneously in patients with 
type 1 diabetes mellitus (T1DM) 
I agree to conduct this trial according to the Trial Protocol.  
I agree that the trial will be carried out in accordance with Good Clinical Practice (GCP), with the 
Declaration of Helsinki (with amendments) and with the laws and regulations of the countries in 
which the trial takes place. 
 
 
 
Investigator
  
 
 
 
 
Date
Signature
 
 
 
 
 
Name and 
address 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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2. Trial synopsis 
Title of the trial: 
A phase 3, randomized, double-blind, parallel group safety trial to evaluate the immunogenicity of 
dasiglucagon* and GlucaGen® administered subcutaneously in patients with type 1 diabetes mellitus 
(T1DM) 
* Dasiglucagon is the proposed international nonproprietary name 
EudraCT number: 
2017-000062-30 
 
Protocol codes: 
Sponsor: ZP4207-16136 
SynteractHCR: ZEA-DNK-01711 
Sponsor or sponsor's representative in the European Union: 
Zealand Pharma A/S, Smedeland 36, 2600 Glostrup (Copenhagen), Denmark 
Coordinating investigator: 
Thomas R. Pieber, MD, Medical University of Graz, Auenbruggerplatz 15,A-8036 Graz, Austria 
Trial center(s): 
2 centers in the EU, 2 centers in the US, and 3 centers in Canada 
Planned trial period: 
First Patient First Visit: May 2017 
Last Patient First Visit: November 2017 
Phase of Development:  
Phase 3 
Objectives: 
The primary objective is to evaluate the immunogenicity of repeated single doses of dasiglucagon and 
GlucaGen following subcutaneous (s.c.) administration in T1DM patients. 
The secondary objective is to evaluate the safety, tolerability and pharmacodynamic response of 
repeated single doses of dasiglucagon following s.c. administration compared with s.c. GlucaGen in 
T1DM patients. 
Trial design: 
This is a randomized, double-blind, parallel group trial evaluating the immunogenicity of either 
dasiglucagon or GlucaGen administered to euglycemic T1DM patients. Patients will be randomized 
1:1 to receive 3 s.c. injections of dasiglucagon or GlucaGen with 1 week between doses. Patients will 
be followed for at least 3 months from the day of the first dose to assess any immune response. A 
total of 90 patients are expected to complete the trial. Handling, preparation and administration of trial 
medication will be done by unblinded trial personnel. All trial assessments will be done by blinded trial 
personnel. However, exposure assessments and anti-drug antibody (ADA) assessments will be 
performed by unblinded personnel at the specialty laboratories, to make sure that dasiglucagon or 
GlucaGen administration is matched with the applicable bioanalytical assay. 
Planned number of patients: 
90 completed patients (45 completed patients per treatment group). It is expected that 112 patients in 
total will be randomized and treated. 
To qualify as completed, the patient must be dosed according to protocol and have blood drawn for 
the planned anti-drug antibody (ADA) analyses. 
Medical condition or disease under investigation: 
Given the role of the immune system in the pathogenesis of T1DM, the present trial is conducted in 
patients with T1DM. There are no data indicating an altered immune response with varying blood 
glucose levels. Therefore, for the safety and well-being of the patients, they will not be brought into 
hypoglycemia prior to dosing. Patients with previous exogenic glucagon exposure will not be excluded 
from the trial, but the information on previous glucagon administration will be recorded. 
Inclusion criteria: 
To be included in the trial, patients have to fulfill all of the following criteria: 
1. Informed consent obtained before any trial-related activities (trial-related activities are any 
procedure that would not have been performed during normal management of the patient) 
2. Availability for the entire trial period 
3. Age between 18 and 70 years, both inclusive 
4. Male or female patients with T1DM for at least 1 year. Diagnostic criteria as defined by the 

 
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American Diabetes Association 
5. Hemoglobin A1c (HbA1c) <10% 
6. Stable anti-diabetic treatment for at least 1 month (e.g. within 10% insulin dose adjustment) 
7. A female participant must meet one of the following criteria 
a. Participant is of childbearing potential and agrees to use one of the accepted contraceptive 
regimens throughout the entire duration of the trial from screening until last follow-up visit. An 
acceptable method of contraception includes at least one of the following: 
i. Abstinence from heterosexual intercourse 
ii. Systemic contraceptives (birth control pills, injectable/implant/ insertable hormonal birth 
control products, transdermal patch); if the participant is using systemic contraceptives, 
she must use an additional form of acceptable contraception (iii or iv, below) 
iii. Intrauterine device (with and without hormones) 
iv. Condom with spermicide  
or 
b. Participant is of non-childbearing potential, defined as surgically sterile (i.e. has undergone 
complete hysterectomy, bilateral oophorectomy, or tubal ligation), or in a menopausal state (at 
least 1 year without menses) 
8. A male must be surgically sterilized or willing to refrain from sexual intercourse from screening 
and until last follow-up visit or, if sexually active, uses a condom and partner practices 
contraception during the trial from screening and until the last follow-up visit 
 
Exclusion criteria: 
Patients meeting any of the following criteria during screening evaluations will be excluded from trial 
participation: 
1. Previous administration of dasiglucagon (previously referred to as ZP4207) 
2. Known or suspected allergy to trial medication(s) or related products  
3. History of anaphylaxis or symptoms of severe systemic allergy (such as angioedema)  
4. Previous participation (randomization) in this trial 
5. Females who are pregnant according to a positive pregnancy test, actively attempting to get 
pregnant, or are lactating 
6. Patients on a closed loop artificial pancreas 
7. Receipt of any investigational drug within 3 months prior to screening 
8. Active malignancy within the last 5 years 
9. Congestive heart failure, New York Heart Association class II-IV 
10. Inadequately treated blood pressure as defined as systolic blood pressure ≥160 mmHg or diastolic 
blood pressure ≥90 mmHg at screening 
11. Current bleeding disorder, including use of anticoagulant treatment 
12. Known presence or history of pheochromocytoma (i.e. adrenal gland tumor) or insulinoma 
(i.e. insulin-secreting pancreas tumor) 
13. Known or suspected HIV infection 
14. Use of a systemic beta-blocker drug, indomethacin, warfarin or anticholinergic drugs in the 
previous 28 days before Day 1 of this trial 
15. Use of systemic corticosteroids, anti-inflammatory biological agents, kinase inhibitors or other 
immune modulating agents within the last 3 months prior to screening 
16. Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >2.5 X the upper limit of 
normal (ULN), bilirubin >1.5 X ULN, estimated glomerular filtration rate (eGFR) 
<30 mL/min/1.73m2 according to the Modification of Diet in Renal Disease (MDRD) Study 
definition. Altered electrolytes values of clinical relevance for cardiac conduction, as judged by the 
investigator. 
17. Clinically significant abnormal ECG at screening as evaluated by Investigator 
18. Donation of blood or plasma in the past month, or in excess of 500 mL within 12 weeks prior to 
screening 
19. A positive result in the alcohol and/or urine drug screen at the screening visit. Significant history of 
alcoholism or drug abuse as judged by the investigator or consuming more than 24 g alcohol per 
day for men, or more than 12 g alcohol per day for women.  

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 6/ 5 0 
2 0. P ati e nt s wit h m e nt al i n c a p a cit y or l a n g u a g e b arri er s t h at pr e cl u d e a d e q u at e u n d er st a n di n g or 
c o o p er ati o n, w h o ar e u n willi n g t o p arti ci p at e i n t h e tri al, or w h o i n t h e o pi ni o n of t h e I n v e sti g at or 
s h o ul d n ot p arti ci p at e i n t h e tri al 
2 1. S ur g er y or tr a u m a wit h si g nifi c a nt bl o o d l o s s wit hi n t h e l a st 2 m o nt h s pri or t o s cr e e ni n g 
2 2. A n y c o n diti o n i nt erf eri n g wit h tri al p arti ci p ati o n or tri al e n d p oi nt s or t h at c o ul d b e h a z ar d o u s t o t h e 
p ati e nt 
2 3. U s e of pr e s cri pti o n or n o n- pr e s cri pti o n m e di c ati o n s k n o w n t o c a u s e Q T pr ol o n g ati o n 
T e st pr o d u ct, d o s e a n d m o d e of a d mi ni str ati o n: 
D a si gl u c a g o n: 0. 6 m g; li q ui d f or m ul ati o n, 1 m g/ m L i n pr efill e d s yri n g e s c o nt ai ni n g 0. 6 m L 
R ef er e n c e pr o d u ct, d o s e a n d m o d e of a d mi ni str ati o n:  
Gl u c a G e n, 1 m g; p o w d er a n d s ol v e nt f or r e c o n stit uti o n a s 1 m L s ol uti o n f or i nj e cti o n (r e c o m bi n a nt 
gl u c a g o n h y dr o c hl ori d e, N o v o N or di s k) 
D ur ati o n of tr e at m e nt: 
P ati e nt s will r e c ei v e 3 s. c. i nj e cti o n s of tri al m e di c ati o n ( d a si gl u c a g o n or Gl u c a G e n) wit h 1 w e e k 
b et w e e n e a c h d o si n g. 
Pri or t o a d mi ni str ati o n of tri al m e di c ati o n p ati e nt s m u st r e a c h a t ar g et pl a s m a gl u c o s e l e v el of 
7 0- 1 5 0 m g/ d L. Pl a s m a gl u c o s e l e v el s m a y b e a dj u st e d b y s. c. a d mi ni str ati o n of a f a st- a cti n g i n s uli n 
a n al o g or b y gl u c o s e i n g e sti o n. 
Crit eri a f or e v al u ati o n:  
I m m u n o g e ni cit y: 
Pri m ar y e n d p oi nt:  
•  
O v er all A D A i n ci d e n c e 
T hi s will b e c al c ul at e d a s a p er c e nt a g e of t h e c o m bi n e d r e s ult s of tr e at m e nt-i n d u c e d A D A-
p o siti v e p ati e nt s a n d tr e at m e nt- b o o st e d A D A- p o siti v e p ati e nt s a n d t h e t ot al n u m b er of 
e v al u a bl e p ati e nt s, e x cl u di n g b a s eli n e- p o siti v e p ati e nt s wit h o ut a n y s a m pl e s a v ail a bl e aft er 
dr u g a d mi ni str ati o n.  
K e y s e c o n d ar y e n d p oi nt s: 
•  
Tr e at m e nt-i n d u c e d A D A 
I n ci d e n c e c al c ul at e d a s a p er ce nt a g e of t h e t ot al n u m b er of e v al u a bl e p ati e nt s t h at w er e A D A 
n e g ati v e at b a s eli n e a n d A D A p o siti v e aft er dr u g a d mi ni str ati o n a n d t h e t ot al n u m b er of 
e v al u a bl e p ati e nt s, e x cl u di n g b a s eli n e p o siti v e p ati e nt s wit h o ut a n y s a m pl e s a v ail a bl e aft er 
dr u g a d mi ni str ati o n.  
•  
Tr e at m e nt- b o o st e d A D A 
I n ci d e n c e c al c ul at e d a s p er c e nt a g e of b a s eli n e A D A-p o siti v e p ati e nt s wit h si g nifi c a nt i n cr e a s e s 
(≥5- f ol d) i n A D A tit er aft er dr u g a d mi ni str ati o n a n d t h e t ot al n u m b er of e v al u a bl e p ati e nt s, 
e x cl u di n g b a s eli n e- p o siti v e p ati e nt s wit h o ut a n y s a m pl e s a v ail a bl e aft er dr u g a d mi ni str ati o n.  
S e c o n d ar y e n d p oi nt s: 
C h ar a ct eri z ati o n of A D A r e s p o n s e:  
•   
I n ci d e n c e a n d tit er of n e utr ali zi n g a cti vit y of A D A p o siti v e p ati e nt s 
•   
I n ci d e n c e of cr o s s-r e a cti vit y of A D A p o siti v e p ati e nt s t o w ar d s e n d o g e n o u s gl u c a g o n 
•   
Ki n eti c s of A D A: 
T h e ti mi n g a n d d ur ati o n of d et e ct e d A D A r e s p o n s e  
S af et y: 
•   
T h e i n ci d e n c e, t y p e a n d s e v erit y of A E s 
•   
C h a n g e s fr o m b a s eli n e i n cli ni c al l a b or at or y p ar a m et er s 
•   
C h a n g e s fr o m b a s eli n e i n vit al si g n s 
•   
Cli ni c all y 
m e a ni n gf ul  c h a n g es 
fr o m  
b a s eli n e  i n  
p h y si c al  
e x a mi n ati o n  
a n d 
el e ctr o c ar di o gr a m ( E C G)  

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 7/ 5 0 
E x p o s ur e e n d p oi nt s, aft er a d mi ni str ati o n of fir st a n d t hir d d o s e s of tri al m e di c ati o n:  
•  
Pl a s m a d a si gl u c a g o n a n d gl u c a g o n c o n c e ntr ati o n s fr o m 0- 9 0 mi n aft er d o si n g will b e 
e v al u at e d b a s e d o n t h e f oll o wi n g e n d p oi nt s: A U C 0- 3 0 mi n , A U C0- 9 0 mi n , Cm a x , tm a x  
P h ar m a c o d y n a mi c s, aft er a d mi ni str ati o n of fir st a n d t hir d d o s e s of tri al m e di c ati o n: 
•   
Pl a s m a gl u c o s e pr ofil e s o v er t h e p eri o d fr o m 0-9 0 mi n aft er d o si n g will b e e v al u at e d 
b a s e d o n t h e f oll o wi n g e n d p oi nt s: A U E 0- 3 0 mi n , A U E0- 9 0 mi n , C Em a x , tm a x  
•   
A c hie vi n g a pl a s m a gl u c o s e i n cr e a s e of ≥2 0 m g/ d L wit hi n 3 0 mi n ut e s aft er tr e at m e nt 
St ati sti c al m et h o d s: 
All st ati sti c al a n al y si s will b e d e s cri pti v e i. e. n o f or m al st ati sti c al t e sti n g will b e p erf or m e d. C o nti n u o u s 
v ari a bl e s will b e s u m m ari z e d wit h m e a n s, st a n d ar d d e vi ati o n s, m e di a n s, mi ni m u m s, a n d m a xi m u m s, 
a n d v ali d c a s e s. Ot h er s u m m ari e s ( e. g. q u artil e s, 9 5 % c o nfi d e n c e i nt er v al s) m a y b e u s e d a s 
a p pr o pri at e. C at e g ori c al v ari a bl e s will b e s u m m ari z e d b y c o u nt s a n d b y p er c e nt a g e of p ati e nt s i n 
c orr e s p o n di n g c at e g ori e s. 
 
S a m pl e si z e c al c ul ati o n: 
T h e p ur p o s e of t h e pr e s e nt tri al i s t o g e n er at e d at a d e s cri bi n g t h e i m m u n o g e ni c p ot e nti al of 
d a si gl u c a g o n a n d Gl u c a G e n. T h e A D A a s s a y s t o b e u s e d i n t hi s tri al ar e b ot h v ali d at e d, b ut s p e cifi c 
f or Gl u c a G e n a n d d a si gl u c a g o n, r e s p e cti v el y,  a n d t h e p erf or m a n c e of t h e a s s a y s ar e t h u s n ot 
dir e ctl y c o m p ar a bl e. A s a c o n s e q u e n c e, a f or m al c o m p ari s o n or n o n-i nf eri orit y a n al y si s will n ot b e 
p erf or m e d. 
C urr e ntl y, n o A D A i n ci d e n c e s h a v e b e e n d et e ct e d i n t h e c o m pl et e d cli ni c al tri al s, w h er e u p t o 5 
r e p e at e d d o s e s of d a si gl u c a g o n h a v e b e e n a d mi ni st er e d t o t h e s a m e p ati e nt s wit hi n a w e e k. A cr o s s 
t h e t w o p h a s e 1 cli ni c al tri al s a n d a c o m pl et e d p h a s e 2 p h ar m a c o ki n eti c/ p h ar m a c o d y n a mi c tri al, a 
t ot al of 1 4 1 s u bj e ct s h a v e b e e n e x p o s e d t o d a si gl u c a g o n a n d n o i n ci d e n c e s of A D A d e v el o p m e nt 
h a v e b e e n o b s er v e d. T h e o bt ai n e d d at a i n di c at e t h at d a si gl u c a g o n h a s a l o w ri s k f or i n d u cti o n of 
A D A s i n t h e i n v e sti g at e d s etti n g s a n d a s a c o n s e q u e n c e a m e a ni n gf ul s a m pl e si z e t o c o m p ar e b ot h 
tr e at m e nt s c a n n ot b e e sti m at e d. 
T h e s a m pl e si z e i s t h er ef or e b a s e d o n a c ert ai n pr e ci si o n of t h e c o nfi d e n c e i nt er v al f or t h e o v er all 
A D A i n ci d e n c e if n o e v e nt s ar e o b s er v e d, r e s p e cti v el y t o e n s ur e a c ert ai n pr o b a bilit y f or o b s er vi n g 
o n e e v e nt. 
W h e n n o e v e nt s ar e o b s er v e d, t o o bt ai n a n u p p er b o u n d of 0. 0 5 0 o n t h e 9 0. 0 % c o nfi d e n c e i nt er v al 
f or t h e pr o b a bilit y of s u c h a r ar e e v e nt, w o ul d r e q uir e a s a m pl e si z e of 4 5. R e s p e cti v el y, a c c e pti n g a 
c h a n c e of o b s er vi n g at l e a st o n e e v e nt of 9 0 % a n d a n a ct u al pr o b a bilit y of t h e e v e nt of 5 % l e a d s t o a 
s a m pl e si z e of 4 5 p ati e nt s c o m pl eti n g t h e tri al. I n or d er t o a c c o u nt f or dr o p- o ut s, It i s e x p e ct e d t h at 
1 1 2 p ati e nt s i n t ot al will b e r a n d o mi z e d a n d tr e at e d. 

 
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11 Pregnancy test is only applicable for women of childbearing potential. At Visit 1 a serum pregnancy test should be performed. At Visit 2, 3 and 4 a pre-dose urine pregnancy 
test should be performed.  
12 On dosing days Visit 2, 3, and 4 vitals signs are collected pre-dose and at 30, 90 and 120 min post-dosing. The actual time of assessment should not deviate from the 
nominal time by more than ±5 min. Pre-dose is defined as within 5 min prior to dosing. 
 
 
 

 
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3. Table of contents 
1.
SIGNATURES AND AGREEMENT WITH PROTOCOL ..................................................... 2
2.
TRIAL SYNOPSIS ............................................................................................................... 4
3.
TABLE OF CONTENTS .................................................................................................... 11
4.
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ............................................ 14
4.1
Abbreviations ..................................................................................................................... 14
4.2
Definitions of terms ............................................................................................................ 15
5.
INTRODUCTION................................................................................................................ 16
5.1
Background of the trial ....................................................................................................... 16
5.2
Trial rationale ..................................................................................................................... 18
5.3
Assessment of anticipated benefits and risks .................................................................... 19
6.
TRIAL OBJECTIVES ......................................................................................................... 20
7.
INVESTIGATIONAL PLAN ............................................................................................... 22
7.1
Overall trial design and plan .............................................................................................. 22
7.2
Discussion of trial design and choice of control groups ..................................................... 22
7.3
Selection of trial population ................................................................................................ 23
7.3.1 Inclusion criteria ................................................................................................................. 24
7.3.2 Exclusion criteria ................................................................................................................ 24
7.3.3 Premature removal from trial ............................................................................................. 25
7.3.3.1
Possible reasons for patient discontinuation ............................................................ 25
7.3.3.2
Center discontinuation .............................................................................................. 26
7.3.3.3
Trial termination ........................................................................................................ 26
7.3.4 Replacement of patients .................................................................................................... 26
7.4
Investigational medicinal product(s)................................................................................... 27
7.4.1 Identity of investigational medicinal product(s) .................................................................. 27
7.4.2 Treatments administered ................................................................................................... 27
7.4.3 Selection of doses in the trial ............................................................................................. 28
7.4.4 Treatment compliance ....................................................................................................... 28
7.4.5 Method of assigning patients to treatments or treatment sequences ................................ 29
7.4.6 Blinding .............................................................................................................................. 29
7.4.7 Drug accountability and disposal ....................................................................................... 29
7.4.8 Prior and concomitant therapy ........................................................................................... 29
7.4.9 Treatment after end of trial ................................................................................................. 29
7.5
Assessments and schedule of measurements (overview) ................................................ 29
7.5.1 Screening examination ...................................................................................................... 30
7.5.2 Instructions to patients prior to dosing ............................................................................... 30
7.5.3 Procedures and assessments during the treatment period of the trial .............................. 30
7.5.4 Follow-up period of the trial ................................................................................................ 32
7.5.5 Final examination at the end of the trial ............................................................................. 32
7.5.6 Additional (safety) examinations ........................................................................................ 32
7.5.7 Safety laboratory tests ....................................................................................................... 33
7.6
Immunogenicity, pharmacokinetic, pharmacodynamic, tolerability and safety 
measurements ................................................................................................................... 33
7.6.1 Immunogenicity measurements ......................................................................................... 33
7.6.2 Plasma concentrations of dasiglucagon and GlucaGen .................................................... 33
7.6.3 Pharmacodynamic measurements .................................................................................... 34
7.6.4 Safety and tolerability measurements ................................................................................ 34
7.6.4.1
Safety laboratory tests .............................................................................................. 34
7.6.4.2
Safety examinations ................................................................................................. 34

 
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8.
ADVERSE EVENTS .......................................................................................................... 35
8.1
Definitions .......................................................................................................................... 35
8.2
Collection, recording and reporting of adverse events ...................................................... 37
8.3
Follow-up of adverse events .............................................................................................. 38
8.4
Hypoglycemia ..................................................................................................................... 38
8.5
Pregnancy .......................................................................................................................... 38
8.6
Precautions ........................................................................................................................ 39
8.7
Safety Committee............................................................................................................... 39
9.
DATA MANAGEMENT AND QUALITY CONTROL ......................................................... 40
9.1
Case report forms .............................................................................................................. 40
9.2
Quality control .................................................................................................................... 40
9.3
Data management ............................................................................................................. 41
10.
STATISTICAL METHODS AND DETERMINATION OF SAMPLE SIZE ......................... 42
10.1
Statistical and analysis plan ............................................................................................... 42
10.1.1 General considerations .................................................................................................... 42
10.1.2 Classification of patients to subsets................................................................................. 42
10.1.3 Immunogenicity data ........................................................................................................ 42
10.1.4 Exposure and PD endpoints ............................................................................................ 43
10.1.5 Safety data ....................................................................................................................... 43
10.1.6 Further data ..................................................................................................................... 43
10.1.7 Withdrawals, drop-outs and missing data ........................................................................ 43
10.1.8 Baseline and center comparisons.................................................................................... 43
10.1.9 Subgroup analysis ........................................................................................................... 43
10.1.10
Interim analysis ............................................................................................................ 43
10.2
Determination of sample size ............................................................................................. 43
11.
ETHICS AND REGULATIONS .......................................................................................... 45
11.1
Independent ethics committees and competent authorities .............................................. 45
11.2
Ethical conduct of the trial .................................................................................................. 45
11.3
Patient information and consent ........................................................................................ 45
11.4
Legal and regulatory requirements .................................................................................... 45
12.
TRIAL ADMINISTRATION ................................................................................................ 46
12.1
Responsibilities .................................................................................................................. 46
12.2
Protocol deviations ............................................................................................................. 46
12.3
Protocol changes ............................................................................................................... 46
12.4
Publication of results .......................................................................................................... 46
12.5
Clinical trial report .............................................................................................................. 46
12.6
Retention of trial records .................................................................................................... 47
13.
REFERENCES................................................................................................................... 48
 
Appendices: 
(1) 
List of names and addresses 
 
 

 
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Index of in-text tables 
Table 2-1: Flow chart ............................................................................................................................. 1
Table 7-1: Identity of investigational products ................................................................................. 27
 
Index of in-text figures 
Figure 7-1 Overview of the trial design ............................................................................................. 22
 

 
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4. List of abbreviations and definition of terms 
4.1 
Abbreviations 
 
 
ADA 
Anti-drug Antibody 
AE 
Adverse Event 
ALT (SGPT) 
Alanine Aminotransferase (Serum Glutamic Pyruvic Transaminase) 
AST (SGOT) 
Aspartate Aminotransferase (Serum Glutamic Oxaloacetic Transaminase) 
BG 
Blood Glucose 
CA 
Competent Authority (Directive 2001/20/EC) 
CFR 
Code of Federal Regulations 
CRF/eCRF 
Case Report Form/Electronic Case Report Form 
CI 
Confidence Interval 
CRO 
Contract Research Organization 
CSII 
Continuous Subcutaneous Insulin Infusion 
CTA 
Clinical Trial Authorization (Directive 2001/20/EC) 
EC 
Ethics Committee 
ECG 
Electrocardiogram 
EDC 
Electronic Data Capture 
eGFR 
Estimated Glomerular Filtration Rate 
EoT 
End of Trial 
EudraCT 
European Clinical Trials Database 
FAS 
Full Analysis Set 
FDA 
Food and Drug Administration 
gamma-GT 
gamma-Glutamyltransferase 
GCP 
Good Clinical Practice 
HbA1c  
Hemoglobin A1c 
HEENT 
Head, Ears, Eyes, Nose, Throat 
HIV 
Human Immunodeficiency Virus 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonization  
IEC 
Independent Ethics Committee 
IM 
Intramuscular(ly) 
IMP 
Investigational Medicinal Product 
IND 
Investigational New Drug 
INR 
International Normalized Ratio 
IRB  
Institutional Review Board 
i.v. 
Intravenous(ly) 
IWRS 
Interactive Web Response System 
LOCF 
Last Observation Carried Forward 
MDRD 
Modification of Diet in Renal Disease 
MedDRA 
Medical Dictionary for Regulatory Activities  
Nab 
Neutralizing Antibody 
PG 
Plasma Glucose 
ODM 
Operational Data Model 
PD 
Pharmacodynamic(s) 

 
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PK 
Pharmacokinetic(s)  
PPS 
Per Protocol Set 
PT 
Preferred Term 
SAP 
Statistical Analysis Plan 
SAS 
Safety Analysis Set 
SAE 
Serious Adverse Event 
SC 
Safety Committee 
s.c. 
Subcutaneous(ly) 
SOC 
System Organ Class 
SOP 
Standard Operating Procedure 
T1DM 
Type 1 Diabetes Mellitus 
T2DM 
Type 2 Diabetes Mellitus 
ULN 
Upper Limit of Normal 
V 
Visit 
ZP4207 
Dasiglucagon  
 
 
Plasma concentrations of dasiglucagon/GlucaGen  
AUC0-30min 
Area under the plasma concentration curve from administration to observed 
concentration 30 min 
AUC0-90 min  
Area under the plasma concentration curve from administration to observed 
concentration at 90 min 
Cmax 
Maximum plasma concentration 
tmax 
Time until Cmax is reached  
 
 
Plasma glucose concentrations 
AUE0-30min 
Area under the effect curve from administration to 30 min 
AUE0-90 min 
Area under the effect curve from administration to 90 min 
CEmax 
Change from baseline plasma glucose to maximum plasma glucose 
measured post dose 
tmax 
Time to maximum effect 
 
4.2 
Definitions of terms 
 
Definition of the end of the trial: The trial ends with the last visit of the last patient participating in 
the trial. 

 
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5. Introduction  
5.1 
Background of the trial 
Hypoglycemia  
Hypoglycemia in patients with diabetes is defined as episodes of an abnormally low plasma 
glucose concentration.1 This is a common, unpredictable, and potentially dangerous side effect 
of treatment of diabetes mellitus with especially insulin or sulfonylureas. It is more frequent in 
patients with profound endogenous insulin deficiency, such as occurs in type 1 diabetes mellitus 
(T1DM) and advanced type 2 diabetes mellitus (T2DM). Treatment of T2DM with insulin causes 
hypoglycemia progressively and more frequently over time, whereas in T1DM, hypoglycemia is 
experienced throughout the course of established disease. 
Symptoms and signs of hypoglycemia are not specific. Patients undergoing a hypoglycemic 
episode experience unpleasant symptoms such as anxiety, sweating, hunger, tremors, 
palpitations, paresthesia, nausea and pallor. Depending on its severity, the hypoglycemia may 
lead to mild confusion, behavioral changes, loss of consciousness, seizures, coma, and death.2  
The incidence of hypoglycemic events or even the fear of hypoglycemia influences patients’ 
adherence to prescribed treatment regimens for diabetes mellitus. This leads to inadequate 
glycemic control, which in turn may lead to an increased risk of diabetic complications. 
Glucagon 
Glucagon is a naturally occurring hormone, secreted from the alpha cells of the pancreatic 
islets. Glucagon plays a central role in the regulation of glucose homeostasis and is the 
counterpart of insulin for controlling blood glucose levels (i.e. it acts in opposition to insulin in 
terms of effects on blood glucose levels). Glucagon stimulates hepatic glycogenolysis and 
gluconeogenesis in hypoglycemic states, thereby restoring glucose homeostasis. Glucagon 
receptor agonism has also been shown to exert effects on lipid metabolism, energy balance, 
body adipose tissue mass and food intake. Insulin decreases blood glucose levels and cases of 
hypoglycemia can be reversed by glucagon. Therefore, glucagon is indicated for the treatment 
of severe hypoglycemia.  
Antibodies against therapeutic peptides like glucagon and analogues hereof may develop when 
injected subcutaneously. Although important, glucagon is not considered to have a critical 
endogenous function since other counter regulatory hormones are also induced during 
hypoglycemia (e.g. growth hormone, cortisol, and epinephrine). In addition, results from 3 
mouse models defective in various pathways of the glucagon signaling have con rmed that 
glucagon action is dispensable for their development and survival. Also, in non-clinical toxicity 
studies performed with dasiglucagon (see below), no consequences of ADA formation have 
currently been observed. In summary, glucagon appears to have a partly redundant 
endogenous function. These non-clinical data are of importance when evaluating the 
consequences of ADA formation. 
Dasiglucagon  
Dasiglucagon (ZP4207) is a stable peptide analog of human glucagon, available in a ready-to-
use liquid formulation and is in development for the treatment of severe hypoglycemia in insulin 
dependent patients with diabetes mellitus. Dasiglucagon is a specific and full glucagon receptor 
agonist designed to mimic the effects of glucagon, having a fast absorption and elimination 
(minutes). It is a peptide of 29 amino acids, with 7 amino acid substitutions compared to native 
glucagon. The main purpose of the substitutions is to increase the physical and chemical 
stability of the glucagon analog compared to marketed glucagon products such as Lilly 
Glucagon or GlucaGen®. Dasiglucagon exhibits improved physical and chemical stability and is 
available in an aqueous solution at neutral pH.3 

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 1 7/ 5 0 
T hr e e cli ni c al tri al s h a v e b e e n c o m pl et e d wit h d a si gl u c a g o n, a fir st h u m a n d o s e tri al ( Z P 4 2 0 7-
1 4 0 1 3), a m ulti pl e- d o s e d o s e- e s c al ati o n tri al ( Z P 4 2 0 7- 1 5 0 0 7) t o e v al u at e t h e s af et y, t ol er a bilit y, 
p h ar m a c o ki n eti c s ( P K) a n d p h ar m a c o d y n a mi c s ( P D) of d a si gl u c a g o n, a n d a p h a s e 2 cr o s s o v er 
tri al t o a s s e s s t h e p h ar m a c o ki n eti c s a n d p h ar m a c o d y n a mi c s of a si n gl e d o s e of a n o pti mi z e d 
f or m ul ati o n of d a si gl u c a g o n a d mi ni st er e d s u b c ut a n e o u sl y (s. c.) i n p ati e nt s wit h T 1 D M ( Z P 4 2 0 7-
1 5 1 2 6). 3  
P h ar m a c o ki n eti c s a n d p h ar m a c o d y n a mi c s of d a si gl u c a g o n  
T h e r e s ult s of t h e p h a s e 1 a n d 2 cli ni c al tri al s c o nfir m d o s e- pr o p orti o n alit y f or d a si gl u c a g o n 
p h ar m a c o ki n eti c s, w hi c h i s c h ar a ct eri z e d b y a f a st a b s or pti o n wit h a p e a k pl a s m a c o n c e ntr ati o n 
o bt ai n e d aft er 3 5 
mi n ut e s. T h er e aft er, t h e pl a s m a c o n c e ntr ati o n r a pi dl y d e cli n e s wit h a n 
a v er a g e h alf-lif e of 2 8 mi n ut e s. T h e m e di a n ti m e t o t h e m a xi m u m pl a s m a c o n c e ntr ati o n ( C m a x ) 
w a s l a t er f or d a si gl u c a g o n t h a n f or Gl u c a G e n ( 3 5 v er s u s 2 0 
mi n ut e s). D o s e s of 0. 3 m g 
d a si gl u c a g o n a n d 0. 5 m g Gl u c a G e n a n d al s o 0. 6 m g d a si gl u c a g o n a n d 1. 0 m g Gl u c a G e n w er e 
si mil ar wit h r e g ar d t o C m a x . F or Cm a x , t h e r e s ult s i n di c at e d t h at 0. 3 
m g d a si gl u c a g o n w a s 
c o m p a r a bl e t o 0. 5 m g Gl u c a G e n ( 9 0 % c o nfi d e n c e i nt er v al ( CI): 0. 8 1 6 7; 1. 0 0 6 8) a n d 0. 6 m g 
d a si gl u c a g o n w a s c o m p ar a bl e t o 1. 0 m g Gl u c a G e n ( 9 0 % CI: 0. 8 8 5 0; 1. 1 9 9 1). 3  At t h e s e d o s e 
l e v el s, t h e t ot al e x p o s ur e s ( A U C0-i nf ) w er e hi g h er f or d a si gl u c a g o n c o m p ar e d t o Gl u c a G e n. 
At al l d o s e l e v el s i n t h e p h a s e 2 tri al, all p ati e nt s a c hi e v e d a pl a s m a gl u c o s e l e v el of at l e a st 
7 0 m g/ d L a s w ell a s a n i n cr e a s e i n pl a s m a gl u c o s e b y at l e a st 2 0 m g/ d L wit hi n 3 0 mi n p o st-
d o s e. T h e m a xi m al o b s er v e d ti m e t o r e a c h t h e 2 0 m g/ d L pl a s m a gl u c o s e i n cr e a s e r a n g e d fr o m 
1 5 t o 2 7 mi n ut e s a cr o s s d o s e s a n d d e cr e a s e d a s t h e d o s e i n cr e a s e d. T h e p h ar m a c o d y n a mi c 
r e s p o n s e s of 0. 6 m g of d a si gl u c a g o n a n d 1. 0 m g of Gl u c a G e n w er e c o m p ar a bl e. 3  
S af et y of d a si gl u c a g o n  
T h e s af et y d at a f or d a si gl u c a g o n di d n ot gi v e ri s e t o a n y r el e v a nt s af et y c o n c er n s f or 
d a si gl u c a g o n b e y o n d t h o s e r el at e d t o t h e p h ar m a c ol o gi c al eff e ct of gl u c a g o n a g o ni s m. All 
a d v er s e e v e nt s ( A E s) r e c or d e d i n t h e tri al s w er e of 
mil d or 
m o d er at e s e v erit y. T h e 
m o st 
fr e q u e ntl y r e p ort e d s y st e mi c 
A E 
w a s n a u s e a, 
w hi c h i s a k n o w n si d e eff e ct f oll o wi n g 
a d mi ni str ati o n of gl u c a g o n. H e a d a c h e w a s t h e n e xt m o st fr e q u e ntl y r e p ort e d e v e nt, o c c urri n g i n 
all d o s e gr o u p s i n t h e p h a s e 2 tri al. I nj e cti o n sit e r e a cti o n s w er e o b s er v e d o nl y s p or a di c all y aft er 
a d mi ni str ati o n wit h eit h er d a si gl u c a g o n or Gl u c a G e n ®  a n d all w er e mil d a n d tr a n si e nt. T h e m o st 
fr e q ue nt i nj e cti o n sit e r e a cti o n w a s er yt h e m a, o c c urri n g i n all tr e at m e nt gr o u p s, i n cl u di n g t h e 
pl a c e b o gr o u p, irr e s p e cti v e of d o s e. Gl u c a g o n h a s b e e n d e s cri b e d t o e x ert p o siti v e i n otr o pi c 
a n d c hr o n otr o pi c eff e ct s a n d m a y t h er ef or e c a u s e t a c h y c ar di a a n d h y p ert e n si o n. I n t h e p h a s e 1 
cli ni c al tri al s, b ut n ot t h e p h a s e 2 tri al, t e m p or ar y b ut cli ni c all y si g nifi c a nt d e cr e a s e s i n bl o o d 
pr e s s ur e w er e o b s er v e d i n a f e w h e alt h y v ol u nt e er s r e c ei vi n g i n v e sti g ati o n al m e di ci n al pr o d u ct 
(I M P) d o s e s of at l e a st 1. 0 
m g ( 4 wit h d a si gl u c a g o n a n d 1 wit h Gl u c a G e n). T hi s i s n ot 
c o n si d er e d a s af et y c o n c er n, h o w e v er h e m o d y n a mi c c h a n g e s p o st d o si n g will b e c o n si d er e d a 
cli ni c al e v e nt of i nt er e st. 
T h e p h a s e 1 a n d 2 r e s ult s a n d t h e s af et y pr ofil e d e s cri b e d t o d at e d o n ot gi v e ri s e t o s p e cifi c 
s af et y c o n c er n s. F or f urt h er i nf or m ati o n, pl e a s e r ef er t o t h e I n v e sti g at or Br o c h ur e. 3   
I m m u n o g e ni cit y of d a si gl u c a g o n  
T o d at e, i n t h e 3 cli ni c al tri al s p erf or m e d wit h d a si gl u c a g o n ( d e s cri b e d a b o v e), t h er e h a v e n ot 
b e e n a n y a nti- dr u g a nti b o d y ( A D A) o c c urr e n c e s i n a t ot al of 1 4 1 s u bj e ct s e x p o s e d t o 1 or m or e 
d o s e s. D at a fr o m t h e n o n- cli ni c al t o xi c ol o g y pr o gr a m ( 7 n o n- cli ni c al t o xi cit y st u di e s) s h o w e d t h at 
A D A s w er e d et e ct e d i n mi c e, r at s, a n d d o g s, a n d w er e m o st fr e q u e nt i n a ni m al s i n t h e hi g h e st 
d a si gl u c a g o n d o s e gr o u p s. A fr a cti o n of t h e A D A s fr o m r at s a n d d o g s w er e a bl e t o cr o s s-r e a ct 
wit h n ati v e gl u c a g o n. H o w e v er, t h e A D A s di d n ot a p p e ar t o b e a s s o ci at e d wit h c h a n g e s i n t h e 
s af et y or t o xi cit y pr ofil e s c o m p ar e d t o A D A- n e g ati v e a ni m al s. I n r at s, t h e a v er a g e e x p o s ur e 
( A U C) w a s i n cr e a s e d f oll o wi n g 1 3 a n d 2 6 w e e k s of tr e at m e nt i n d o s e gr o u p s wit h hi g h er A D A 
fr e q u e n c y (≥8 m g/ k g/ d a y). T h e A D A fr e q u e n c y a n d tit er s of c o n si st e ntl y A D A- p o siti v e r at s w er e 
r e d u c e d fr o m 1 3 t o 2 6 w e e k s of tr e at m e nt, i n di c ati n g a tr a n si e nt r e s p o n s e i n m o st a ni m al s. It 

 
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therefore appears that dasiglucagon has a low risk for induction of ADAs. A fraction of the 
antibodies detected in the non-clinical toxicity studies was found to cross-react with glucagon 
without advert clinical or toxicity findings. These data suggest that dasiglucagon and glucagon 
share epitopes and potential ADAs induced by dasiglucagon in humans may have the ability to 
cross-react with glucagon.3  
Although glucagon is an important hormone for controlling blood glucose levels it is considered 
to have a partially redundant endogenous function since hypoglycemia can also be corrected by 
other means. The overall immunogenicity risk of dasiglucagon in a clinical context is therefore 
considered to be low and the potential effects of induced ADAs judged to be of limited clinical 
consequence.  
As dasiglucagon contains 7 amino acid substitutions compared to native glucagon and historic 
data indicate that the immune system’s tolerance to glucagon can be impaired in the intended 
target population, there is an inherent risk for the induction of an ADA response against 
dasiglucagon. However, other product specific characteristics, i.e. dasiglucagon being a 
chemical synthetized product without host cell contaminants, a reduced potential for 
aggregation, a physiological compatible formulation, and a high bioavailability with a short half-
life, are all in favor of reducing the risk of dasiglucagon to induce an unwanted immune 
response. Considering the intended indication, in which dasiglucagon is administered as a 
single-dose rescue treatment on an infrequent basis (0.21 to 1.6 episodes per patient per 
year),4,5 the induction of a high titer ADA response with effects on clinical safety seems unlikely. 
Overall, the risk of dasiglucagon to induce an ADA response is considered low. The present trial 
aims to evaluate that immunogenicity risk in patients with T1DM administered multiple s.c. 
doses of dasiglucagon.  
5.2 
Trial rationale 
Dasiglucagon is in clinical development as a rescue treatment for severe hypoglycemia in 
patients with insulin-dependent diabetes mellitus. Immune responses to therapeutic peptides 
and proteins may develop after subcutaneous administration and could potentially adversely 
affect their safety and efficacy. The potential formation of high titer ADAs to dasiglucagon, 
although considered unlikely in a rescue indication, could influence the efficacy of dasiglucagon, 
either indirectly by interacting with the pharmacokinetics of dasiglucagon or directly by 
neutralizing the glucagon response.  
In recent years, regulatory agencies have outlined and recommended the use of a risk-based 
approach in the evaluation and mitigation of immune responses to therapeutic compounds that 
may adversely affect their safety and/or efficacy. Both transient and persistent antibody 
response should be combined to determine the overall immunogenicity of a product. Persistent 
antibodies are of importance since patients with persistent antibodies could experience clinical 
adverse reactions affecting safety and efficacy, while a transient antibody response can resolve 
without further consequence. 
The present trial aims to evaluate that immunogenicity risk with an assessment of the 
occurrence of ADAs and neutralizing ADAs, and of cross-reactivity with native glucagon, 
following repeated single doses of dasiglucagon by s.c. administration in T1DM patients. The 
trial further aims to evaluate the pharmacodynamics and pharmacokinetic responses and to 
correlate the consequence of an antibody response, if any, to pharmacodynamic and 
pharmacokinetic endpoints. The reference product in this trial is GlucaGen, a recombinant 
human glucagon approved for the treatment of the severe hypoglycemic reactions that may 
occur in the management of insulin-treated children and adults with diabetes mellitus. Given the 
differences in ADA assay for dasiglucagon and GlucaGen, a formal statistical comparison or 
non-inferiority testing is not performed. 

 
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5.3 
Assessment of anticipated benefits and risks 
As glucagon and its analogs belong to a well-known drug class with a known mode of action, 
dasiglucagon is not expected to be a high-risk molecule.  
Treatment with an investigational medicinal product may result in undesired effects or 
complaints. Undesired effects and complaints such as nausea, vomiting, and diarrhea are 
known AEs occurring with glucagon administration. Similar AEs have also been observed to a 
limited degree in the 3 clinical studies conducted with dasiglucagon. As with every novel drug 
substance, new and as yet unknown side effects also may occur.  
There are limited data available to assess the immunogenic potential of glucagon products 
available on the market, but the data available indicate that marketed glucagon only has a small 
immunogenic potential. Based on the 3 clinical studies conducted with dasiglucagon to date 
(see Section 5.2), no anti-dasiglucagon or anti-glucagon antibodies have been detected.  
In relation to diabetes therapy, development of insulin-antibodies is documented more 
substantially and the route of administration has been shown to influence the immunogenic 
potential of insulins. However, antibodies against insulin do not generally have an impact on 
insulin action and are thus not clinically relevant. In terms of consequence, development of high 
titer antibodies against dasiglucagon could, in theory reduce the activity of endogenous 
glucagon, which, in theory, could influence hypoglycemic episodes. Limited suppression of 
glucagon would, however, not be considered critical, since low glucose levels can also be 
corrected by other means, including oral intake of glucose and the action of other endogenous 
hormones such as oxyntomodulin and epinephrine. 
Overall, dasiglucagon is judged to be a low-risk molecule, based upon the available clinical data 
as well as the outcome of the risk-based approach to the immunogenicity assessment. In line 
with the primary objective of this trial to assess the immunogenicity of dasiglucagon, sampling 
for measurement of antibodies against dasiglucagon will take place prior to first dosing (Visit 2), 
pre-dose at subsequent visits during the treatment period (Visits 3 and 4), and at all Follow-up 
visits (at 35, 60, and 104 days after the first dose of trial medication; i.e. at Visits 5, 6, and 7 
(End of Trial [EoT] visit), respectively).  
Administration of dasiglucagon may be associated with a risk of allergic reactions similar to 
those observed for other therapeutic peptides or proteins. Patients with known or suspected 
allergies to the trial medications or related products will be excluded from the trial. Mild or 
moderate allergic reactions may include symptoms of rash, fever, flu-like symptoms, nausea, 
headache, and myalgia. Acute generalized hypersensitivity reactions are usually very rare but 
may include symptoms of flushing, sweating, dizziness, change in blood pressure and 
difficulties in breathing. No severe acute hypersensitivity reactions have been observed in the 3 
clinical trials conducted with dasiglucagon. Direct access to resuscitation equipment is ensured 
at the clinical trial sites. 
With the exception of medical examinations, a patient participating in this trial is not likely to 
derive any personal health-related benefits. The results of the trial may contribute to the future 
use of dasiglucagon in patients with diabetes mellitus experiencing severe hypoglycemic 
reactions. 
Overall, the benefit to risk ratio for patients entering the ZP4207-16136 trial is considered 
acceptable. 

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 2 0/ 5 0 
6. Tri al o bj e cti v e s  
Pri m ar y o bj e cti v e 
•   
T o e v al u at e t h e i m m u n o g e ni cit y of r e p e at e d si n gl e d o s e s of d a si gl u c a g o n a n d Gl u c a G e n 
f oll o wi n g s. c. a d mi ni str ati o n i n T 1 D M p ati e nt s. 
S e c o n d ar y o bj e cti v e 
•   
T o e v al u at e t h e s af et y, t ol er a bilit y a n d p h ar m a c o d y n a mi c r e s p o n s e of r e p e at e d si n gl e 
d o s e s of d a si gl u c a g o n f oll o wi n g s. c. a d mi ni str ati o n c o m p ar e d wit h s. c. Gl u c a G e n i n 
T 1 D M p ati e nt s. 
Pri m ar y e n d p oi nt:  
•   
O v er all A D A i n ci d e n c e 
T hi s will b e c al c ul at e d a s a p er c e nt a g e of t h e c o m bi n e d r e s ult s of tr e at m e nt-i n d u c e d 
A D A- p o siti v e p ati e nt s a n d tr e at m e nt- b o o st e d A D A- p o siti v e p ati e nt s a n d t h e t ot al n u m b er 
of e v al u a bl e p ati e nt s, e x cl u di n g b a s eli n e- p o siti v e p ati e nt s wit h o ut a n y s a m pl e s a v ail a bl e 
aft er dr u g a d mi ni str ati o n.  
K e y s e c o n d ar y e n d p oi nt s: 
•   
Tr e at m e nt-i n d u c e d A D A 
I n ci d e n c e c al c ul at e d a s a p er c e nt a g e of t h e t ot al n u m b er of e v al u a bl e p ati e nt s t h at w er e 
A D A n e g ati v e at b a s eli n e a n d A D A p o siti v e aft er dr u g a d mi ni str ati o n a n d t h e t ot al n u m b er 
of e v al u a bl e p ati e nt s, e x cl u di n g b a s eli n e p o siti v e p ati e nt s wit h o ut a n y s a m pl e s a v ail a bl e 
aft er dr u g a d mi ni str ati o n.  
•   
Tr e at m e nt- b o o st e d A D A 
I n ci d e n c e c al c ul at e d a s p er c e nt a g e of b a s eli n e A D A- p o siti v e p ati e nt s wit h si g nifi c a nt 
i n cr e a s e s (≥5-f ol d) i n A D A tit er aft er dr u g a d mi ni str ati o n a n d t h e t ot al n u m b er of 
e v al u a bl e p ati e nt s, e x cl u di n g b a s eli n e- p o siti v e p ati e nt s wit h o ut a n y s a m pl e s a v ail a bl e 
aft er dr u g a d mi ni str ati o n.  
S e c o n d ar y e n d p oi nt s: 
C h ar a ct eri z ati o n of A D A r e s p o n s e:  
•   
I n ci d e n c e a n d tit er of n e utr ali zi n g a cti vit y of A D A p o siti v e p ati e nt s 
•   
I n ci d e n c e of cr o s s-r e a cti vit y of A D A p o siti v e p ati e nt s t o w ar d s e n d o g e n o u s gl u c a g o n 
•   
Ki n eti c s of A D A: 
T h e ti mi n g a n d d ur ati o n of d et e ct e d A D A r e s p o n s e  
S af et y: 
•   
T h e i n ci d e n c e, t y p e a n d s e v erit y of A E s 
•   
C h a n g e s fr o m b a s eli n e i n cli ni c al l a b or at or y p ar a m et er s 
•   
C h a n g e s fr o m b a s eli n e i n vit al si g n s 
•   
Cli ni c all y  
m e a ni n gf ul  
c h a n g e s  fr o m  
b a s eli n e  i n  
p h y si c al  
e x a mi n ati o n  
a n d 
el e ctr o c ar di o gr a m ( E C G) 
E x p o s ur e e n d p oi nt s, aft er a d mi ni str ati o n of fir st a n d t hir d d o s e s of tri al m e di c ati o n:  
•  
Pl a s m a d a si gl u c a g o n a n d gl u c a g o n c o n c e ntr ati o n s fr o m 0- 9 0 mi n aft er d o si n g will b e 
e v al u at e d b a s e d o n t h e f oll o wi n g e n d p oi nt s: A U C 0- 3 0 mi n , A U C0- 9 0 mi n , Cm a x , tm a x  

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 2 1/ 5 0 
P h ar m a c o d y n a mi c s aft er a d mi ni str ati o n of fir st a n d t hir d d o s e s of tri al m e di c ati o n: 
•   
Pl a s m a gl u c o s e pr ofil e s o v er t h e p eri o d fr o m 0- 9 0 mi n aft er d o si n g will b e e v al u at e d 
b a s e d o n t h e f oll o wi n g e n d p oi nt s: A U E 0- 3 0 mi n , A U E0- 9 0 mi n , C Em a x , tm a x  
•   
A c hi e vi n g a pl a s m a gl u c o s e i n cr e a s e of ≥2 0 m g/ d L wit hi n 3 0 mi n ut e s  aft er tr e at m e nt 

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 2 2/ 5 0 
7. I n v e sti g ati o n al pl a n 
7. 1  
O v er all tri al d e si g n a n d pl a n 
T hi s i s a r a n d o mi z e d, d o u bl e- bli n d, p ar all el gr o u p tri al c o m p ari n g t h e i m m u n o g e ni cit y of 3 fi x e d 
d o s e s of eit h er d a si gl u c a g o n or Gl u c a G e n a d mi ni st er e d t o e u gl y c e mi c T 1 D M p ati e nt s.  
P ati e nt s wit h T 1 D M will b e r a n d o mi z e d 1: 1 t o r e c ei v e 3 s. c. i nj e cti o n s of eit h er d a si gl u c a g o n 
( 0. 6 m g) or Gl u c a G e n ( 1 m g), wit h 1 w e e k b et w e e n e a c h d o s e. P ati e nt s will b e f oll o w e d f or at 
l e a st 3 m o nt h s fr o m t h e d a y of t h e fir st d o s e t o a s s e s s a n y i m m u n e r e s p o n s e. P ati e nt s wit h 
pr e vi o u s e x o g e ni c gl u c a g o n e x p o s ur e will n ot b e e x cl u d e d fr o m t h e tri al, b ut t h e i nf or m ati o n o n 
pr e vi o u s gl u c a g o n a d mi ni str ati o n will b e r e c or d e d t o e n a bl e s u b gr o u p a n al y s e s. A t ot al of 
9 0 p ati e nt s ar e e x p e ct e d t o p arti ci p at e i n a n d c o m pl et e t h e tri al ( 4 5 i n e a c h tr e at m e nt ar m). T o 
q u alif y a s c o m pl et e d, t h e p ati e nt m u st b e d o s e d a c c or di n g t o pr ot o c ol a n d h a v e bl o o d dr a w n f or 
t h e A D A a n al y s e s ( a s s c h e d ul e d i n T a bl e 2- 1). It i s e x p e ct e d 1 1 2 p ati e nt s i n t ot al will b e 
r a n d o mi z e d a n d tr e at e d. 
F or t h e s af et y a n d w ell- b ei n g of t h e p ati e nt s, t h e y will n ot b e br o u g ht i nt o h y p o gl y c e mi a pri or t o 
d o si n g. Pri or t o a d mi ni str ati o n of tri al pr o d u ct p ati e nt s m u st r e a c h a t ar g et pl a s m a gl u c o s e l e v el 
of 7 0- 1 5 0 m g/ d L.  
T h e tri al will i n cl u d e t h e f oll o wi n g p eri o d s ( a s ill u str at e d i n Fi g ur e 7- 1, b el o w). 
•  
A s cr e e ni n g p eri o d fr o m D a y - 3 0 t o D a y - 3 
•  
A tr e at m e nt p eri o d, fr o m D a y 0 ( d a y of r a n d o mi z ati o n) t o D a y 1 4 ( d a y of t hir d a n d fi n al 
d o si n g wit h tri al m e di c ati o n), wit h s. c. tri al m e di c ati o n a d mi ni st er e d o n D a y 0, D a y 7, a n d 
D a y 1 4. H a n dli n g, pr e p ar ati o n a n d a d mi ni str ati o n of tri al m e di c ati o n will b e d o n e b y 
u n bli n d e d tri al p er s o n n el. All tri al a s s e s s m e nt s will b e d o n e b y bli n d e d tri al p er s o n n el.  
•  
A f oll o w- u p p eri o d, fr o m t h e e n d of t h e Tr e at m e nt P eri o d, wit h f oll o w- u p vi sit s at D a y 3 5, 
D a y 6 0, a n d D a y 1 0 4 (t h e E o T vi sit) 
Ti m e wi n d o w s f or e a c h tri al vi sit ar e gi v e n i n T a bl e 2- 1. 
Fi g ur e 7- 1 O v er vi e w of t h e tri al d e si g n 
 
A n o v er vi e w o n t h e tri al pr o c e d ur e s i s gi v e n i n t h e fl o w c h art ( T a bl e 2- 1). P ati e nt s s h o ul d b e 
s e e n f or all vi sit s o n t h e d e si g n at e d d a y or a s cl o s e t o it a s p o s si bl e.  
7. 2  
Di s c u s si o n of tri al d e si g n a n d c h oi c e of c o ntr ol gr o u p s 
T h e tri al will b e r a n d o mi z e d a n d d o u bl e- bli n d t o i n cr e a s e tri al v ali dit y a n d t o r e d u c e bi a s d uri n g 
e v al u ati o n of a s s e s s m e nt s wit h t h e t w o tr e at m e nt s. Si n c e t h e 2 tri al 
m e di c ati o n s ar e n ot 
i d e nti c al i n a p p e ar a n c e ( d a si gl u c a g o n i s a li q ui d f or m ul ati o n a n d Gl u c a G e n i s a v ail a bl e a s a 
p o w d er f or r e c o n stit uti o n), t h e h a n dli n g, pr e p ar ati o n a n d a d mi ni str ati o n of tri al m e di c ati o n will b e 

 
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done by unblinded trial personnel who will not be involved in other trial procedures and 
assessments. All trial assessments performed at the trial site will be done by blinded trial 
personnel. However, exposure assessments and ADA assessments will be performed by 
unblinded personnel at the specialty laboratories, to make sure that dasiglucagon or GlucaGen 
administration is matched with the applicable bioanalytical assay.    
Euglycemic patients with T1DM will be randomized 1:1 in order to evaluate the immunogenicity 
of dasiglucagon and GlucaGen. The randomized, double-blind, parallel group design, with 
administration of 3 fixed consecutive doses of randomized trial medication (dasiglucagon or 
GlucaGen) to the same patient will allow characterization of immunogenic potential for the 2 
products. Treatment with the 3 repeated doses (each separated by 1 week), with follow-up visits 
at Days 35 (where potential immune responses are known to be most pronounced), and at 60 
and 104 days after the first dose (following the patient for 2-3 antibody half-lives after expected 
peak titer), is deemed relevant and sufficient for evaluating any immunogenic response to 
treatment. Patients will be monitored until the ADA levels return to baseline, and samples from 
the ADA positive patients will be tested for neutralizing potential in a NAb (neutralizing antibody) 
assay. Further, a patient with a treatment induced or treatment boosted ADA response will be 
called in for an additional (unscheduled) visit to evaluate the clinical effect of immunogenicity of 
the pharmacodynamic and pharmacokinetic reponses.  
Dasiglucagon and GlucaGen will be administered at fixed doses independent of body weight 
because this is the intended therapeutic dosing regimen in the emergency treatment of 
hypoglycemia. The selected dose of 1 mg GlucaGen is the recommended dose for treatment of 
severe hypoglycemia. Based on pre-clinical and clinical studies, it has been demonstrated that 
0.6 mg of dasiglucagon results in an initial pharmacodynamic response (i.e. acute glucose 
mobilization) comparable to 1 mg GlucaGen (see also Section 5.1).  
For the safety and well-being of the patients, they will not be brought into hypoglycemia prior to 
dosing. However, very high blood glucose levels at dosing will potentially impact the reporting of 
nausea and other associated AE’s. Therefore, to enable a more precise safety assessment, 
patients are required to be dosed while at a normal blood glucose level, and a pre-treatment 
plasma glucose level of 70-150 mg/dL will be targeted. Plasma glucose levels may be adjusted 
by s.c. administration of a fast-acting insulin analog or by glucose ingestion. Even with this 
precaution, it cannot be excluded that a higher frequency of nausea may be anticipated, if this 
AE is caused by hyperglycaemia. 
The safety profile described to date does not give rise to specific safety concerns. In previous 
studies, dasiglucagon was associated with the AE’s nausea, a known side effect following 
administration of glucagon, headache, and injection site reactions (erythema).  
7.3 
Selection of trial population 
Dasiglucagon is indicated for treatment of severe hypoglycemia in patients with T1DM. Given 
the role of the immune system in the pathogenesis of T1DM, the present trial aims to evaluate 
the immune response of patients with T1DM taking repeated single doses of s.c. dasiglucagon 
and GlucaGen.  
There are no data indicating an altered immune response with varying blood glucose levels, 
therefore, for the safety and well-being of the patients, they will not be brought into a 
hypoglycemic state prior to dosing. Patients with previous exogenic glucagon exposure will not 
be excluded from the trial, but the information on previous glucagon administration will be 
recorded to enable subgroup analyses. 
The trial will enroll patients in centers in the EU, in the US, and in Canada.  

 
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7.3.1 Inclusion criteria 
To be included in the trial, patients have to fulfill all of the following criteria: 
(1) 
Informed consent obtained before any trial-related activities (trial-related activities 
are any procedure that would not have been performed during normal management 
of the patient) 
(2) 
Availability for the entire trial period 
(3) 
Age between 18 and 70 years, both inclusive 
(4) 
Male or female patients with T1DM for at least 1 year. Diagnostic criteria as defined 
by the American Diabetes Association 
(5) 
Hemoglobin A1c (HbA1c) <10% 
(6) 
Stable antidiabetic treatment for at least 1 month (e.g. within 10% insulin dose 
adjustment) 
(7) 
A female participant must meet 1 of the following criteria 
a. Participant is of childbearing potential and agrees to use one of the accepted 
contraceptive regimens throughout the entire duration of the trial from screening 
until last follow-up visit. An acceptable method of contraception includes at least 
one of the following: 
i. Abstinence from heterosexual intercourse 
ii. Systemic contraceptives (birth control pills, injectable/implant/ insertable 
hormonal birth control products, transdermal patch); if the participant is 
using systemic contraceptives, she must use an additional form of 
acceptable contraception (iii or iv, below) 
iii. Intrauterine device (with and without hormones) 
iv. condom with spermicide 
or 
b. Participant is of non-childbearing potential, defined as surgically sterile (i.e. has 
undergone complete hysterectomy, bilateral oophorectomy, or tubal ligation), or 
in a menopausal state (at least 1 year without menses). 
(8) 
A male must be surgically sterilized or willing to refrain from sexual intercourse from 
screening and until last follow-up visit or, if sexually active, uses a condom and 
partner practices contraception during the trial from screening and until the last 
follow-up visit. 
7.3.2 Exclusion criteria 
Patients meeting any of the following criteria during screening evaluations will be excluded from 
trial participation: 
(1) 
Previous administration of dasiglucagon (previously referred to as ZP4207). 
(2) 
Known or suspected allergy to trial medication(s) or related products  
(3) 
History of anaphylaxis or symptoms of severe systemic allergy (such as 
angioedema)  
(4) 
Previous participation (randomization) in this trial 
(5) 
Females who are pregnant according to a positive pregnancy test, actively 
attempting to get pregnant, or are lactating 
(6) 
Patients on a closed loop artificial pancreas 
(7) 
Receipt of any investigational drug within 3 months prior to screening 
(8) 
Active malignancy within the last 5 years 
(9) 
Congestive heart failure, New York Heart Association class II-IV 

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 2 5/ 5 0 
( 1 0) I n a d e q u at el y tr e at e d bl o o d pr e s s ur e a s d efi n e d a s s y st oli c bl o o d pr e s s ur e ≥1 6 0 
m m H g or di a st oli c bl o o d pr e s s ur e ≥9 0 m m H g at s cr e e ni n g. 
( 1 1) 
C urr e nt bl e e di n g di s or d er, i n cl u di n g u s e of a nti c o a g ul a nt tr e at m e nt 
( 1 2) 
K n o w n pr e s e n c e or hi st or y of p h e o c hr o m o c yt o m a (i. e. a dr e n al gl a n d t u m or) or 
i n s uli n o m a (i. e. i n s uli n- s e cr eti n g p a n cr e a s t u m or) 
( 1 3) 
K n o w n or s u s p e ct e d HI V i nf e cti o n 
( 1 4) 
U s e of a s y st e mi c b et a- bl o c k er dr u g, i n d o m et h a ci n, w arf ari n or a nti c h oli n er gi c 
dr u g s i n t h e pr e vi o u s 2 8 d a y s b ef or e D a y 1 of t hi s tri al) 
( 1 5) 
U s e 
of s y st e mi c c orti c o st er oi d s, 
a nti-i nfl a m m at or y 
bi ol o gi c al 
a g e nt s, ki n a s e 
i n hi bit or s or ot h er i m m u n e m o d ul ati n g a g e nt s wit hi n t h e l a st 3 
m o nt h s pri or t o 
s cr e e ni n g 
( 1 6) 
A s p art at e a mi n otr a n sf er a s e ( A S T) or al a ni n e a mi n otr a n sf er a s e ( A L T) > 2. 5 X t h e 
u p p er li mit of n or m al ( U L N), bilir u bi n > 1. 5 X U L N, e sti m at e d gl o m er ul ar filtr ati o n 
r at e ( e G F R) < 3 0 m L/ mi n/ 1. 7 3 m2  a c c or di n g t o t h e M o difi c ati o n of Di et i n R e n al 
Di s e a s e ( M D R D) St u d y d efi niti o n. Alt er e d el e ctr ol yt e s v al u e s of cli ni c al r el e v a n c e 
f or c ar di a c c o n d u cti o n, a s j u d g e d b y t h e i n v e sti g at or. 
( 1 7) 
Cli ni c all y si g nifi c a nt a b n or m al E C G at s cr e e ni n g, a s e v al u at e d b y I n v e sti g at or 
( 1 8) 
D o n ati o n of bl o o d or pl a s m a i n t h e p a st m o nt h, or i n e x c e s s of 5 0 0 m L wit hi n 
1 2 w e e k s pri or t o s cr e e ni n g 
( 1 9) 
A p o siti v e r e s ult i n t h e al c o h ol a n d/ or uri n e dr u g s cr e e n at t h e s cr e e ni n g vi sit. 
Si g nifi c a nt hi st or y of al c o h oli s m or dr u g a b u s e a s j u d g e d b y t h e i n v e sti g at or or 
c o n s u mi n g m or e t h a n 2 4 g al c o h ol p er d a y f or m e n, or m or e t h a n 1 2 g al c o h ol p er 
d a y f or w o m e n. 
( 2 0) 
P ati e nt s 
wit h 
m e nt al i n c a p a cit y or l a n g u a g e b arri er s t h at pr e cl u d e a d e q u at e 
u n d er st a n di n g or c o o p er ati o n, w h o ar e u n willi n g t o p arti ci p at e i n t h e tri al, or w h o i n 
t h e o pi ni o n of t h e I n v e sti g at or s h o ul d n ot p arti ci p at e i n t h e tri al 
( 2 1) 
S ur g er y or tr a u m a wit h si g nifi c a nt bl o o d l o s s wit hi n t h e l a st 2 
m o nt h s pri or t o 
s cr e e ni n g 
( 2 2) 
A n y c o n diti o n i nt erf eri n g wit h tri al p arti ci p ati o n or tri al e n d p oi nt s or t h at c o ul d b e 
h a z ar d o u s t o t h e p ati e nt 
( 2 3) 
U s e 
of 
pr e s cri pti o n 
or 
n o n- pr e s cri pti o n 
m e di c ati o n s 
k n o w n t o 
c a u s e 
Q T 
pr ol o n g ati o n 
7. 3. 3 
Pr e m at ur e r e m o v al fr o m tri al 
P arti ci p ati o n i n t h e tri al i s stri ctl y v ol u nt ar y. A p ati e nt h a s t h e ri g ht t o wit h dr a w fr o m t h e tri al at 
a n y ti m e a n d f or a n y r e a s o n. If h e/ s h e c h o o s e s t o wit h dr a w, t h e i n v e sti g at or m u st b e i nf or m e d 
i m m e di at el y. T h e i n v e sti g at or h a s t h e ri g ht t o t er mi n at e p arti ci p ati o n of a n y p ati e nt at a n y ti m e if 
t h e i n v e sti g at or d e e m s it i n t h e p ati e nt' s b e st i nt er e st. T h e r e a s o n a n d cir c u m st a n c e s f or 
pr e m at ur e di s c o nti n u ati o n will b e d o c u m e nt e d i n t h e el e ctr o ni c C a s e R e p ort F or m ( e C R F). 
7. 3. 3. 1 
P o s si bl e r e a s o n s f or p ati e nt di s c o nti n u ati o n 
A p ati e nt will b e di s c o nti n u e d if t h e f oll o wi n g a p pli e s: 
•   
If a pr ot o c ol d e vi ati o n o c c ur s w hi c h, i n t h e cli ni c al j u d g m e nt of t h e I n v e sti g at or, c a n 
i n v ali d at e t h e a s s e s s m e nt of A D A r e s p o n s e s t o d a si gl u c a g o n or gl u c a g o n, t h e p ati e nt will 
b e wit h dr a w n b y t h e I n v e sti g at or 
•   
A E s t h at ar e c o n si d er e d u n a c c e pt a bl e b y t h e p ati e nt or t h e I n v e sti g at or 
•   
P o siti v e r e s ult fr o m a n uri n e dr u g s cr e e n t e st 
•   
Pr e g n a n c y. If a f e m al e p ati e nt b e c o m e s pr e g n a nt i n t h e ti m e b et w e e n t h e s cr e e ni n g vi sit 
a n d a n y o n e of t h e d o si n g vi sit s 

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 2 6/ 5 0 
If di s c o nti n u ati o n o c c ur s f oll o wi n g a d mi ni str ati o n of a n y tri al m e di c ati o n, t h e p ati e nt will b e 
a s k e d t o r et ur n a n d p arti ci p at e i n t h e c o m pl et e f oll o w- u p vi sit s at tri al D a y 3 5, 6 0, a n d 1 0 4. 
If tri al p arti ci p ati o n i s t er mi n at e d d u e t o a n A E p o s si bl y r el at e d t o t h e tri al m e di c ati o n (i n cl u di n g 
r ef er e n c e pr o d u ct) or tri al e x a mi n ati o n s, t h e p ati e nt 
m u st b e f oll o w e d u p b y a d diti o n al 
e x a mi n ati o n s a c c or di n g t o t h e m e di c al j u d g m e nt of t h e i n v e sti g at or u ntil t h e a b n or m al c o n diti o n 
i s r e s ol v e d or t h e i n v e sti g at or d e e m s f urt h er o b s er v ati o n s or e x a mi n ati o n s t o b e n o l o n g er 
m e di c all y i n di c at e d. 
P ati e nt s, w h o m e et o n e or m or e of t h e f oll o wi n g d o si n g d a y e x cl u si o n crit eri a at a d o si n g vi sit, 
will b e e x cl u d e d fr o m t h e d o si n g vi sit, b ut c a n b e r e s c h e d ul e d t o o n e of t h e f oll o wi n g d a y s 
( m a xi m u m 3 d a y s p o st p o n e m e nt). E a c h d o si n g vi sit c a n o nl y b e r e s c h e d ul e d o n c e. 
•   
Str e n u o u s e x er ci s e wit hi n 4 d a y s pri or t o d o si n g, a s j u d g e d b y t h e I n v e sti g at or. Str e n u o u s 
e x er ci s e i s n ot all o w e d d uri n g t h e tr e at m e nt p eri o d of t h e tri al 
•   
Cli ni c all y si g nifi c a nt ill n e s s t h at m a y i nt erf er e wit h tri al o bj e cti v e s or i m p o s e a ri s k t o 
p ati e nt s, a s j u d g e d b y t h e I n v e sti g at or 
•   
C o n s u m pti o n of al c o h ol wit hi n 2 4 h pri or t o d o si n g vi sit, or p o siti v e r e s ult s fr o m a n al c o h ol 
br e at h t e st 
•   
C h a n g e s i n m e di c al hi st or y or c o n c o mit a nt m e di c ati o n r e s ulti n g i n f ulfill m e nt of cli ni c al 
e x cl u si o n crit eri a, a s j u d g e d b y t h e I n v e sti g at or 
A t ot al of 9 0 p ati e nt s m u st c o m pl et e t h e tri al. T o q u alif y a s c o m pl et e d, t h e p ati e nt m u st b e 
d o s e d a c c or di n g t o pr ot o c ol a n d h a v e bl o o d dr a w n f or t h e A D A a n al y s e s d e s cri b e d i n t h e 
pr ot o c ol.  
7. 3. 3. 2 
C e nt er di s c o nti n u ati o n 
T h e c e nt er c a n b e cl o s e d a n d t h e tri al t er mi n at e d f or t h e f oll o wi n g r e a s o n s: 
•  T h e c e nt er i s u nli k el y t o b e a bl e t o r e cr uit s uffi ci e nt p ati e nt s wit hi n t h e a gr e e d ti m e fr a m e 
•  T h e c e nt er d o e s n ot r e s p o n d t o tri al m a n a g e m e nt r e q u e st s 
•  
R e p e at pr ot o c ol vi ol ati o n s 
7. 3. 3. 3 Tri al t er mi n ati o n 
T h e s p o n s or r e s er v e s t h e ri g ht t o m o dif y or t er mi n at e t h e tri al at a n y ti m e. P o s si bl e r e a s o n s f or 
t er mi n ati o n ar e: 
•   
S af et y r e a s o n s – t h e i n ci d e n c e of A E s i n t hi s or a n y ot h er tri al u si n g t h e s a m e tri al 
m e di c ati o n i n di c at e s a p ot e nti al h e alt h ri s k f or t h e p ati e nt s. 
•   
N e w s ci e ntifi c k n o wl e d g e b e c o m e s k n o w n t h at m a k e s t h e o bj e cti v e s of t h e tri al n o l o n g er 
f e a si bl e/ v ali d 
•   
U n s ati sf a ct or y e nr ol m e nt of p ati e nt s 
7. 3. 4 
R e pl a c e m e nt of p ati e nt s  
P ati e nt s pr e m at ur el y wit h dr a w n fr o m t h e tri al will n ot b e r e pl a c e d.  

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 2 7/ 5 0 
7. 4  
I n v e sti g ati o n al m e di ci n al pr o d u ct( s) 
7. 4. 1 I d e ntit y of i n v e sti g ati o n al m e di ci n al pr o d u ct( s)  
T h e i d e ntit y of t h e i n v e sti g ati o n pr o d u ct s i s s u m m ari z e d i n T a bl e 7- 1. 
T a bl e 7- 1: I d e ntit y of i n v e sti g ati o n al pr o d u ct s 
 
T e st pr o d u ct 
R ef er e n c e pr o d u ct 
N a m e 
D a si gl u c a g o n 
Gl u c a G e n ®  
A cti v e s u b st a n c e  
Z P 4 2 0 7  
R e c o m bi n a nt gl u c a g o n 
h y dr o c hl ori d e  
F or m ul ati o n 
Li q ui d f or m ul ati o n, 0. 6 m L  
P o w d er a n d s ol v e nt f or 
r e c o n stit uti o n a s 1 m L s ol uti o n f or 
i nj e cti o n 
Str e n gt h 
1 m g/ m L 
1 m g 
C o nt ai n er 
Si n gl e u s e pr e-fill e d s yri n g e 
P o w d er a n d s ol v e nt f or 
r e c o n stit uti o n p a c k e d t o g et h er i n a 
pl a sti c b o x. A “ h y p o- kit”  
M a n uf a ct ur er 
Z e al a n d P h ar m a A/ S, Gl o str u p 
( C o p e n h a g e n), D e n m ar k 
N o v o N or di s k A/ S, B a g s v ær d, 
D e n m ar k 
St or a g e r e q uir e m e nt s  
St or e b et w e e n 2 a n d 8° C  
St or e b et w e e n 2 a n d 8° C 
H a n dli n g, pr e p ar ati o n a n d a d mi ni str ati o n of tri al m e di c ati o n will b e d o n e b y u n bli n d e d tri al 
p er s o n n el. All tri al a s s e s s m e nt s o n t h e tri al sit e will b e d o n e b y bli n d e d tri al p er s o n n el. 
H o w e v er, e x p o s ur e a s s e s s m e nt s a n d A D A a s s e s s m e nt s will b e p erf or m e d b y u n bli n d e d 
p er s o n n el at t h e s p e ci alt y l a b or at ori e s, t o 
m a k e s ur e t h at d a si gl u c a g o n or 
Gl u c a G e n 
a d mi ni str ati o n i s m at c h e d wit h t h e a p pli c a bl e bi o a n al yti c al a s s a y.   
T h e t e st pr o d u ct will b e p a c k e d b y t h e s p o n s or. T h e i nf or m ati o n o n t h e l a b el s will b e i n t h e l o c al 
l a n g u a g e. T h e l a b el o n t h e pr o d u ct will b e c o m pli a nt wit h l o c al l a w s a n d r e g ul ati o n s. 
7. 4. 2 Tr e at m e nt s a d mi ni st er e d 
D a si gl u c a g o n i s a st a bl e p e pti d e a n al o g of h u m a n gl u c a g o n i n a r e a d y-t o- u s e li q ui d f or m ul ati o n 
i n di c at e d f or tr e at m e nt of s e v er e h y p o gl y c e mi a i n i n s uli n d e p e n d e nt p ati e nt s wit h di a b et e s 
m ellit u s. D a si gl u c a g o n i s i n cli ni c al d e v el o p m e nt a n d h a s n o m ar k eti n g a ut h ori z ati o n a s y et. 
Gl u c a G e n i s a p pr o v e d i n t h e E U a n d U S a n d i s i n di c at e d f or tr e at m e nt of s e v er e h y p o gl y c e mi c 
r e a cti o n s, w hi c h 
m a y o c c ur i n t h e 
m a n a g e m e nt of i n s uli n-tr e at e d c hil dr e n a n d a d ult s wit h 
di a b et e s m ellit u s. 
P ati e nt s i n t hi s tri al h a v e n ot pr e vi o u sl y b e e n tr e at e d wit h d a si gl u c a g o n ( Z P 4 2 0 7) a n d will b e 
r a n d o ml y a s si g n e d ( 1: 1) t o r e c ei v e 1 of t h e f oll o wi n g tri al m e di c ati o n s: 
•   
0. 6 m g d a si gl u c a g o n 
•   
1 m g Gl u c a G e n 
Pri or t o a d mi ni str ati o n of tri al m e di c ati o n at all d o si n g vi sit s p ati e nt s m u st r e a c h a t ar g et pl a s m a 
gl u c o s e l e v el of 7 0- 1 5 0 m g/ d L. If t h e p ati e nt pr e s e nt s wit h pl a s m a gl u c o s e > 1 5 0 
m g/ d L, 
c orr e cti v e a m o u nt s of f a st a cti n g i n s uli n will b e a d mi ni st er e d at t h e i n v e sti g at or’ s di s cr eti o n. 
Pl a s m a gl u c o s e m e a s ur e d aft er 2 0 a n d aft er 4 0 mi n ut e s s h o ul d e n s ur e t h at t h e p ati e nt h a s 
r e a c h e d t h e t ar g et e d 7 0- 1 5 0 m g/ d L. If t h e p ati e nt pr e s e nt s wit h pl a s m a gl u c o s e < 7 0 m g/ d L 
gl u c o s e i n g e sti o n will b e pr o vi d e d i n or d er t o r e a c h t ar g et pl a s m a gl u c o s e of 7 0- 1 5 0 m g/ d L 
d o c u m e nt e d b y pl a s m a gl u c o s e m e a s ur e m e nt s aft er 2 0 a n d 4 0 mi n ut e s, r e s p e cti v el y. 

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 2 8/ 5 0 
F oll o wi n g t h e fir st ( Vi sit 2) a n d t hir d ( Vi sit 4) d o s e a d mi ni str ati o n, p ati e nt s m u st b e f a sti n g f or 9 0 
mi n aft er d o si n g. F oll o wi n g t h e 9 0- mi n bl o o d s a m pl e dr a w aft er t h e a d mi ni str ati o n of t h e fir st 
( Vi sit 2) a n d t hir d ( Vi sit 4) d o s e a d mi ni str ati o n, p ati e nt s m a y b e tr e at e d i n di vi d u all y i n or d er t o 
all e vi at e a n y p ot e nti al si d e eff e ct s i n or d er t o mi ni mi z e pr e m at ur el y tr e at m e nt di s c o nti n u ati o n 
a n d c o n s e q u e ntl y r e d u c e t h e a m o u nt of mi s si n g d at a. T hi s tr e at m e nt c a n al s o b e i n stit ut e d 
i m m e di at el y aft er t h e s e c o n d d o s e a d mi ni str ati o n ( Vi sit 3), a s p h ar m a c o d y n a mi c s will n ot b e 
a s s e s s e d at t hi s vi sit.  
I n or d er t o 
mi ni mi z e t h e n u m b er of p ati e nt s di s c o nti n ui n g tr e at m e nt pr e m at ur el y a n d 
c o n s e q u e ntl y r e d u c e t h e a m o u nt of mi s si n g d at a, t h e f oll o wi n g tr e at m e nt m o d aliti e s m a y b e 
u s e d, a s c o n si d er e d a p pr o pri at e b y t h e i n v e sti g at or:  
At vi sit 2 a n d 4: 
•   
9 0 mi n aft er d o si n g p ati e nt s will b e all o w e d t o e at a n d dri n k m o d er at el y t o m a k e t h e m 
f e el c o mf ort a bl e 
•   
9 0 mi n aft er d o si n g a m o d er at e a n d i n di vi d u ali z e d c orr e cti v e d o s e of i n s uli n t o c o n v ert 
t h e i n d u c e d h y p er gl y c e mi a t o e u gl y c e mi a, aft er a gr e e m e nt wit h t h e i n v e sti g at or 
•   
a nti e m eti c tr e at m e nt i n t h e f or m of m et o cl o pr a mi d e ( Pri m p er a n® ) a s p er l o c al l a b el, 
a d mi ni st er e d b ef or e or aft er d o si n g  
 
At vi sit 3:  
•   
p ati e nt s will b e all o w e d t o e at a n d dri n k m o d er at el y t o m a k e t h e m f e el c o mf ort a bl e 
•   
a 
m o d er at e a n d i n di vi d u ali z e d c orr e cti v e d o s e of i n s uli n t o c o n v ert t h e i n d u c e d 
h y p er gl y c e mi a t o e u gl y c e mi a, aft er a gr e e m e nt wit h t h e i n v e sti g at or 
•   
a nti e m eti c tr e at m e nt i n t h e f or m of m et o cl o pr a mi d e ( Pri m p er a n® )  a s p er l o c al l a b el, 
a d mi ni st er e d b ef or e or aft er d o si n g  
 
P ati e nt s 
m u st b e 
m o nit or e d f or at l e a st 5 h aft er d o si n g at t h e cli ni c al sit e f or s af et y 
o b s er v ati o n s, i n cl u di n g bl o o d gl u c o s e m o nit ori n g.  
P ati e nt s will n ot b e di s c h ar g e d u ntil t h e y ar e c o n si d er e d st a bl e a n d wit h a bl o o d gl u c o s e l e v el i n 
t h e r a n g e of 7 0- 1 8 0 m g/ d L. B ef or e di s c h ar g e, t h e i n v e sti g at or will pr o vi d e i n str u cti o n s t o t h e 
p ati e nt s o n m a n a g e m e nt of t h eir bl o o d gl u c o s e l e v el s. E a c h tri al m e di c ati o n will b e a d mi ni st er e d 
s. c. 3 ti m e s i n t ot al, wit h 7 d a y s b et w e e n d o si n g (i. e. d o si n g o c c ur s at D a y s 0, 7, a n d 1 4; Vi sit s 
2, 3, a n d 4). S h o ul d t h e p ati e nt e x p eri e n c e v o miti n g f oll o wi n g t h e fir st or s e c o n d d a si gl u c a g o n 
or Gl u c a G e n a d mi ni str ati o n, t h e i n v e sti g at or m u st e n s ur e n or m al el e ctr ol yt e s pri or t o t h e n e xt 
d o si n g d a y. A n el e ctr ol yt e i m b al a n c e c a n b e c orr e ct e d b y a d mi ni str ati o n of a n el e ctr ol yt e 
s u p pl e m e nt or b y a n y ot h er tr e at m e nt m o d alit y c o n si d er e d a p pr o pri at e b y t h e i n v e sti g at or.   
7. 4. 3 
S el e cti o n of d o s e s i n t h e tri al 
T h e s el e ct e d d o s e of 1 
m g Gl u c a G e n i s t h e r e c o m m e n d e d d o s e f or tr e at m e nt of s e v er e 
h y p o gl y c e mi a. B a s e d o n pr e- cli ni c al a n d cli ni c al st u di e s, it h a s b e e n d e m o n str at e d t h at 0. 6 m g 
of d a si gl u c a g o n r e s ult s i n a n i niti al p h ar m a c o d y n a mi c r e s p o n s e (i. e. a c ut e gl u c o s e m o bili z ati o n) 
c o m p ar a bl e t o 1 m g Gl u c a G e n. 
7. 4. 4 Tr e at m e nt c o m pli a n c e 
All tri al m e di c ati o n s will b e pr e p ar e d a n d a d mi ni st er e d b y u n bli n d e d tri al p er s o n n el.  

 
Clinical Trial Protocol, final version 3 
ZP4207-16136 (ZEA-DNK-01711) 
 
21 August 2017  
CONFIDENTIAL 
Page 29/50 
7.4.5 Method of assigning patients to treatments or treatment sequences 
Patients who meet all inclusion and none of the exclusion criteria and have given written 
informed consent will be randomized in a 1:1 ratio to either dasiglucagon or GlucaGen via an 
Interactive Web Response System (IWRS) that will assign a kit number to one of the 2 
aforementioned treatment arms. 
Patients with previous exogenic glucagon exposure will not be excluded from the trial, but the 
information on previous glucagon administration will be recorded, to enable subgroup analyses.  
In the event of an emergency, e.g., when it becomes necessary for the investigator to know 
which treatment the patient is taking, the code for that patient can be broken by the investigator, 
preferably after consultation with the medical monitor. Emergency code breaks can be 
performed using the IWRS. 
7.4.6 Blinding 
This is a double-blind trial. Since dasiglucagon is available as a liquid formulation and GlucaGen 
is available as a powder for reconstitution, and they are therefore not identical in appearance, 
unblinded trial personnel will be responsible for handling, preparing according to the prescription 
from the IWRS, administering the trial medication and keep the records strictly confidential and 
accessible only for unblinded staff until after database lock. To maintain double-blind conditions, 
all trial assessments at the trial site will be done by blinded trial personnel not involved in the 
administration of trial medications. However, exposure assessments and ADA assessments will 
be performed by unblinded personnel at the specialty laboratories, to make sure that 
dasiglucagon or GlucaGen administration is matched with the applicable bioanalytical assay.  
7.4.7 Drug accountability and disposal 
Handling, preparation and administration of trial medication will be done by unblinded trial 
personnel. Each center will keep accurate records of the trial supplies received, stored, and 
dispensed, using appropriate forms. The trial supplies will be stored under appropriate 
conditions, locked and with restricted access.  
All unused supplies and all empty and partially empty containers of trial medication will be 
stored until the trial closure visit has been performed and then sent to the sponsor.  
7.4.8 Prior and concomitant therapy 
Prior glucagon exposure will be recorded in the eCRF at screening. All concomitant medications 
will be recorded in the eCRF at each visit.  
Patients using any new concomitant medication resulting in fulfillment of a dosing day exclusion 
criterion will be excluded from the dosing visit, but can be rescheduled to one of the following 
days. Each dosing visit can only be rescheduled once. See Section 7.3.3.1 for possible reasons 
for patient discontinuation. 
7.4.9 Treatment after end of trial  
Not applicable in this trial.  
7.5 
Assessments and schedule of measurements (overview) 
The following assessments and measurements will be carried out at the times specified in the 
trial flow chart (Table 2-1).  
Informed consent will be obtained prior to any trial-related procedures; see Section 11.3. 

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 3 0/ 5 0 
7. 5. 1 
S cr e e ni n g e x a mi n ati o n 
At s cr e e ni n g ( Vi sit 1), t h e f oll o wi n g a s s e s s m e nt s will t a k e pl a c e: 
•   
I nf or m e d c o n s e nt 
•   
C h e c k of p ati e nt eli gi bilit y 
•   
D e m o gr a p hi c s  
•   
B o d y m e a s ur e m e nt 
•   
M e di c al hi st or y 
•   
Hi st or y of al c o h ol/ dr u g a b u s e 
•   
C o n c o mit a nt ill n e s s e s 
•   
Pri or m e di c ati o n s 
•   
C o n c o mit a nt m e di c ati o n s 
•   
P h y si c al e x a mi n ati o n 
•   
Vit al si g n s 
•   
E C G 
•   
A E s  
•   
H e m at ol o g y, bi o c h e mi str y, c o a g ul ati o n 
•   
Pr e g n a n c y t e st ( w o m e n of c hil d b e ari n g p ot e nti al o nl y) 
•   
Uri n al y si s  
•   
Uri n e dr u g s cr e e n (tri al sit e t e sti n g) 
•   
Al c o h ol br e at h t e st 
7. 5. 2 I n str u cti o n s t o p ati e nt s pri or t o d o si n g 
O n d o si n g d a y s, p ati e nt s ar e all o w e d t o c o n s u m e a s m all m e al f or br e a kf a st wit h c orr e s p o n di n g 
a d mi ni str ati o n of r a pi d a cti n g i n s uli n t o a d dr e s s t h e m e al a n d i n a c c or d a n c e wit h t h eir n or m al 
m a n a g e m e nt of bl o o d gl u c o s e l e v el s. At vi sit 2 a n d vi sit 4 t h e p ati e nt s h o ul d ai m t o h a v e a 
si mil ar si z e d br e a kf a st a n d c orr e s p o n di n g r a pi d a cti n g i n s uli n d o s e.  
U s e of l o n g- a cti n g i n s uli n a n d r at e of b a s al c o nti n u o u s s u b c ut a n e o u s i n s uli n i nf u si o n ( C SII) will 
b e c o nti n u e d a c c or di n g t o n or m al gl y c e mi c m a n a g e m e nt of t h e i n di vi d u al p ati e nt s d uri n g d o si n g 
d a y s.  
7. 5. 3 
Pr o c e d ur e s a n d a s s e s s m e nt s d uri n g t h e tr e at m e nt p eri o d of t h e tri al 
At Vi sit 2 ( D a y 0) p ati e nt eli gi bilit y i s r e c h e c k e d ( c h e c k of c h a n g e s b et w e e n t h e s cr e e ni n g vi sit 
a n d Vi sit 2) a n d p ati e nt s eli gi bl e t o p arti ci p at e will b e r a n d o mi z e d t o tr e at m e nt wit h d a si gl u c a g o n 
or Gl u c a G e n.  
A d diti o n all y, d uri n g t h e tr e at m e nt p eri o d of t h e tri al, at Vi sit s 2 a n d 4 ( D a y s 0 a n d 1 4), t h e 
f oll o wi n g a s s e s s m e nt s will t a k e pl a c e: 
•   
C o n c o mit a nt m e di c ati o n 
•   
C h e c k of wit h dr a w al crit eri a 
•   
C h e c k of d o si n g d a y e x cl u si o n crit eri a 
•   
Vit al si g n s ( pr e- d o s e, a n d at 3 0, 9 0 a n d 1 2 0 mi n p o st- d o si n g) 
•   
E C G ( pr e- d o s e, a n d at 2 0, 3 5, 4 5 a n d 6 0 mi n p o st- d o si n g) 
•   
L o c al t ol er a bilit y ( at 0. 5 a n d 2 h p o st- d o si n g) 
•   
A E s  
•   
H e m at ol o g y a n d bi o c h e mi str y ( pr e- d o s e, a n d at 3 0 a n d 9 0 mi n p o st- d o si n g) 
•   
Uri n al y si s ( pr e- d o s e) 

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 3 1/ 5 0 
•   
Uri n e dr u g s cr e e n ( pr e- d o s e) at tri al sit e 
•   
Uri n e pr e g n a n c y t e st ( pr e- d o s e) at tri al sit e ( w o m e n of c hil d b e ari n g p ot e nti al o nl y) 
•   
Al c o h ol br e at h t e st ( pr e- d o s e) 
•   
D a si gl u c a g o n/ gl u c a g o n pl a s m a c o n c e ntr ati o n s  
( Pr e- d o s e, 5, 1 0, 3 0, 6 0, a n d 9 0 mi n p o st- d o si n g. T h e a ct u al ti m e of bl o o d s a m pli n g f or 
e x p o s ur e s h o ul d n ot d e vi at e fr o m t h e n o mi n al ti m e b y m or e t h a n ± 1 mi n. Pr e- d o s e i s 
d efi n e d a s wit hi n 5 mi n pri or t o d o si n g.) 
•   
Pl a s m a gl u c o s e c o n c e ntr ati o n  
( Pr e- d o s e, 5, 1 0, 3 0, 6 0, a n d 9 0 mi n p o st- d o si n g. T h e a ct u al ti m e f or bl o o d s a m pli n g f or 
pl a s m a gl u c o s e s h o ul d n ot d e vi at e fr o m t h e n o mi n al ti m e b y m or e t h a n ± 1 mi n. Pr e- d o s e 
i s d efi n e d a s wit hi n 5 mi n pri or t o d o si n g.) 
•   
A nti b o di e s a g ai n st d a si gl u c a g o n/ gl u c a g o n ( pr e- d o s e) 
•   
A d mi ni str ati o n of tri al m e di c ati o n 
Pri or t o a d mi ni str ati o n of tri al m e di c ati o n p ati e nt s m u st r e a c h a t ar g et pl a s m a gl u c o s e 
l e v el of 7 0- 1 5 0 
m g/ d L. If t h e p ati e nt pr e s e nt s wit h pl a s m a gl u c o s e > 1 5 0 
m g/ d L, 
c orr e cti v e a m o u nt s of f a st a cti n g i n s uli n will b e a d mi ni st er e d at t h e i n v e sti g at or’ s 
di s cr eti o n. Pl a s m a gl u c o s e m e a s ur e d aft er 2 0 a n d aft er 4 0 mi n ut e s s h o ul d e n s ur e t h at 
t h e p ati e nt h a s r e a c h e d t h e t ar g et e d 7 0- 1 5 0 m g/ d L. If t h e p ati e nt pr e s e nt s wit h pl a s m a 
gl u c o s e < 7 0 m g/ d L gl u c o s e i n g e sti o n will b e pr o vi d e d i n or d er t o r e a c h t ar g et pl a s m a 
gl u c o s e of 7 0- 1 5 0 m g/ d L d o c u m e nt e d b y pl a s m a gl u c o s e m e a s ur e m e nt s aft er 2 0 a n d 4 0 
mi n ut e s, r e s p e cti v el y . P ati e nt s m u st b e f a sti n g f or 9 0 mi n aft er a d mi ni str ati o n of tri al 
m e di c ati o n, a n d c a n b e tr e at e d i n di vi d u all y t o all e vi at e a n y p ot e nti al si d e eff e ct s. S e e 
s e cti o n 7. 4. 2. P ati e nt s will b e o b s er v e d f or at l e a st 5 h p o st- d o s e . 
At Vi sit 3 of t h e tr e at m e nt p eri o d ( D a y 7), o nl y t h e f oll o wi n g a s s e s s m e nt s will t a k e pl a c e 
•   
C o n c o mit a nt m e di c ati o n  
•   
C h e c k of wit h dr a w al crit eri a 
•   
C h e c k of d o si n g d a y e x cl u si o n crit eri a 
•   
Vit al si g n s ( pr e- d o s e, a n d at 3 0, 9 0 a n d 1 2 0 mi n p o st- d o si n g) 
•   
E C G ( pr e- d o s e, a n d at 2 0, 3 5, 4 5 a n d 6 0 mi n p o st- d o si n g) 
•   
L o c al t ol er a bilit y ( at 0. 5 a n d 2 h p o st- d o si n g) 
•   
A E s  
•   
Uri n e dr u g s cr e e n ( pr e- d o s e) at tri al sit e 
•   
Uri n e pr e g n a n c y t e st ( pr e- d o s e) at tri al sit e ( w o m e n of c hil d b e ari n g p ot e nti al o nl y) Al c o h ol 
br e at h t e st ( pr e- d o s e) 
•   
A nti b o di e s a g ai n st d a si gl u c a g o n/ gl u c a g o n ( pr e- d o s e) 
•   
A d mi ni str ati o n of tri al m e di c ati o n 
Pri or t o a d mi ni str ati o n of tri al m e di c ati o n p ati e nt s m u st r e a c h a t ar g et pl a s m a gl u c o s e 
l e v el of 7 0- 1 5 0 
m g/ d L. If t h e p ati e nt pr e s e nt s wit h pl a s m a gl u c o s e > 1 5 0 
m g/ d L, 
c orr e cti v e a m o u nt s of f a st a cti n g i n s uli n will b e a d mi ni st er e d at t h e i n v e sti g at or’ s 
di s cr eti o n. Pl a s m a gl u c o s e m e a s ur e d aft er 2 0 a n d aft er 4 0 mi n ut e s s h o ul d e n s ur e t h at 
t h e p ati e nt h a s r e a c h e d t h e t ar g et e d 7 0- 1 5 0 m g/ d L. If t h e p ati e nt pr e s e nt s wit h pl a s m a 
gl u c o s e < 7 0 m g/ d L gl u c o s e i n g e sti o n will b e pr o vi d e d i n or d er t o r e a c h t ar g et pl a s m a 
gl u c o s e of 7 0- 1 5 0 m g/ d L d o c u m e nt e d b y pl a s m a gl u c o s e m e a s ur e m e nt s aft er 2 0 a n d 4 0 
mi n ut e s, r e s p e cti v el y.  P ati e nt s ar e N O T r e q uir e d t o b e f a sti n g aft er a d mi ni str ati o n of tri al 
m e di c ati o n, a n d c a n b e tr e at e d i n di vi d u all y t o all e vi at e a n y p ot e nti al si d e eff e ct s 
i m m e di at el y f oll o wi n g d o si n g. S e e s e cti o n 7. 4. 2. P ati e nt s will b e o b s er v e d f or at l e a st 5 h 
p o st- d o s e. 

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 3 2/ 5 0 
7. 5. 4 F oll o w- u p p eri o d of t h e tri al 
Aft er t h e fi n al d o s e of tri al m e di c ati o n ( at Vi sit 4, D a y 1 4, d e s cri b e d a b o v e), p ati e nt s will b e 
f oll o w e d u p u ntil D a y 1 0 4 ( Vi sit 7). D uri n g t h e f oll o w- u p p eri o d, vi sit s t a k e pl a c e at D a y s 3 5, 6 0, 
a n d 1 0 4 ( Vi sit s 5, 6, a n d 7).  
At Vi sit s 5 a n d 6 d uri n g t h e f oll o w- u p p eri o d, t h e f oll o wi n g a s s e s s m e nt s will t a k e pl a c e: 
•   
C o n c o mit a nt m e di c ati o n  
•   
C h e c k of wit h dr a w al crit eri a 
•   
A E s  
•   
A nti b o di e s a g ai n st d a si gl u c a g o n/ gl u c a g o n 
A d diti o n all y, t h e f oll o wi n g a s s e s s m e nt s will t a k e pl a c e at Vi sit 5 o nl y: 
•   
Vit al si g n s 
•   
E C G  
•   
H e m at ol o g y a n d bi o c h e mi str y  
At Vi sit 7, t h e fi n al vi sit of t h e f oll o w- u p p eri o d a n d of t h e tri al ( E o T vi sit), t h e f oll o wi n g 
a s s e s s m e nt s will t a k e pl a c e: 
•   
C o n c o mit a nt m e di c ati o n  
•   
P h y si c al e x a mi n ati o n 
•   
Vit al si g n s 
•   
E C G 
•   
A E s  
•   
H e m at ol o g y a n d bi o c h e mi str y 
•   
Uri n al y si s 
•   
A nti b o di e s a g ai n st d a si gl u c a g o n/ gl u c a g o n 
7. 5. 5 Fi n al e x a mi n ati o n at t h e e n d of t h e tri al  
T h e fi n al vi sit of t h e tri al i s Vi sit 7 ( D a y 1 0 4 of t h e f oll o w- u p p eri o d; E o T vi sit). S e e S e cti o n 7. 5. 4 
f or f urt h er d et ail s.  
7. 5. 6 
U n s c h e d ul e d vi sit f or A D A p o siti v e p ati e nt s 
A p ati e nt wit h a tr e at m e nt i n d u c e d or tr e at m e nt b o o st e d A D A r e s p o n s e at vi sit 3- 7 m u st b e 
c all e d i n f or a n u n s c h e d ul e d vi sit. T h e pr o c e d ur e s of t hi s vi sit will b e i d e nti c al t o t h e pr o c e d ur e s 
p erf or m e d at 
Vi sit 4 i n cl u di n g a d mi ni str ati o n of tri al 
m e di c ati o n a n d a s s e s s m e nt s of 
p h ar m a c o d y n a mi c a n d p h ar m a c o ki n eti c r e s p o n s e s. 
T h e vi sit s h o ul d b e s c h e d ul e d a s s o o n a s t h e i n v e sti g at or i s i nf or m e d a b o ut a p o siti v e A D A 
r e s ult. T h e i n v e sti g at or s h o ul d i n str u ct t h e p ati e nt of t h e s a m e d o si n g d a y r e q uir e m e nt s a s f or 
t h e r e g ul ar d o si n g vi sit s ( S e cti o n 7. 5. 2) a n d i n str u ct t h e p ati e nt t o ai m of h a vi n g a si mil ar si z e d 
br e a kf a st a n d c orr e s p o n di n g r a pi d a cti n g i n s uli n d o s e a s pri or Vi sit 2 a n d Vi sit 4. 
A p ati e nt wit h a tr e at m e nt i n d u c e d or tr e at m e nt b o o st e d A D A r e s p o n s e will b e m o nit or e d u ntil 
t h e A D A l e v el s r et ur n t o b a s eli n e. 
7. 5. 7 
A d diti o n al ( s af et y) e x a mi n ati o n s 
If t h er e ar e a n y u n cl e ar s y m pt o m s or o b s er v ati o n s t h e r e s p o n si bl e p h y si ci a n i n c h ar g e m a y 
p erf or m f urt h er m e di c al e x a mi n ati o n s, ot h er t h a n o utli n e d i n t hi s pr ot o c ol, i n cl u di n g f urt h er 
cli ni c al l a b or at or y t e st s, i n or d er t o cl arif y t h e r el e v a n c e or t o di a g n o s e s y m pt o m s.  

 
Clinical Trial Protocol, final version 3 
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CONFIDENTIAL 
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7.5.8 Safety laboratory tests 
Samples obtained will be prepared and transferred to the appropriate laboratory by 
SynteractHCR according to Standard Operating Procedures. The parameters listed in Section 
7.6.4.1 will be determined using standard methods. 
The total volume of blood sampled per patient for safety analyses is 68 mL. 
7.6 
Immunogenicity, pharmacokinetic, pharmacodynamic, tolerability and safety 
measurements 
Details of sampling for immunogenicity testing, plasma glucose concentrations, plasma trial 
medication concentrations, and safety laboratory testing are provided in a laboratory manual 
(see the Investigator site file).  
7.6.1 Immunogenicity measurements 
Antibodies against dasiglucagon/glucagon will be measured at all visits after screening. During 
the treatment period (Visits 2, 3, and 4) samples will be collected pre-dose as well as at 
unscheduled dosing visits for ADA positive patients.  
The ADA samples will be analyzed at a special laboratory (refer to Appendix 1). Samples 
collected at the planned visits will be analyzed in batches at three occasions during the trial and 
any positive results will immediately be communicated to the investigator in a blinded manner. 
The clinical ADA assays have been validated in accordance with existing guidelines and 
recommendations.6,7,8,9,10  
Confirmed positive anti- dasiglucagon antibody samples, (treatment-induced or treatment-
boosted) from anti-dasiglucagon antibody-positive patients will be evaluated for binding titer 
neutralizing potential and titer as well as cross-reactivity towards endogenous glucagon.  
No further serum sampling will be needed as the ADA samples can be used for Nab analysis. 
The in vitro neutralizing effect of antibodies will be measured using an assay9,12 based on 
glucagon receptor transfected human embryonic kidney cells. The calculated sensitivity in 
previous studies was about 51.8 ng/mL. The assay was also validated for recombinant glucagon 
with similar results.11,12 In case of a positive result in the Nab assay, a titer estimation will be 
performed. The cell-based Nab analyses will be performed by a special laboratory, BioAgilytix, 
Durham, NC, USA. 
In vivo neutralizing effect will be evaluated by comparing PK and PD endpoints between ADA 
positive and ADA negative patients, further investigation may be performed by correlating ADA 
titer with PK and PD endpoints. 
Residual and additional antibody serum samples may be stored until approval of market 
authorization by the health authorities. Further characterization of the antibody response may be 
requested by the health authorities. 
7.6.2 Plasma concentrations of dasiglucagon and GlucaGen  
The exposure to trial medication (dasiglucagon or GlucaGen) will be assessed based on plasma 
concentration data (AUC0-30min, AUC0-90 min, Cmax, tmax) from samples collected at Visits 2 and 4 
(after administration of the first and third doses of trial medication).  
Samples will be collected pre-dose, and at 5, 10, 30, 60, and 90 min post-dosing. The actual 
time of blood sampling for exposure should not deviate from the nominal time by more than ±1 
min. Pre-dose is defined as within 5 min prior to dosing. 
 

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 3 4/ 5 0 
7. 6. 3 
P h ar m a c o d y n a mi c m e a s ur e m e nt s 
T h e pl a s m a gl u c o s e pr ofil e will b e a s s e s s e d b a s e d o n pl a s m a c o n c e ntr ati o n d at a ( A U E 0- 3 0 mi n , 
A U E 0- 9 0  mi n, C Em a x , tm a x ) fr o m s a m pl e s c oll e ct e d at d o si n g Vi sit s 2 a n d 4 (fir st a n d t hir d d o si n g 
vi sit).  
S a m pl e s will b e c oll e ct e d pr e- d o s e, a n d at 5, 1 0, 3 0, 6 0, a n d 9 0 mi n p o st- d o si n g. T h e a ct u al 
ti m e of bl o o d s a m pli n g f or e v al u ati o n of pl a s m a gl u c o s e s h o ul d n ot d e vi at e fr o m t h e n o mi n al 
ti m e b y m or e t h a n ± 1 mi n. Pr e- d o s e i s d efi n e d a s wit hi n 5 mi n pri or t o d o si n g.  
T h e s a m pl e s will b e s e nt t o t h e cli ni c al l a b or at or y a n d a n al y z e d u si n g a s e n siti v e a n d v ali d at e d 
a s s a y f or gl u c o s e m e a s ur e m e nt s. 
 
7. 6. 4 
S af et y a n d t ol er a bilit y m e a s ur e m e nt s  
7. 6. 4. 1 
S af et y l a b or at or y t e st s 
R o uti n e s af et y l a b or at or y t e st s will b e p erf or m e d c e ntr all y. S a m pl e s f or s af et y l a b or at or y 
p ar a m et er s will b e c oll e ct e d at Vi sit s 1, 2, 4, 5, a n d 7. S a m pl e s f or uri n al y si s will b e c oll e ct e d at 
Vi sit s 1, 2, 4, a n d 7. T h e f oll o wi n g p ar a m et er s will b e d et er mi n e d: 
•   
Cli ni c al c h e mi str y: s o di u m, p ot a s si u m, c al ci u m, gl u c o s e, ur e a, cr e ati ni n e, t ot al bilir u bi n, 
A S T ( S G O T), A L T ( S G P T), g a m m a- G T, al k ali n e p h o s p h at a s e, t ot al pr ot ei n, C-r e a cti v e 
pr ot ei n, H b A 1 c , C- p e pti d e  
•   
H e m at ol o g y: h e m o gl o bi n, r e d bl o o d c ell c o u nt ( er yt hr o c yt e s), h e m at o crit, pl at el et c o u nt 
(t hr o m b o c yt e s), t ot al w hit e bl o o d c ell c o u nt (l e u c o c yt e s) 
•   
C o a g ul ati o n: i nt er n ati o n al n or m ali z e d r ati o (I N R), fi bri n o g e n ( at s cr e e ni n g vi sit o nl y)  
•   
Uri n al y si s: p H, bl o o d (l e u k o c yt e s a n d er yt hr o c yt e s), pr ot ei n, gl u c o s e, k et o n e s, nitrit e 
A pr e g n a n c y t e st will b e p erf or m e d at s cr e e ni n g ( Vi sit 1) a n d pr e- d o s e at t h e t hr e e d o si n g vi sit s 
( Vi sit 2, 3 a n d 4) f or w o m e n of c hil d b e ari n g p ot e nti al o nl y. 
Al c o h ol br e at h t e st s a n d uri n e dr u g s cr e e n ( a m p h et a mi n e, c o c ai n e, M D M A, m et h a m p h et a mi n e, 
o pi at e/ m or p hi n e, m ari h u a n a) will b e p erf or m e d at S cr e e ni n g ( Vi sit 1) a n d at Vi sit s 2, 3, a n d 4. 
F or f urt h er d et ail s, pl e a s e r ef er t o t h e l a b or at or y m a n u al.  
7. 6. 4. 2 
S af et y e x a mi n ati o n s 
P h y si c al e x a mi n ati o n i s p erf or m e d at S cr e e ni n g ( Vi sit 1) a n d E o T ( Vi sit 7).  
A E s ar e a s s e s s e d at all vi sit s. L o c al t ol er a bilit y i s a s s e s s e d at all d o si n g vi sit s ( Vi sit s 2, 3, a n d 
4). E C G i s a s s e s s e d at S cr e e ni n g ( Vi sit 1) Vi sit s 2, 3, a n d 4 a n d vit al si g n s ar e a s s e s s e d at 
S cr e e ni n g ( Vi sit 1) Vi sit s 2, 3, 4, 5, a n d 7.  
•   
P h y si c al e x a mi n ati o n i n cl u d e s e x a mi n ati o n of t h e f oll o wi n g b o d y s y st e m s: h e a d, e ar s, 
e y e s, n o s e, t hr o at ( H E E N T), i n cl u di n g t h e t h yr oi d gl a n d; h e art, l u n g, c h e st; a b d o m e n; 
s ki n; m u s c ul o s k el et al s y st e m; n er v o u s s y st e m; l y m p h n o d e 
•   
Vit al si g n s i n cl u d e: p ul s e r at e a n d bl o o d pr e s s ur e i n a sitti n g p o siti o n aft er 5 mi n, b o d y 
t e m p er at ur e 
•   
L o c al t ol er a bilit y: s ki n r e a cti o n s will b e a s s e s s e d at t h e i nj e cti o n sit e at 0. 5 a n d 2 h p o st-
d o si n g. S ki n r e a cti o n s will b e r e p ort e d a s A E s ( s e e S e cti o n 8). 
•   
1 2-l e a d E C G. D et ail s fr o m E C G a s s e s s m e nt s will b e r e c or d e d, i n cl u di n g P R, Q R S a n d 
Q T i nt er v al s.   

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 3 5/ 5 0 
8. 
A d v er s e e v e nt s 
8. 1  
D efi niti o n s 
A d v er s e E v e nt ( A E) 
A n A E i s a n y u nt o w ar d m e di c al o c c urr e n c e i n a tri al p ati e nt a d mi ni st er e d a n i n v e sti g ati o n al 
m e di ci n al pr o d u ct (I M P) a n d w hi c h d o e s n ot n e c e s s aril y h a v e a c a u s al r el ati o n s hi p wit h t h e 
tr e at m e nt. A n A E c a n t h er ef or e b e a n y u nf a v or a bl e a n d u ni nt e n d e d si g n (f or e x a m pl e, a n 
a b n or m al l a b or at or y fi n di n g), s y m pt o m, or di s e a s e t e m p or all y a s s o ci at e d wit h t h e u s e of a n 
I M P, w h et h er or n ot c o n si d er e d r el at e d t o t h e I M P.  
N ot e: T hi s i n cl u d e s e v e nt s fr o m t h e fir st tri al r el at e d a cti vit y aft er t h e p ati e nt h a s si g n e d t h e 
i nf or m e d c o n s e nt.  
A E s i n cl u d e: 
•   
A cli ni c all y si g nifi c a nt w or s e ni n g of a c o n c o mit a nt ill n e s s. 
•   
A cli ni c al l a b or at or y a b n or m alit y w hi c h i s cli ni c all y si g nifi c a nt, i. e. a n y a b n or m alit y t h at 
s u g g e st s a di s e a s e a n d/ or or g a n t o xi cit y a n d i s of a s e v erit y t h at r e q uir e s a cti v e 
m a n a g e m e nt. A cti v e m a n a g e m e nt i n cl u d e s a cti v e tr e at m e nt or f urt h er i n v e sti g ati o n s, f or 
e x a m pl e c h a n g e of m e di ci n e d o s e or m or e fr e q u e nt f oll o w- u p d u e t o t h e a b n or m alit y. 
•   
H y p o gl y c e mi c e pi s o d e s ( s e e S e cti o n 8. 4) 
•   
I nj e cti o n sit e r e a cti o n s 
T h e f oll o wi n g s h o ul d n ot b e r e c or d e d a s A E s, if r e c or d e d at s cr e e ni n g ( o n S cr e e ni n g F or m or 
C R F): 
•   
Pr e- pl a n n e d pr o c e d ur e, u nl e s s t h e c o n diti o n f or w hi c h t h e pr o c e d ur e w a s pl a n n e d h a s 
w or s e n e d fr o m t h e fir st tri al r el at e d a cti vit y aft er t h e p ati e nt h a s si g n e d t h e i nf or m e d 
c o n s e nt. 
•   
Pr e- e xi sti n g c o n diti o n s f o u n d a s a r e s ult of s cr e e ni n g pr o c e d ur e s ( pr e- e xi sti n g c o n diti o n s 
s h o ul d b e r e p ort e d a s m e di c al hi st or y or c o n c o mit a nt ill n e s s). 
S eri o u s a d v er s e e v e nt ( S A E) 
A S A E i s a n y u nt o w ar d m e di c al o c c urr e n c e t h at at a n y d o s e:  
•   
r e s ult s i n d e at h  
•   
i s lif e-t hr e at e ni n g  
•   
r e q uir e s i n p ati e nt h o s pit ali z ati o n or pr ol o n g ati o n of e xi sti n g h o s pit ali z ati o n 
•   
r e s ult s i n p er si st e nt or si g nifi c a nt di s a bilit y or i n c a p a cit y 
•   
i s a c o n g e nit al a n o m al y or birt h d ef e ct 
•   
i s m e di c all y i m p ort a nt 
M e di c al j u d g e m e nt 
m u st b e e x er ci s e d i n d e ci di n g w h et h er a n A E i s b eli e v e d t o b e 
‘ m e di c all y i m p ort a nt’. M e di c all y i m p ort a nt e v e nt m a y n ot b e i m m e di at el y lif e-t hr e at e ni n g 
or r e s ult i n d e at h or h o s pit ali z ati o n b ut 
m a y j e o p ar di z e t h e p ati e nt or 
m a y r e q uir e 
i nt er v e nti o n t o pr e v e nt o n e of t h e ot h er o ut c o m e s li st e d i n t h e d efi niti o n a b o v e. 

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 3 6/ 5 0 
S u s p e ct e d u n e x p e ct e d s eri o u s a d v er s e r e a cti o n s ( S U S A R) 
A n A E, f ulfilli n g o n e of t h e crit eri a of s eri o u s n e s s a n d b ei n g a s s e s s e d a s r el at e d t o I M P 
a p pli c ati o n, t h e n at ur e or s e v erit y of w hi c h i s n ot c o n si st e nt wit h t h e a p pli c a bl e r ef er e n c e 
d o c u m e nt ( e. g. Z P 4 2 0 7 I B 3  or p a c k a g e l e afl et/ S m P C f or a n a p pr o v e d pr o d u ct s u c h a s 
G l u c a G e n1 3 ).  
Cli ni c al e v e nt of i nt er e st 
A cli ni c al e v e nt of i nt er e st i s a n e v e nt w hi c h, i n t h e e v al u ati o n of s af et y, h a s a s p e ci al f o c u s ( e. g. 
r e q uir e d b y h e alt h a ut h oriti e s). 
I n t hi s tri al h e m o d y n a mi c c h a n g e s, a s d efi n e d b el o w, ar e c o n si d er e d cli ni c al e v e nt s of i nt er e st: 
•   
P o st- d o s e cli ni c al si g n s or m e a s ur e d vit al si g n s i n di c ati n g a cli ni c al si g nifi c a nt dr o p i n 
bl o o d pr e s s ur e i n cl u di n g si g n s of ort h o st ati c h y p ot e n si o n, v a s o v a g al r e s p o n s e s or 
br a d y c ar di a. 
•   
P o st- d o s e c h a n g e i n p ul s e or bl o o d pr e s s ur e c o n si d er e d a n e v e nt of h y p o- or 
h y p ert e n si o n a s j u d g e d b y t h e i n v e sti g at or. 
I nt e n sit y of a n a d v er s e e v e nt 
T h e 
m a xi m u m i nt e n sit y ( s e v erit y) of all A E s 
m u st b e a s s e s s e d b y t h e I n v e sti g at or a n d 
d o c u m e nt e d. S e v erit y s h o ul d b e gr a d e d w h e n t h e A E o ut c o m e i s k n o w n: 
Mil d:   
A t y p e of a d v er s e e v e nt t h at i s u s u all y tr a n si e nt a n d m a y r e q uir e o nl y mi ni m al 
tr e at m e nt or t h er a p e uti c i nt er v e nti o n. T h e e v e nt d o e s n ot g e n er all y i nt erf er e wit h 
u s u al a cti viti e s of d ail y li vi n g. 
M o d er at e:  
A t y p e of a d v er s e e v e nt t h at i s u s u all y all e vi at e d wit h a d diti o n al s p e cifi c t h er a p e uti c 
i nt er v e nti o n. T h e e v e nt i nt erf er e s wit h u s u al a cti viti e s of d ail y li vi n g, c a u si n g 
di s c o mf ort b ut p o s e s n o si g nifi c a nt or p er m a n e nt ri s k of h ar m t o t h e r e s e ar c h 
p arti ci p a nt. 
S e v er e:   
A t y p e of a d v er s e e v e nt t h at i nt err u pt s u s u al a cti viti e s of d ail y li vi n g, or si g nifi c a ntl y 
aff e ct s cli ni c al st at u s, or m a y r e q uir e i nt e n si v e t h er a p e uti c i nt er v e nti o n. 
A ‘ s e v er e’ r e a cti o n d o e s n ot n e c e s s aril y d e e m t h e A E a s ‘ s eri o u s’ a n d a S A E m a y n ot b e 
‘ s e v er e’ i n n at ur e. 
C a u s alit y r el ati o n s hi p t o tri al m e di c ati o n 
T h e c a u s alit y of e a c h A E s h o ul d b e a s s e s s e d b y t h e I n v e sti g at or a c c or di n g t o t h e f oll o wi n g 
cl a s sifi c ati o n: 
Pr o b a bl e: G o o d r e a s o n a n d s uffi ci e nt d o c u m e nt ati o n t o a s s u m e a c a u s al r el ati o n s hi p. 
P o s si bl e: A c a u s al r el ati o n s hi p i s c o n c ei v a bl e a n d c a n n ot b e di s mi s s e d. 
U nli k el y: T h e e v e nt i s m o st li k el y r el at e d t o eti ol o g y ot h er t h a n t h e tri al pr o d u ct. 
N ot r el at e d:   
N o r el ati o n s hi p t o tri al pr o d u ct 
O ut c o m e of a n a d v er s e e v e nt 
T h e o ut c o m e of all A E s m u st b e a s s e s s e d b y t h e I n v e sti g at or a n d d o c u m e nt e d b y hi s/ h er st aff. 
T h e f oll o wi n g d efi niti o n s s h o ul d b e u s e d: 
R e c o v er e d/r e s ol v e d:  
T h e p ati e nt h a s f ull y r e c o v er e d, or b y m e di c al or s ur gi c al 
tr e at m e nt t h e c o n diti o n h a s r et ur n e d t o t h e l e v el o b s er v e d 
at t h e fir st tri al-r el at e d a cti vit y aft er t h e p ati e nt si g n e d t h e 
i nf or m e d c o n s e nt.  

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 3 7/ 5 0 
R e c o v eri n g/r e s ol vi n g: 
T h e c o n diti o n i s i m pr o vi n g a n d t h e p ati e nt i s e x p e ct e d t o 
r e c o v er fr o m t h e e v e nt. T hi s t er m i s o nl y a p pli c a bl e if t h e 
p ati e nt h a s c o m pl et e d t h e tri al. 
R e c o v er e d/r e s ol v e d wit h s e q u el a e:  T h e p ati e nt h a s r e c o v er e d fr o m t h e c o n diti o n, b ut wit h 
l a sti n g eff e ct d u e t o a di s e a s e, i nj ur y, tr e at m e nt or 
pr o c e d ur e. If a s e q u el a m e et s a n S A E crit eri o n, t h e A E 
m u st b e r e p ort e d a s a n S A E. 
N ot r e c o v er e d/ n ot r e s ol v e d:   
T h e c o n diti o n of t h e p ati e nt h a s n ot i m pr o v e d a n d t h e 
s y m pt o m s ar e u n c h a n g e d. 
F at al:  
T hi s t er m i s o nl y a p pli c a bl e if t h e p ati e nt di e d fr o m a 
c o n diti o n r el at e d t o t h e r e p ort e d A E. O ut c o m e s of ot h er 
r e p ort e d A E s i n a p ati e nt b ef or e h e/ s h e di e d s h o ul d b e 
a s s e s s e d a s "r e c o v er e d/r e s ol v e d", "r e c o v eri n g/r e s ol vi n g", 
"r e c o v er e d/ r e s ol v e d wit h s e q u el a e" or " n ot r e c o v er e d/ n ot 
r e s ol v e d". A n A E wit h f at al o ut c o m e m u st b e r e p ort e d a s 
a n S A E. 
U n k n o w n:  
T hi s t er m i s o nl y a p pli c a bl e if t h e p ati e nt i s l o st t o f oll o w-
u p. 
8. 2  
C oll e cti o n, r e c or di n g a n d r e p orti n g of a d v er s e e v e nt s 
All e v e nt s m e eti n g t h e d efi niti o n of a n A E m u st b e c oll e ct e d a n d r e p ort e d fr o m t h e fir st tri al 
r el at e d a cti vit y aft er t h e p ati e nt h a s si g n e d t h e i nf or m e d c o n s e nt u ntil t h e e n d of t h e p o st-
tr e at m e nt f oll o w- u p p eri o d. At e a c h c o nt a ct wit h t h e sit e ( vi sit or t el e p h o n e, e x cl u di n g vi sit s, 
w h er e t h e p ati e nt i s n ot s e ei n g t h e I n v e sti g at or or hi s st aff ( e. g. vi sit s t o t h e l a b or at or y)) t h e 
p ati e nt m u st b e a s k e d a b o ut A E s. All A E s, eit h er o b s er v e d b y t h e I n v e sti g at or or r e p ort e d b y t h e 
p ati e nt, m u st b e r e c or d e d b y t h e I n v e sti g at or a n d e v al u at e d. 
T h e I n v e sti g at or s h o ul d r e c or d t h e di a g n o si s, if p o s si bl e. If n o di a g n o si s c a n b e m a d e t h e 
I n v e sti g at or s h o ul d r e c or d e a c h si g n a n d s y m pt o m a s i n di vi d u al A E s. 
All A E s m u st b e r e c or d e d b y t h e I n v e sti g at or. O n e si n gl e A d v er s e E v e nt F or m m u st b e u s e d p er 
A E fr o m st art t o r e s ol uti o n. F or S A E s, t h e S eri o u s A d v er s e E v e nt F or m m u st al s o b e c o m pl et e d. 
F or cli ni c al e v e nt s of i nt er e st, t h e Cli ni c al E v e nt of I nt er e st F or m m u st al s o b e c o m pl et e d. 
A E i nf or m ati o n s h o ul d i n cl u d e t h e f oll o wi n g: 
•   
D at e a n d ti m e of o n s et a n d r e s ol uti o n 
•   
D at e a n d ti m e of I n v e sti g at or’ s fir st i nf or m ati o n o n t h e ( S) A E 
•   
S eri o u s n e s s 
•   
S e v erit y 
•   
C a u s al r el ati o n s hi p wit h I M P 
•   
I nt err u pti o n or wit h dr a w al of tr e at m e nt wit h I M P a n d ot h er m e a s ur e s t a k e n 
•   
O ut c o m e 
All A E s ar e c o d e d; d et ail s ar e d e s cri b e d i n t h e tri al s p e cifi c D at a M a n a g e m e nt Pl a n.  
If a n e v e nt cl a s sifi e s a s a cli ni c al e v e nt of i nt er e st, t h e I n v e sti g at or m u st ti c k t h e Cli ni c al E v e nt 
of I nt er e st b o x o n t h e A E f or m a n d c o m pl et e t h e Cli ni c al E v e nt of I nt er e st F or m. T h e Cli ni c al 
E v e nt of I nt er e st f or m will c a pt ur e if t h e e v e nt w a s a s s o ci at e d wit h a n y si g n s or s y m pt o m s a n d 
c a pt ur e t h e hi g h e st/l o w e st bl o o d pr e s s ur e a n d p ul s e m e a s ur e d d uri n g t h e e v e nt. 
T h e I n v e sti g at or m u st r e p ort i niti al i nf or m ati o n i n writi n g (f a x or e m ail) o n all S A E s t o t h e 
S p o n s or’ s r e s p o n si bl e p h ar m a c o vi gil a n c e u nit ( S af et y C R O) i m m e di at el y ( wit hi n 2 4 h o ur s) aft er 

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 3 8/ 5 0 
o bt ai ni n g k n o wl e d g e a b o ut t h e e v e nt. Pl e a s e r ef er t o A p p e n di x 1 f or c o nt a ct d et ail s. T h e S af et y 
C R O will i nf or m t h e m e di c al m o nit or a n d t h e s p o n s or a b o ut t h e r e p ort e d S A E s. 
It i s t h e r e s p o n si bilit y of t h e S af et y C R O t o r e p ort all S U S A R s t h at o c c ur i n t hi s tri al t o t h e 
C o m p et e nt A ut h oriti e s a n d I R B s/I E C s i n a c c or d a n c e wit h t h e l o c al r e q uir e m e nt s i n f or c e a n d 
I C H g ui d eli n e f or G C P. T h e tri al m o nit or m u st b e i nf or m e d a c c or di n gl y. 
8. 3  
F oll o w- u p of a d v er s e e v e nt s 
All A E s t h at ar e o n g oi n g at t h e e n d of t h e p ati e nt’ s p arti ci p ati o n i n t h e st u d y will b e f oll o w e d- u p 
u ntil t h e e v e nt i s r e s ol v e d or r e a c h e s a s ati sf a ct or y o ut c o m e a s d e e m e d b y t h e I n v e sti g at or.  
F oll o w- u p a cti o n s f or all S A E s will b e p erf or m e d a c c or di n g t o a p pr o pri at e cli ni c al c ar e pr a cti c e s 
a n d m a y d e p e n d o n t h e n at ur e of t h e e v e nt. T h e s e will b e d et er mi n e d aft er i nt er n al r e vi e w 
a n d/ or s p o n s or r e vi e w. 
T h e f oll o w u p i nf or m ati o n s h o ul d o nl y i n cl u d e n e w ( u p d at e d a n d/ or a d diti o n al) i nf or m ati o n t h at 
r efl e ct s t h e sit u ati o n at t h e ti m e of t h e I n v e sti g at or’ s si g n at ur e. 
F oll o w- u p i nf or m ati o n o n ( S) A E s will b e u p d at e d u si n g t h e ( S) A E F or m. If a n o n- s eri o u s e v e nt 
b e c o m e s s eri o u s d uri n g t h e f oll o w- u p t h e A E F or m a n d S A E F or m h a v e t o b e u s e d a n d 
r e p orti n g ti m eli n e s f oll o w t h o s e of a S A E. 
T h e I n v e sti g at or m u st f or w ar d f oll o w- u p i nf or m ati o n o n S A E s a n d if pr e vi o u sl y n o n- s eri o u s A E s 
b e c o m e S A E s t o t h e S p o n s or i m m e di at el y ( wit hi n 2 4 h o ur s) aft er o bt ai ni n g k n o wl e d g e a b o ut t h e 
n e w i nf or m ati o n. 
8. 4  
H y p o gl y c e mi a 
H y p o gl y c e mi a will b e r e g ar d e d a s a n A E a n d r e c or d e d a n d d o c u m e nt e d o n a n A E F or m. 
H y p o gl y c e mi a i s d efi n e d a s a f all of pl a s m a gl u c o s e b el o w 3. 9 m m ol/ L ( 7 0 m g/ d L). 
D uri n g t h e d o si n g vi sit s, mil d t o m o d er at e s y m pt o m s of h y p o gl y c e mi a, or a bl o o d gl u c o s e ( B G) 
v al u e l e s s t h a n a t hr e s h ol d of < 2. 8 m m ol/ L ( 5 0 m g/ d L), c orr e s p o n di n g t o a pl a s m a gl u c o s e ( P G) 
v al u e of < 3. 1 m m ol/ L ( 5 6 m g/ d L), will b e tr e at e d b y i. v. gl u c o s e s ol uti o n at t h e i n v e sti g at or’ s 
di s cr eti o n a c c or di n g t o b e st a v ail a bl e m e di c al pr a cti c e. Tr e at m e nt i s t o b e r e p e at e d u ntil B G 
v al u e st a bili z e d a b o v e t h e t hr e s h ol d li mit a g ai n. B G m e a s ur e m e nt s will o nl y b e d o n e d u e t o 
s af et y c o n c er n s. I n s uli n-i n d u c e d h y p o gl y c e mi a s h o ul d b e r e c or d e d a s a n A E. 
8. 5  
Pr e g n a n c y 
F e m al e p ati e nt s 
m u st b e i n str u ct e d t o n otif y t h e I n v e sti g at or i m m e di at el y if t h e y b e c o m e 
pr e g n a nt or if t h e y s u s p e ct t o b e pr e g n a nt d uri n g t h e tri al. T h e S p o n s or h a s a r e s p o n si bilit y t o 
m o nit or t h e o ut c o m e of all pr e g n a n ci e s r e p ort e d d uri n g t h e cli ni c al tri al. 
M al e p ati e nt s m u st b e i n str u ct e d t o n otif y t h e I n v e sti g at or i m m e di at el y if t h eir p art n er b e c o m e s 
pr e g n a nt or s u s p e ct s t o b e pr e g n a nt. T h e S p o n s or h a s a r e s p o n si bilit y t o m o nit or t h e o ut c o m e 
of all pr e g n a n ci e s r e p ort e d d uri n g t h e cli ni c al tri al. D uri n g a n i nf or m ati o n m e eti n g at t h e tri al sit e, 
t h e p ati e nt’ s p art n er will b e f ull y i nf or m e d b y a p h y si ci a n of h er p arti ci p ati o n i n c a pt uri n g t h e 
o ut c o m e d at a, a n d will b e a s k e d t o pr o vi d e h er writt e n c o n s e nt. 
T h e I n v e sti g at or m u st r e p ort all i nf or m ati o n o n pr e g n a n ci e s o n t h e i niti al pr e g n a n c y f or m. T h e 
c o m pl et e d i niti al pr e g n a n c y f or m m u st b e f or w ar d e d t o t h e S p o n s or a c c or di n g t o t h e pr o c e d ur e 
st at e d i n S e cti o n 8. 2. A n y ( S) A E s i n t h e m ot h er, a s w ell a s ot h er pr e g n a n c y c o m pli c ati o n s 
( e ct o pi c pr e g n a n c y) f ulfilli n g t h e crit eri a of a n ( S) A E, m u st b e r e p ort e d o n t h e ( S) A E f or m.  
T h e f oll o wi n g m u st b e c oll e ct e d i n t h e i niti al pr e g n a n c y f or m:  
•   
M e di c al hi st or y of t h e m ot h er 
•   
F a mil y hi st or y 

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 3 9/ 5 0 
•   
C o ur s e of t h e pr e g n a n c y, i n cl u di n g e x p e ct e d d eli v er y d at e 
T h e I n v e sti g at or m u st f oll o w t h e pr e g n a n c y u ntil t h e pr e g n a n c y o ut c o m e a n d t h e n e w b or n 
i nf a nt( s) u ntil t h e a g e of 1 m o nt h. T h e I n v e sti g at or m u st c oll e ct i nf or m ati o n o n t h e pr e g n a n c y 
a n d pr e g n a n c y c o m pli c ati o n s a s w ell a s t h e pr e g n a n c y o ut c o m e i n cl u di n g t h e h e alt h of t h e 
n e w b or n i nf a nt( s) o n t h e pr e g n a n c y o ut c o m e f or m. T h e c o m pl et e d pr e g n a n c y o ut c o m e f or m 
m u st b e f or w ar d e d t o t h e S p o n s or a c c or di n g t o t h e pr o c e d ur e st at e d i n S e cti o n 8. 2. A n y ( S) A E s 
i n t h e n e w b or n m u st b e r e p ort e d o n t h e ( S) A E f or m. 
T h e S A E s t h at m u st b e r e p ort e d i n cl u di n g a b n or m al o ut c o m e - s u c h a s c o n g e nit al a n o m ali e s, 
f et al d e at h a n d t er mi n ati o n of pr e g n a n c y ( s p o nt a n e o u s or el e cti v e a b orti o n), i n cl u di n g a n y 
a n o m ali e s of t h e f et u s o b s er v e d at gr o s s e x a mi n ati o n or d uri n g a ut o p s y.  
T h e f oll o wi n g m u st b e c oll e ct e d i n t h e pr e g n a n c y o ut c o m e f or m:  
•   
C o ur s e of t h e pr e g n a n c y 
•   
O ut c o m e of t h e pr e g n a n c y 
•   
C o n diti o n of t h e n e w b or n 
•   
A n y A E s i n t h e n e w b or n i nf a nt m u st b e f oll o w e d till t h e a g e of 1 m o nt h 
8. 6  
Pr e c a uti o n s 
N or m al pr e c a uti o n s t a k e n f or a h u m a n tri al, i n cl u di n g t h e pr o vi si o n of e m er g e n c y e q ui p m e nt, 
will b e t a k e n d uri n g t hi s tri al. Q u alifi e d a n d w ell tr ai n e d p h y si ci a n s a n d m e di c al st aff will i n str u ct 
t h e p ati e nt s. D uri n g a p ati e nt’ s p arti ci p ati o n i n t h e tri al, t h e I n v e sti g at or s h o ul d e n s ur e t h at 
a d e q u at e m e di c al c ar e i s pr o vi d e d t o t h e p ati e nt s f or a n y A E s, i n cl u di n g cli ni c all y si g nifi c a nt 
l a b or at or y v al u e s r el at e d t o t h e tri al. T h e I n v e sti g at or s h o ul d i nf or m t h e p ati e nt w h e n m e di c al 
c ar e i s n e e d e d f or i nt er c urr e nt ill n e s s e s of w hi c h t h e I n v e sti g at or b e c o m e s a w ar e.  
F or f urt h er i nf or m ati o n o n s af et y pr e c a uti o n s f or Z P 4 2 0 7 a n d Gl u c a G e n, pl e a s e r ef er t o t h e 
c urr e nt v er si o n of t h e I n v e sti g at or’ s Br o c h ur e 3  a n d t h e S m P C f or Gl u c a G e n1 3 , r e s p e cti v el y. 
8. 7  
S a f et y C o m mitt e e 
T h e i nt er n al Z e al a n d P h ar m a S af et y C o m mitt e e ( S C) i s c o n stit ut e d t o p erf or m o n g oi n g s af et y 
s ur v eill a n c e of cli ni c al tri al s wit h d a si gl u c a g o n, i n cl u di n g t hi s tri al. 
If s af et y si g n al s ar e o b s er v e d, eit h er b a s e d o n r e p ort e d S A E s, p eri o di c r e vi e w of l a b or at or y 
p ar a m et er s, r e vi e w of all A E s r e p ort e d b et w e e n t h e S C m e eti n g s, or o n n otifi c ati o n of si g nifi c a nt 
fi n di n g s, t h e S C will t a k e a p pr o pri at e m e a s ur e s t o s af e g u ar d t h e p ati e nt s.  
A s a mi ni m u m t h e S C c o n v e n e s e v er y q u art er t o r e vi e w r el e v a nt s af et y i nf or m ati o n, i n cl u di n g 
A E s a n d l a b or at or y d at a.  

 
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9. Data management and quality control 
9.1 
Case report forms 
All the information collected during the trial will be recorded in the eCRFs, which are identified 
by patient number. Suitable eCRFs will be designed by SynteractHCR. The investigator will 
ensure that the eCRFs are correctly completed. All key pages will be signed or initialed by the 
investigator, signifying agreement with and responsibility for the recorded data. Key pages are 
the following: AE-reporting form, trial medication form, concomitant medication form and trial-
closure form. 
Any information (e.g. results from the neutralizing antibody assay or additional unscheduled 
visits) may be reported separately pending availability of the results. 
Data directly captured in the eCRF (i.e., data assigned or calculated automatically by the EDC 
system) is called e-source. This means that these data fields in the CRF are source documents. 
For the other CRF data fields, which are entered by medical personnel during the trial, the 
source data will be found in other documents (such as patients’ files, worksheets, etc.), i.e. for 
these CRF data fields the “other” documents are the source documents.  
9.2 
Quality control 
The investigator will permit trial-related monitoring, IEC review, and regulatory inspections, 
providing direct access to source data /documents. Sponsor-authorized quality assurance 
personnel may carry out audits for which the investigator must provide support. 
The trial will be supervised by a monitor from SynteractHCR. The trial monitor will contact the 
investigator regularly to discuss the progress of the trial and to check the trial documents 
including the informed consent forms for completeness and consistency.  
The trial monitor or a representative of the sponsor will cross-check the data entered in the 
eCRFs with the source data at the trial site and observe the trial procedures in order to verify 
adherence to the trial protocol. 
The eCRFs will be checked for completeness and correctness by the monitor and data 
management department of SynteractHCR according to the SynteractHCR SOPs and any queries 
will be resolved by the investigator. 
All of the clinical data will be captured via electronic data capture (EDC) using a web-based tool. 
The software Marvin from the company XClinical (www.xclinical.com/) is the preferred EDC 
software. Marvin is compliant with all legislation relevant to electronic data capture (FDA 21 
CFR Part 11, GCP). 
The investigator site staff will enter and edit the data via a secure network, with secure access 
features (username and password). A complete electronic audit trail will be maintained. The 
investigator will approve the data using an electronic signature (Ref: 21 CFR Part 11), and this 
approval is used to confirm the accuracy of the data recorded. 
eCRFs will be used for all patients. The investigator’s data will be accessible from the 
investigator’s site throughout the trial. The electronic CRFs must be kept current to reflect 
patient status at each phase during the course of the trial. The electronic CRF will not capture 
personalized data. The investigator must make a separate confidential record of personalized 
details (name and initials) on the patient identification and enrollment log. All changes to data 
are done by the investigator through the EDC system.  
It is the responsibility of the Principal Investigator of the respective site to ensure that all patient 
discontinuations or changes in trial or other medications entered on the patient’s eCRF are also 
made on the patient’s medical records. 

 
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The eCRFs for any patient leaving the trial should be completed at the time of the final visit or 
shortly thereafter. 
9.3 
Data management 
Data management will be performed according to SynteractHCR SOPs. 
 

 
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10. Statistical methods and determination of sample size 
10.1 Statistical and analysis plan 
A separate Statistical Analysis Plan (SAP) will be finalized that details the planned statistical 
analysis and may include necessary adaptations to the planned statistical analysis before 
unblinding of the data.  
Any deviations from the planned analyses will be described and justified in the final integrated 
trial report. 
10.1.1 General considerations 
All data obtained in this trial and documented in the eCRFs will be listed and summarized with 
statistics or frequency tables as appropriate. In case of termination of the trial, all data collected 
up to that time point will be included into the analysis. 
Raw data listings and summary tables will be generated using the software SAS© Version 9 or 
higher.  
All statistical analysis will be descriptive i.e. no formal testing will be performed. 
Continuous variables will be summarized with means, standard deviations, medians, minimums, 
and maximums and valid cases.  
Other summaries (e.g. quartiles, 95% confidence intervals) may be used as appropriate. 
Categorical efficacy and safety variables will be summarized by counts and by percentage of 
patients in corresponding categories.  
10.1.2 Classification of patients to subsets 
For the statistical analysis the randomized patients will be divided up into the following datasets: 
The following definitions are applicable: 
Safety analysis set 
(SAS) 
all patients who were randomized and received at least one dose of 
trial medication 
Full analysis set 
(FAS) 
all patients of the SAS with at least one measurement of the ADA 
titer at baseline 
Per Protocol set 
(PPS) 
all patients of the FAS for whom no relevant protocol deviations 
were documented 
The analysis of the primary endpoint will be based on the FAS. A secondary analysis of the 
primary endpoint will be based on the PPS. Safety analysis will be based on the SAS. 
The decision whether a protocol deviation is relevant or not for the exclusion of patients from the 
PPS set will be made case-by-case in a data review meeting. 
10.1.3 Immunogenicity data 
All immunogenicity parameters will be analyzed descriptively per treatment group. No statistical 
tests are planned. Baseline ADA-positive patients will be calculated as a percentage of the total 
number of patients whose baseline samples were tested for ADA. Titer will be reported as 
median and interquartile range. 
95% confidence intervals for incidence rates and for rate differences will be given. 
Secondary immunogenicity parameters will be described with appropriate descriptive statistics 
for dichotomous, categorical or continuous variables. 

 
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10.1.4 Exposure and PD endpoints 
Plasma dasiglucagon and glucagon concentrations 0-90 min from dosing: AUC0-30min, AUC0-90 
min, Cmax, and tmax will be summarized with descriptive statistics. 
Plasma glucose profiles 0-90 min from dosing: AUE0-30min, AUE0-90 min, CEmax, and tmax will be 
summarized with descriptive statistics. 
Achieving a plasma glucose increase of ≥20 mg/dL (1.1 mmol/mL) within 30 minutes post-
treatment will be summarized with descriptive statistics. 
10.1.5 Safety data 
Clinical laboratory data 
Clinical laboratory test results will be marked whether the result is below, within or above the 
respective reference range. The number of values outside of the reference range will be 
counted. 
Adverse events 
Adverse events will be tabulated by system organ class (SOC) and preferred term (PT) after 
medical coding using the Medical Dictionary for Regulatory Activities (MedDRA). AE summary 
tables will include counts and percentages of patients who experienced adverse events 
summarized by system organ class (SOC) and preferred term (PT). 
Other safety data 
Vital signs, physical examination, ECG and local tolerability data will be summarized with 
descriptive statistics. 
10.1.6 Further data 
		
	

		
    	       
   

	 
All other data obtained in this trial and documented in the eCRF will be listed. 
10.1.7 Withdrawals, drop-outs and missing data 
In the case of drop-outs, no imputation of values for immunogenicity measurements will be 
done. Analysis is done on valid cases only i.e. no imputation technique like LOCF (last 
observation carried forward) will be applied. 
10.1.8 Baseline and center comparisons 
Demographic and other baseline characteristics will be compared. 
10.1.9 Subgroup analysis 
Subgroup analyses for the primariy endpoint (voerl ADA incidence) by gender, age, and race 
will be performed. 
10.1.10 Interim analysis 
No interim analysis is currently planned. 
10.2 Determination of sample size 
The purpose of the present trial is to generate data describing the immunogenic potential of 
dasiglucagon and GlucaGen. The ADA assays to be used in this trial are both validated, but 

 
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specific for GlucaGen and dasiglucagon, respectively,  and the performance of the assays are 
thus not directly comparable. As a consequence, a formal comparison or non-inferiority analysis 
will not be performed 
Currently, no ADA incidences have been detected in the completed clinical trials, where up to 5 
repeated doses of dasiglucagon have been administered to the same patients within a week. 
Across the two phase 1 clinical trials and a completed phase 2 PK/PD trial, a total of 141 
subjects have been exposed to dasiglucagon and no incidences of ADA development have 
been observed. The obtained data indicate that dasiglucagon has a low risk for induction of 
ADAs in the investigated settings and as a consequence  a meaningful sample size to compare 
both treatments cannot be estimated. 
The sample size is therefore based on a certain precision of the confidence interval for the 
overall ADA incidence if no events are observed, respectively to ensure a certain probability for 
observing one event. 
When no events are observed, to obtain an upper bound of 0.050 on the 90.0% confidence 
interval for the probability of such a rare event, would require a sample size of 45. Respectively, 
accepting a chance of observing at least one event of 90% and an actual probability of the event 
of 5% leads to a sample size of 45 patients completing the trial. In order to account for drop-
outs, It is expected that 112 patients in total will be randomized and treated. 

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 4 5/ 5 0 
1 1. 
Et hi c s a n d r e g ul ati o n s 
1 1. 1 I n d e p e n d e nt et hi c s c o m mitt e e s a n d c o m p et e nt a ut h oriti e s 
T h e cli ni c al tri al a ut h ori z ati o n ( C T A) gr a nt e d b y t h e c o m p et e nt a ut h orit y ( C A) a n d a f a v or a bl e 
o pi ni o n fr o m t h e r el e v a nt i n d e p e n d e nt et hi c s c o m mitt e e( s) (I E C( s)) /I n stit uti o n al R e vi e w B o ar d 
(I R B) will b e o bt ai n e d pri or t o t h e st art of t h e tri al. T h e l o c al a ut h oriti e s will b e n otifi e d a b o ut t h e 
tri al a s r e q uir e d b y l a w. 
T h e C A a n d t h e E C/I R B will b e n otifi e d a b o ut t h e e n d of t h e tri al a n d a r e p ort s u m m ari zi n g t h e 
tri al r e s ult s will b e s e nt t o t h e C A a n d t h e E C wit hi n o n e y e ar aft er t h e e n d of t h e tri al. If t h e tri al 
i s t er mi n at e d e arl y, t h e C A a n d t h e E C will b e n otifi e d wit hi n 1 5 d a y s. 
T h e I E C s a n d/ or I R B s m et t h e r e q uir e m e nt s of t h e I nt er n ati o n al C o nf er e n c e o n H ar m o ni s ati o n 
(I C H) H ar m o ni s e d Tri p artit e G ui d eli n e f or G o o d Cli ni c al Pr a cti c e ( G C P) a n d l o c al l e gi sl ati o n. 
T h e y al s o m et t h e r e q uir e m e nt s of 2 1 C F R 3 1 2. 3. 
1 1. 2 
Et hi c al c o n d u ct of t h e tri al  
T h e tri al will b e c o n d u ct e d i n a c c or d a n c e wit h t h e et hi c al pri n ci pl e s s et f ort h i n t h e D e cl ar ati o n of 
H el si n ki (i n cl u di n g a m e n d m e nt s).  
1 1. 3 
P ati e nt i nf or m ati o n a n d c o n s e nt 
Writt e n i nf or m e d c o n s e nt will b e o bt ai n e d fr o m all p ati e nt s pri or t o e ntr y i nt o t h e tri al. T h e 
i n v e sti g at or will e x pl ai n t o e a c h p ati e nt or all y a n d i n writi n g ( p ati e nt i nf or m ati o n s h e et) t h e 
n at ur e, si g nifi c a n c e, ri s k s a n d i m pli c ati o n s of t h e tri al b ef or e i n cl u si o n. I n p arti c ul ar, t h e p ati e nt s 
will b e i nf or m e d a b o ut t h e f oll o wi n g: 
•   
t h e p o s si bilit y of wit h dr a wi n g fr o m t h e cli ni c al tri al at a n y ti m e b y r e v o ki n g t h e c o n s e nt a n d 
wit h o ut a n y r e s ulti n g di s a d v a nt a g e 
•   
h o w p er s o n al a n d h e alt h-r el at e d d at a will b e c oll e ct e d a n d u s e d d uri n g t h e tri al 
•   
t h e p ati e nt m u st b e i nf or m e d t h at hi s/ h er m e di c al r e c or d s m a y b e e x a mi n e d b y a ut h ori z e d 
m o nit or s or Cli ni c al Q u alit y A s s ur a n c e a u dit or s a p p oi nt e d b y t h e S p o n s or, b y a p pr o pri at e 
I E C m e m b er s, a n d b y i n s p e ct or s fr o m r e g ul at or y a ut h oriti e s. 
All p ati e nt s will r e c ei v e a c o p y of t h e p ati e nt i nf or m ati o n s h e et a n d a c o p y of t h eir si g n e d a n d 
d at e d i nf or m e d c o n s e nt f or m.  
All p ati e nt s will b e i n s ur e d a g ai n st i nj ur y c a u s e d b y t h eir p arti ci p ati o n i n t h e tri al a c c or di n g t o 
l e g al r e q uir e m e nt s. T h e y will b e i nf or m e d a b o ut t h e i n s ur a n c e a n d t h e r e s ulti n g o bli g ati o n s o n 
t h eir p art. 
1 1. 4 
L e g al a n d r e g ul at or y r e q uir e m e nt s 
T hi s tri al will b e c arri e d o ut i n a c c or d a n c e wit h: 
•   
I C H g ui d eli n e s f or G C P, U nit e d St at e s i n v e sti g ati o n al n e w dr u g (I N D) r e g ul ati o n s ( 2 1 C F R 
3 1 2), t h e r e g ul ati o n s o n el e ctr o ni c r e c or d s a n d el e ctr o ni c si g n at ur e ( 2 1 C F R 1 1), t h e m o st 
r e c e nt g ui d eli n e s of t h e D e cl ar ati o n of H el si n ki, a n d t h e r el e v a nt l a w s a n d r e g ul ati o n s of t h e 
c o u ntr y i n w hi c h t h e tri al t a k e s pl a c e. 
•   
St a n d ar d o p er ati n g pr o c e d ur e s ( S O P s f or cli ni c al i n v e sti g ati o n a n d d o c u m e nt ati o n i n f or c e 
at S y nt er a ct H C R) 

 
Cli ni c al Tri al Pr ot o c ol, fi n al v er si o n 3 
Z P 4 2 0 7- 1 6 1 3 6 ( Z E A- D N K- 0 1 7 1 1) 
 
2 1 A u g u st 2 0 1 7  
C O N FI D E N TI A L  
P a g e 4 6/ 5 0 
1 2. Tri al a d mi ni str ati o n 
1 2. 1 
R e s p o n si biliti e s 
Z e al a n d A/ S i s t h e s p o n s or of t hi s tri al. S y nt er a ct H C R, a c o ntr a ct r e s e ar c h or g a ni z ati o n ( C R O), 
will or g a ni z e t h e p erf or m a n c e of t hi s tri al.  
A li st wit h t h e n a m e s a n d a d dr e s s e s of t h e r e s p o n si bl e i n stit uti o n s a n d p er s o n s i s pr o vi d e d i n 
A p p e n di x 1 of t hi s pr ot o c ol. 
1 2. 2 
Pr ot o c ol d e vi ati o n s 
T h e i n v e sti g at or a gr e e s t o c o n d u ct t h e tri al i n c o m pli a n c e wit h t h e pr ot o c ol. Pr o s p e cti v e pr ot o c ol 
d e vi ati o n s or w ai v er s will n ot b e gr a nt e d f or t hi s tri al. 
A n y d e vi ati o n fr o m t h e cli ni c al tri al pr ot o c ol i n t h e c o n d u ct of t h e cli ni c al tri al will b e n otifi e d t o 
t h e M o nit or o n a n o n g oi n g b a si s.  
1 2. 3 
Pr ot o c ol c h a n g e s  
A m e n d m e nt s t o t hi s tri al pr ot o c ol m a y b e m a d e f oll o wi n g t h e pr o c e d ur e s s p e cifi e d b y l o c al l a w s 
a n d r e g ul ati o n s. S u b st a nti al a m e n d m e nt s t o t hi s tri al pr ot o c ol m a y b e i m pl e m e nt e d o nl y if t h e 
a p pr o v al of t h e C A( s) a n d a f a v or a bl e o pi ni o n of t h e et hi c s c o m mitt e e( s) h a v e b e e n o bt ai n e d. 
S u b st a nti al a m e n d m e nt s t o t h e c o n d u ct of t h e cli ni c al tri al m a y ari s e fr o m c h a n g e s t o t h e 
pr ot o c ol or fr o m n e w i nf or m ati o n r el ati n g t o t h e s ci e ntifi c d o c u m e nt s i n s u p p ort of t h e tri al. 
A m e n d m e nt s t o t h e tri al ar e r e g ar d e d a s “ s u b st a nti al” w h er e t h e y ar e li k el y t o h a v e a si g nifi c a nt 
i m p a ct o n: 
•   
t h e s af et y, p h y si c al h e alt h a n d m e nt al i nt e grit y of t h e p ati e nt s; 
•   
t h e s ci e ntifi c v al u e of t h e tri al; 
•   
t h e c o n d u ct or m a n a g e m e nt of t h e tri al; or 
•   
t h e q u alit y or s af et y of a n y i n v e sti g ati o n al m e di ci n al pr o d u ct u s e d i n t h e tri al. 
If a n e w e v e nt o c c ur s r el at e d t o t h e c o n d u ct of t h e tri al or t h e d e v el o p m e nt of t h e i n v e sti g ati o n al 
pr o d u ct, w hi c h m a y aff e ct t h e s af et y of t h e p ati e nt s, t h e s p o n s or a n d t h e i n v e sti g at or will t a k e 
a p pr o pri at e s af et y m e a s ur e s t o pr ot e ct t h e p ati e nt s a g ai n st a n y i m m e di at e h a z ar d. T h e s p o n s or 
will i m m e di at el y i nf or m t h e C A( s) a n d et hi c s c o m mitt e e( s) of t h e n e w e v e nt s a n d t h e m e a s ur e s 
t a k e n. 
1 2. 4 
P u bli c ati o n of r e s ult s 
T h e ori gi n al e C R F s a n d t h e d at a g e n er at e d fr o m t h e e C R F s or ot h er wi s e o bt ai n e d d uri n g t h e 
tri al u n d er t hi s tri al pr ot o c ol will b e c o m e t h e pr o p ert y of t h e s p o n s or. P u bli c ati o n of t h e r e s ult s of 
t hi s tri al b y S y nt er a ct H C R or t h e i n v e sti g at or i s p o s si bl e o nl y aft er writt e n c o n s e nt h a s b e e n 
o bt ai n e d fr o m t h e s p o n s or. A n y m at eri al i nt e n d e d f or p u bli c ati o n will b e gi v e n t o t h e s p o n s or at 
l e a st 4 w e e k s b ef or e s u b mi s si o n f or p u bli c ati o n. T h e s p o n s or will h a v e t h e ri g ht t o c o m m e nt o n 
t h e i nt e n d e d p u bli c ati o n a n d t o t a k e a n y r e a s o n a bl e m e a s ur e s f or p at e nt pr ot e cti o n. 
1 2. 5 
Cli ni c al tri al r e p ort 
Aft er c o m pl eti o n of t h e tri al, t h e r e s ult s will b e t a b ul at e d, e v al u at e d a n d i s s u e d a s a c o m pl et e 
fi n al cli ni c al tri al r e p ort a c c or di n g t o t h e I C H- E 3 N ot e f or g ui d a n c e o n str u ct ur e a n d c o nt e nt of 
cli ni c al tri al r e p ort s.  
T h e s p o n s or will s e n d a s u m m ar y of t hi s cli ni c al tri al r e p ort t o t h e E C a n d C A wit hi n o n e y e ar 
aft er t h e e n d of t h e tri al.  

 
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12.6 Retention of trial records 
Records and documents pertaining to the conduct of the trial and the distribution of the 
investigational product (e.g. ICFs, laboratory slips, medication inventory records, and other 
pertinent information) must be retained by the Investigator according to local requirements. 
To meet regulatory requirements, the eCRF data will be electronically stored at sites. The 
CDISC ODM (see http://www.cdisc.org/ for details) will be used to store and archive all 
electronic data at the sites. Since CDISC ODM is also the source for the EDC-web-based 
system, no transcription of data is necessary. CDISC ODM is a platform-independent 
standardized data format including the complete trial metadata and audit trail. The data can be 
reviewed at a later stage using off-the-shelf tools. CDISC provides a complete CDISC ODM 
Viewer for these purposes. If needed, PDF-files can be created from the ODM file. 

 
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13. References  
1. 
Seaquist ER, Anderson J., Childs B, Cryer P, Dagogo-Jack S, Fish L, et al. Hypoglycemia 
and diabetes: a report of a workgroup of the American Diabetes Association and the 
Endocrine Society. Diabetes Care 2013; 36(5):1384-95. doi:10.2337/dc12-2480. 
2. 
American Diabetes Association Position Statement Standards of medical care in diabetes - 
2016. Diabetes Care 2016; 39(Suppl. 1):S1-S112. 
3. 
Dasiglucagon Investigator Brochure, Edition 3, 12 Dec 2016. Zealand Pharma A/S.  
4. 
Kedia N. Treatment of severe diabetic hypoglycemia with glucagon: an underutilized 
therapeutic approach. Diabetes Metab Syndr Obes 2011;4:337-46. 
5. 
UK Hypoglycaemia Study Group. Risk of hypoglycaemia in types 1 and 2 diabetes: effects 
of treatment modalities and their duration, Diabetologia 2007;50:1140–7. 
6. 
FDA. 
Guidance 
for 
Industry. 
Bioanalytical 
Method 
Validation. 
May 
2001. 
http://www.fda.gov/downloads/Drugs/Guidance/ucm070107.pdf. 
7. 
Viswanathan CT, Bansal S, Booth B, DeStefano AJ, Rose MJ, Saistad J, et al. 
Workshop/conference 
report—Quantitative 
bioanalytical 
methods 
validation 
and 
implementation: Best practices for chromatographic and ligand binding assays. AAPS J 
9(1): E30-42. doi:10.1208/aapsj0901004.  
8. 
Shankar G, Devanaryan V, Amaravadi L, Barrett YCBowsher R, Finco-Kent D, et al. 
Recommendations for the validation of immunoassays used for detection of host antibodies 
against biotechnology products. J Pharm Biomed Anal 2008; 48(5):1267-81. 
9. 
Commissioning and validation of a method for the validation of anti-ZP4207 antibodies in 
human serum. Zealand Pharma Report, Study 14-173 
10. 
Commissioning and validation of a method for the validation of anti-glucagon antibodies in 
human serum. Zealand Pharma Report, Study 14-174 
11. 
Bioagilytix Labs. Validation of an Assay to detect neutralizing Antibodies to ZP4207 by 
Measuring Cyclic Adenosine Monophosphate (cAMP) in Glucagon Receptor Transected 
Cell Line, study no. BAL-14-206-004-REP. Zealand Pharma, Study 15-039. 09 Aug 2016. 
12. 
Bioagilytix Labs. Validation of an Assay to Detect Neutralizing Antibodies to Glucagon by 
Measuring Cyclic Adenosine Monophosphate (cAMP) in a Glucagon Receptor Transfected 
Cell Line, BAL-14-206-005. Zealand Pharma, Study 15-040. 04 Jul 2016. 
13. 
SPC Novo Nordisk GlucaGen® HypoKit 1 mg powder and solvent for solution for injection. 
http://www.medicines.org.uk/emc/medicine/4258/SPC/GlucaGen+Hypokit+1+mg 
 

 
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APPENDIX 1: 
List of names and addresses 
 
Sponsor 
Zealand Pharma A/S 
Smedeland 36 
2600 Glostrup, Copenhagen 
Denmark 
 
Contract Research 
Organization (CRO) 
SynteractHCR Deutschland GmbH 
Albrechtstr. 14 
80636 Munich, Germany 
Coordinating investigator 
Thomas R. Pieber, MD 
Medical University of Graz  
Auenbruggerplatz 15 
A-8036 Graz, Austria 
 
Trial monitor 
SynteractHCR Deutschland GmbH 
Albrechtstr. 14 
80636 Munich, Germany 
 
Statistician 
 
Senior Director Biometrics EMEA 
SynteractHCR Deutschland GmbH 
Albrechtstr. 14 
80636 Munich, Germany 
 
 
Sponsor representative 
 
Clinical Project Manager  
Zealand Pharma A/S 
Smedeland 36, 2600 Glostrup, Denmark 
Tel: 
 
E-mail: 
 
Sponsor’s medical expert 
Medical OfficerZealand Pharma A/S 
Smedeland 36, 2600 Glostrup, Denmark 
Tel:
 
E-mail: 
  
 
Sponsor representative for 
pharmacovigilance 
 
PharmaLex A/S Agern Allé 24, 2970 Hørsholm, Denmark 
Tel: 
 (8 a.m. to 4 p.m.) 
 
 (outside 8 a.m. to 4 p.m.)   
Fax:  
 
E-mail: drugsafety@lindeq.com 
 
 
Clinical laboratory 
MLM Medical Labs Gmbh 
 
Dohrweg 63, 41066 Mönchengladbach, Germany 

 
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Tel: 
 
E-mail: 
 
 
 
Analytical laboratory 
(ZP4207 PK, ZP4207 ADA, 
Glucagon ADA) 
 
 
 
 
 
 
 
 
 
(ZP4207 and Glucagon Nab) 
York Bioanalytical Solutions (YBS) 
 (ZP4207 Bioanalysis)  
 (ADA analyses) 
Cedar House  
Northminster Business Park  
Northfield Lane  
York, YO26 6QR 
United Kingdom 
E-mail: 
 
E-mail: 
 
 
 
 
BioAgilytix Labs 
2300 Englert Drive 
Durham, NC 27713 
USA