The Effects of GSK2586881 on the Responses to Acute Hypoxia and Exercise
Phase: PHASE1
Conditions: Healthy Volunteers
Sponsor: GlaxoSmithKline

2016N283626_03
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The GlaxoSmithKline group of companies
204987
1
TITLE PAGE
Division: Worldwide Development
Information Type: Protocol Amendment
Title:
The effects of GSK2586881 on the responses to acute hypoxia 
and exercise
Compound Number:
GSK2586881
Development Phase:
I
Effective Date:
06-MAR-2018
Protocol Amendment Number:  03
Author (s):
 
Copyright 2018 the GlaxoSmithKline group of companies.  All rights reserved. 
Unauthorised copying or use of this information is prohibited
 
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Revision Chronology
GlaxoSmithKline 
Document Number
Date
Version
2016N283626_00
2016-SEP-23
Original
2016N283626_01
2017-FEB-24
Amendment No. 1
Additional Inclusion Criteria (Section 5.2) and Subject Stopping Criteria (Section 5.4) 
added in response to comments from BfArM.
A summary of changes is presented in Appendix 6.
2016N283626_02
2017-MAR-07
Amendment No. 2
This is a substantial protocol amendment to:

Reduce the number of participants in the study from approximately 35 healthy 
volunteers to approximately 25 healthy volunteers.
This is a non-substantial protocol amendment to:

Remove some of the exploratory biomarkers.

Add a spirometry assessment at screening.

Add a pre-dose pulse oximetry assessment.

Add continuous ECG telemetry.

Move the immunogenicity screening sample to Pre-dose in Treatment Period 1.

Remove height and weight assessments from the follow-up visit.

Clarify the sequence and priority of assessments.  

Correct typographical errors.
A summary of changes is presented in Appendix 6.
 
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2016N283626_03
2018-MAR-06
Amendment No. 3
This is a substantial protocol amendment to restart the trial following a temporary halt.  
The trial was halted following the planned interim analysis (when 10 subjects had 
completed both Treatment Periods) to allow the study team time to consider the data 
from the first part of the study (Part 1), and decide what changes would be made to the 
second part of the study (Part 2).  The study team made the following changes to the
study in Part 2:

Increasing the altitude of the hypoxia chamber (Part 1: 4000 m, and Part 2: 
5000 m).  

Changing the individual subject withdrawal criteria for oxygen saturation 
threshold during the hypoxia challenge (Part 1: below 65%; and Part 2:  below
60% persistently for >15 seconds).

Modification of the exercise challenge:  
Changing from an upright ergometer (Part 1) to a semi-recumbent ergometer 
(Part 2).  
Echo recordings taken during exercise (Part 2), rather than after exercise 
(Part 1).
Changing the workload of the exercise challenge, due to the change in chamber 
altitude (Part 1: 70% VO2 max to Part 2: 50% VO2 max).  

Modification of the echo recording procedure:  calculation of pulmonary artery 
systolic pressure (PASP) conducted after image acquisition in Part 2 (rather than 
during the recording, Part 1); and the addition of a physician ‘over-reader’ in 
Part 2 to review all echo images/calculations and provide a quality statement (not 
used in Part 1).  

Addition of an exploratory echo endpoint in Part 2 allowing estimation of 
pulmonary vascular resistance.
A summary of changes is presented in Appendix 6.
 
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MEDICAL MONITOR/SPONSOR INFORMATION PAGE
Medical Monitor/SAE Contact Information: 
Role
Name
Day Time Phone 
Number and email 
address
After-hours 
Phone/Cell/
Pager Number
Fax 
Number
Site Address
Primary
Medical 
Monitor
Gunnels 
Wood Road, 
Stevenage, 
Hertfordshire, 
SG1 2NY, UK
Secondary
Medical 
Monitor 
709 Swedeland 
Road
UW2531
King of Prussia, 
PA  19406 USA
SAE
contact
information
[Medical
monitor
as 
above]
Sponsor Legal Registered Address: 
GlaxoSmithKline Research & Development Limited
980 Great West Road
Brentford
Middlesex, TW8 9GS
UK
In some countries, the clinical trial sponsor may be the local GlaxoSmithKline Affiliate 
Company (or designee). If applicable, the details of the alternative Sponsor and contact 
person in the territory will be provided to the relevant regulatory authority as part of the 
clinical trial application.   
Regulatory Agency Identifying Number(s):  2016-002465-55
 
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INVESTIGATOR PROTOCOL AGREEMENT PAGE
For protocol 204987.
I confirm agreement to conduct the study in compliance with the protocol, as amended by 
this protocol amendment.
I acknowledge that I am responsible for overall study conduct. I agree to personally 
conduct or supervise the described study.
I agree to ensure that all associates, colleagues and employees assisting in the conduct of 
the study are informed about their obligations. Mechanisms are in place to ensure that site 
staff receives the appropriate information throughout the study. 
Investigator Name:
Investigator Address:
Investigator Phone Number:
Investigator Signature
Date
 
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TABLE OF CONTENTS
PAGE
1.
PROTOCOL SYNOPSIS FOR STUDY 204987......................................................10
2.
INTRODUCTION....................................................................................................15
2.1.
Study Rationale ..........................................................................................16
2.1.1.
Rationale for Changes to the Study following Interim 
Analysis .......................................................................................17
3.
OBJECTIVE(S) AND ENDPOINT(S) ......................................................................19
4.
STUDY DESIGN ....................................................................................................20
4.1.
Overall Design ............................................................................................20
4.2.
Treatment Arms and Duration.....................................................................20
4.2.1.
Follow Up.....................................................................................21
4.3.
Type and Number of Subjects.....................................................................21
4.4.
Design Justification.....................................................................................22
4.5.
Dose Justification........................................................................................22
4.6.
Benefit:Risk Assessment ............................................................................23
4.6.1.
Risk Assessment .........................................................................24
4.6.2.
Benefit Assessment.....................................................................26
4.6.3.
Overall Benefit:Risk Conclusion...................................................26
5.
SELECTION OF STUDY POPULATION AND WITHDRAWAL CRITERIA .............26
5.1.
Inclusion Criteria.........................................................................................26
5.2.
Exclusion Criteria........................................................................................28
5.3.
Screening/Baseline/Run-in Failures............................................................30
5.4.
Withdrawal/Stopping Criteria.......................................................................30
5.4.1.
Study Stopping Criteria................................................................31
5.4.2.
QTc Stopping Criteria ..................................................................32
5.4.3.
Liver Chemistry Stopping Criteria ................................................32
5.4.3.1.
Study Treatment Restart or Rechallenge....................33
5.5.
Subject and Study Completion....................................................................33
6.
STUDY TREATMENT ............................................................................................33
6.1.
Investigational Product and Other Study Treatment....................................33
6.2.
Treatment after the End of the Study ..........................................................34
6.2.1.
Meals and Dietary Restrictions ....................................................34
6.2.2.
Caffeine, Alcohol, and Tobacco ...................................................35
6.2.3.
Activity .........................................................................................35
6.3.
Planned Dose Adjustments.........................................................................35
6.4.
Blinding.......................................................................................................36
6.5.
Packaging and Labeling..............................................................................37
6.6.
Preparation/Handling/Storage/Accountability..............................................37
6.7.
Compliance with Study Treatment Administration.......................................37
6.8.
Treatment of Study Treatment Overdose....................................................38
6.9.
Concomitant Medications and Non-Drug Therapies....................................38
6.9.1.
Permitted Medications and Non-Drug Therapies..........................38
6.9.2.
Prohibited Medications and Non-Drug Therapies.........................38
 
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7.
STUDY ASSESSMENTS AND PROCEDURES .....................................................39
7.1.
Time and Events Table...............................................................................40
7.1.1.
Screening and Follow up .............................................................40
7.1.2.
Treatment Period 1 and 2 ............................................................42
7.2.
Safety .........................................................................................................44
7.2.1.
Adverse Events (AE) and Serious Adverse Events (SAEs)..........44
7.2.1.1.
Time period and Frequency for collecting AE 
and SAE information...................................................44
7.2.1.2.
Method of Detecting AEs and SAEs ...........................45
7.2.1.3.
Follow-up of AEs and SAEs........................................45
7.2.1.4.
Regulatory Reporting Requirements for SAEs............45
7.2.2.
Physical Exams ...........................................................................46
7.2.3.
Vital Signs....................................................................................46
7.2.4.
Electrocardiogram (ECG).............................................................46
7.2.5.
Clinical Safety Laboratory Assessments ......................................46
7.3.
Hypoxia Challenge......................................................................................47
7.3.1.
Part 1...........................................................................................47
7.3.2.
Part 2...........................................................................................48
7.4.
Exercise Challenge.....................................................................................48
7.4.1.
Part 1...........................................................................................48
7.4.2.
Part 2...........................................................................................48
7.5.
Echocardiogram..........................................................................................48
7.6.
Ventilatory parameters................................................................................49
7.7.
Pulse Oximetry ...........................................................................................49
7.8.
Telemetry....................................................................................................49
7.9.
Pharmacokinetics .......................................................................................50
7.9.1.
Blood Sample Collection..............................................................50
7.9.2.
Sample Analysis ..........................................................................50
7.10.
Biomarker(s)/Pharmacodynamic Markers ...................................................50
7.10.1.
Renin-angiotensin system biomarkers .........................................50
7.10.2.
Surfactant Protein-D and other biomarkers..................................50
7.11.
Genetics .....................................................................................................50
7.11.1.
Blood sample collection ...............................................................51
7.12.
Immunogenicity...........................................................................................51
7.12.1.
Sample collection.........................................................................51
7.12.2.
Sample analysis...........................................................................51
8.
DATA MANAGEMENT ...........................................................................................51
9.
STATISTICAL CONSIDERATIONS AND DATA ANALYSES .................................52
9.1.
Hypotheses.................................................................................................52
9.2.
Sample Size Considerations.......................................................................52
9.2.1.
Sample Size Assumptions ...........................................................52
9.2.2.
Sample Size Re-estimation..........................................................54
9.3.
Data Analysis Considerations .....................................................................55
9.3.1.
Analysis Populations....................................................................55
9.3.2.
Interim Analysis ...........................................................................56
9.3.2.1.
Part 1 .........................................................................56
9.3.2.2.
Part 2 .........................................................................60
9.3.3.
Multiple Comparisons and Multiplicity ..........................................60
9.4.
Key Elements of Analysis Plan ...................................................................60
9.4.1.
Pharmacokinetic Analyses...........................................................62
 
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10. STUDY GOVERNANCE CONSIDERATIONS........................................................62
10.1.
Posting of Information on Publicly Available Clinical Trial Registers............62
10.2.
Regulatory and Ethical Considerations, Including the Informed 
Consent Process ........................................................................................62
10.3.
Quality Control (Study Monitoring) ..............................................................63
10.4.
Quality Assurance.......................................................................................64
10.5.
Study and Site Closure ...............................................................................64
10.6.
Records Retention......................................................................................64
10.7.
Provision of Study Results to Investigators, Posting of Information 
on Publically Available Clinical Trials Registers and Publication .................65
11. REFERENCES.......................................................................................................66
12. APPENDICES........................................................................................................69
12.1.
Appendix 1: Abbreviations and Trademarks................................................69
12.2.
Appendix 2: Liver Safety Required Actions and Follow up 
Assessments ..............................................................................................72
12.3.
Appendix 3: Genetic Research ...................................................................74
12.4.
Appendix 4: Definition of and Procedures for Recording, Evaluating, 
Follow-Up and Reporting of Adverse Events...............................................77
12.4.1.
Definition of Adverse Events........................................................77
12.4.2.
Definition of Serious Adverse Events...........................................78
12.4.3.
Definition of Cardiovascular Events .............................................80
12.4.4.
Recording of AEs and SAEs ........................................................80
12.4.5.
Evaluating AEs and SAEs............................................................81
12.4.6.
Reporting of SAEs to GSK...........................................................82
12.5.
Appendix 5: Modified List of Highly Effective Methods for Avoiding 
Pregnancy and Collection of Pregnancy Information...................................84
12.5.1.
Modified List of Highly Effective Methods for Avoiding 
Pregnancy ...................................................................................84
12.5.2.
Collection of Pregnancy Information ............................................85
12.5.3.
References ..................................................................................86
12.6.
Appendix 6:  Protocol Changes...................................................................87
12.6.1.
Protocol Amendment 01 (24-Feb-2017) from Original 
Protocol  (23-Sep-2016)...............................................................87
12.6.1.1.
Summary of Changes and Rationale for 
Amendment................................................................87
12.6.1.2.
List of Specific Changes .............................................87
12.6.2.
Protocol Amendment 02 (07-Mar-2017) from Protocol 
Amendment 01 (24-Feb-2017).....................................................89
12.6.2.1.
Summary of Changes and Rationale for 
Amendment................................................................89
12.6.2.2.
List of Specific Changes .............................................89
12.6.3.
Protocol Amendment 03 (06-Mar-2018) from Protocol 
Amendment 02 (07-Mar-2017)...................................................109
12.6.3.1.
Summary of Changes and Rationale for 
Amendment..............................................................109
12.6.3.2.
List of Specific Changes ...........................................109
 
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1.
PROTOCOL SYNOPSIS FOR STUDY 204987
Rationale
The purpose of this study is to examine how GSK2586881, a recombinant human ACE2 
peptide, modulates the acute hypoxic pulmonary vasoconstriction (HPV) response in 
healthy volunteers. 
HPV is an acute physiological response that plays a fundamental role in maintaining 
optimal arterial oxygen (PaO2) levels in healthy and in pathophysiological settings, such 
as acute respiratory distress syndrome (ARDS) by facilitating re-distribution of 
pulmonary blood flow to areas of ventilated lung. The literature supports a role for the 
renin angiotensin system (RAS) in driving acute HPV and while there is a strong 
biological rationale for modulation of RAS in the treatment of ARDS patients, 
therapeutic strategies aimed at RAS may have unintended, negative consequences for 
ARDS patients if they blunt the normal HPV response and negatively impact on arterial 
oxygenation (PaO2).  Thus, from a safety (and efficacy) perspective it is important to 
understand the impact of modulation of the RAS system by GSK2586881 on the acute 
HPV response.
Protocol Changes Post Interim Analysis
An interim analysis was conducted when 10 subjects had completed both Treatment 
Periods.  Adverse Event (AE) data indicated no safety concerns, and RAS peptide data 
indicated target engagement.  However, review of pulmonary artery systolic pressure 
(PASP) data indicated that an HPV response could not consistently be detected in the first 
10 subjects who completed the study.  The study was placed on hold to allow the study 
team to consider the data from the first part of the study (Part 1), and decide what 
changes would be made to the second part of the study (Part 2).  The study team made the 
following changes to the study in Part 2:

Increasing the altitude of the hypoxia chamber (Part 1: 4000 m, and Part 2: 5000 m).  

Changing the individual subject withdrawal criteria for oxygen saturation threshold 
during the hypoxia challenge (Part 1: below 65%; and Part 2:  below 60%
persistently for >15 seconds).

Modification of the exercise challenge:  
Changing from an upright ergometer (Part 1) to a semi-recumbent ergometer 
(Part 2).  
Echo recordings taken during exercise (Part 2), rather than after exercise (Part 1).
Changing the workload of the exercise challenge, due to the change in chamber 
altitude (Part 1: 70% VO2 max to Part 2: 50% VO2 max).  

Modification of the echo recording procedure:  calculation of pulmonary artery 
systolic pressure conducted after image acquisition in Part 2 (rather than during the 
recording, Part 1); and the addition of a physician ‘over-reader’ in Part 2 to review 
all echo images/calculations and provide a quality statement (not used in Part 1).  
 
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
Addition of an exploratory echo endpoint in Part 2 allowing estimation of pulmonary 
vascular resistance (PVR).
Objective(s)/Endpoint(s)
Objectives
Endpoints
Primary

To evaluate the effect of a single IV dose of 
GSK2586881 on the HPV response in 
healthy volunteers during exercise under 
hypoxic conditions.

Change from baseline of Pulmonary Artery 
Systolic Pressure (PASP) measured via 
Echocardiography.
Secondary

To evaluate the effect of a single IV dose 
GSK2586881 on RAS peptide responses. 

Effect of GSK2586881 on baseline levels 
and changes in response to hypoxia and 
exercise of RAS peptides (e.g. Ang II, 
Ang(1-7), Ang(1-5)).

To evaluate the safety of a single IV dose of 
GSK2586881 in healthy volunteers.

Vital signs (heart rate, systolic and diastolic 
blood pressure), oxygen saturation, 12-lead 
ECGs, AEs, immunogenicity and clinical 
laboratory assessments and continuous 
pulse oximetry.

To evaluate the pharmacokinetics of a 
single IV dose of GSK2586881. 

Plasma concentrations of GSK2586881 and 
derived pharmacokinetic parameters.
Exploratory 

To evaluate the effect of a single IV dose of 
GSK2586881 on ventilatory parameters in 
healthy volunteers during exercise in 
hypoxic conditions.

Change from baseline of oxygen 
consumption (VO2), carbon dioxide 
production (CO2) and other parameters as 
data permit.

To evaluate the pharmacodynamic activity 
of a single IV dose of GSK2586881 in 
healthy volunteers during exercise in 
hypoxic conditions.

Change from baseline in Surfactant Protein-
D and/or additional analytes to be 
determined.

To evaluate Pharmacogenetics.

Evaluate I/D polymorphisms in the 
Angiotensin Converting Enzyme (ACE) 
gene and analyse the impact on Ang II (and 
possibly other RAS peptides), hypoxic 
pulmonary vasoconstriction and responses 
to GSK2586881 administration.

To evaluate the effect of a single IV dose of 
GSK2586881 on the HPV response in 
healthy volunteers under hypoxic conditions 
(and during exercise under hypoxic 
conditions).

Estimation of pulmonary vascular resistance 
(PVR) measured via Echocardiography
 
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Overall Design
The study will be single-centre, randomised, placebo-controlled and double blind
(sponsor open).  Subjects will be randomised to receive a single IV dose of GSK2586881 
or saline in a crossover design. 
A schematic of the study is shown below.  Echocardiograms (echo) approximate timings 
are indicated by bold arrows.  
Part 1:  Approximate timing of simulated altitude and echocardiogram 
measurements (black arrows) during Treatment Periods 1 and 
2
The above schematic is applicable also to Part 2 of the study, with the following 
modifications:  simulated altitude will be 5000 m, and the T3 echo will be taken 
2 minutes into the exercise challenge (rather than at the end of a 10-minute exercise 
challenge).
Treatment Groups, Randomisation Arms and Duration
The study is intended to follow a double blind (sponsor open) two-period cross-over 
design.
Treatment Group A:  matching volume of placebo, administered as a single IV dose 
Treatment Group B:  GSK2586881 0.8 mg/kg, administered as a single IV dose. 
 
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Subjects will receive both treatments during the course of the study, and will be 
randomised to one of two sequences, each of which describes the order in which those 
treatments are received:
Sequence 1:  AB: Placebo in the first period followed by GSK2586881 in the second.
Sequence 2:  BA: GSK2586881 in the first period followed by Placebo in the second.
The total study duration for each subject is expected to be a maximum of 56 days.
Type and Number of Subjects
Approximately 25 subjects will be enrolled to ensure that a minimum of 20 subjects 
complete all dosing and critical assessments. Eleven subjects were enrolled into Part 1 of 
the study (before the first interim analysis), and up to 14 subjects will be enrolled into 
Part 2 of the study. The target of 20 evaluable subjects may be revised by the sample size 
re-estimation.
If subjects prematurely discontinue the study, additional replacement subjects will not be 
recruited in order to preserve randomisation integrity.  
Analysis
This study is designed to estimate the effect of GSK2586881 relative to placebo on 
change from baseline in PASP following exercise under hypoxic conditions.  No formal 
hypothesis will be tested.  Point estimates will be calculated together with corresponding 
95% confidence intervals (or credible intervals if utilising a Bayesian framework) for the 
difference between the mean of the test treatment and the mean of the reference 
treatment.
Analysis of PASP: Statistical modelling of changes from baseline (Ti-T0) will be done 
using a Bayesian mixed effects regression model, including covariates for period, 
treatment, period baseline and subject baseline (the mean of the two period baselines).  
Subject will be included as a random effect.  An unstructured covariance structure within 
each subject-period-treatment cell will be assumed to account for repeated measurements.  
Non-informative priors will be used for the model parameters.  Posterior distributions 
will be obtained for the GSK2586881 Vs Placebo comparisons at each of the post dosing 
time-points (T1-T4).  These distributions will be used to produce several posterior 
probability statements; the most important being the probability that the change from 
baseline in PASP is reduced by the GSK2586881 at time T3.  Separate analyses will be 
performed for Part 1 and Part 2.
Oxygenation saturation will also be analysed in a similar way; although of interest is the 
posterior probability that the study drug causes (absolute) reductions in oxygenation 
saturation in excess of 5%.
An interim analysis was conducted when 10 subjects had completed Treatment Periods 1 
and 2 (Part 1), and the following data were reviewed:  PASP, oxygen saturation, 
 
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AE/SAE, and RAS peptide.  The decision was taken to continue the study with 
modifications to the protocol (Part 2).  
During Part 2 of the study, further interim analyses are planned, as follows:

Review of PASP, oxygen saturation and AE data when approximately 3 subjects 
have completed Treatment Periods 1 and 2.

Review of PASP, oxygen saturation and AE data when approximately 6 subjects 
have completed Treatment Periods 1 and 2.  This second review may not be required 
and will be dependent on data observed during the first interim review.  The timing 
of this review may be altered, as necessary, dependent on subject recruitment.  
Further interim reviews may take place, if appropriate.
 
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2.
INTRODUCTION
GSK2586881 is a purified intravenous formulation of soluble recombinant human
angiotensin converting enzyme type 2 (rhACE2), which is expressed in Chinese Hamster
Ovary cells. Angiotensin converting enzyme type 2 (ACE2) is a zinc carboxypeptidase 
involved in the Renin-Angiotensin System (RAS) that controls blood pressure, 
electrolytes, and intravascular fluid volume. A key function of ACE2 is believed to be 
the cleavage of Angiotensin II (Ang II) to Ang (1-7), which have opposing physiological 
roles. Elevated levels of Ang II are associated with vasoconstriction, inflammation, 
fibrosis, vascular leak, and sodium absorption. Ang (1-7) appears to be a counter-
regulatory protein in the RAS; associated with vasodilation, anti-proliferation, anti-
inflammation, and reduced vascular leak, as noted in Figure 1 below [Paul, 1992; Santos, 
2005; Suzuki, 2003].
Figure 1
Renin Angiotensin System
Angiotensinogen
Angiotensin I (1-10)
Angiotensin II(1-8)
Angiotensin (1-9)
Angiotensin (1-7)
Renin
ACE 1
Aldosterone
Vascular leak
Vasoconstriction
Pro-inflammatory
Pro-fibrotic/apoptotic
Sodium/water retention
ACE 1
ACE 2
ACE 2
Reduced vascular leak
Vasodilatation
Anti-inflammatory
Anti-proliferation/apoptotic
Ang II binds to two distinct receptors called AT-1 and AT-2, with the AT-1 receptor 
mediating the vasoconstrictive, proliferative and pro-inflammatory actions of Ang II. 
The function of the AT-2 receptor has not been fully elucidated. Ang (1-7) initiates its 
effects by binding to the Mas-receptor, and also acts by inhibiting the activity of the 
carboxyterminal domain of angiotensin converting enzyme (ACE), which prevents ACE 
from fully acting on its substrates Angiotensin I and bradykinin.
ACE and Angiotensin II has been implicated in the pathogenesis of acute respiratory 
distress syndrome (ARDS), and pulmonary hypertension. It has been observed that 
circulating Ang II levels and lung ACE levels are increased in humans with ARDS and 
pulmonary hypertension. It has also been shown that the DD ACE polymorphism, which 
is associated with higher ACE activity, is associated with susceptibility to development 
of lung injury and worsened outcome (mortality) in patients with ARDS [Marshall, 2002] 
and to the development of pulmonary hypertension [Abraham, 2003].
It is expected that the reduction of Ang II and simultaneous formation of Ang (1-7) 
should have positive impacts in ARDS and on pulmonary haemodynamics in patients 
with pulmonary hypertension. This dual action can be achieved by ACE2, and thus, an 
 
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enhancement of the activity of this enzyme is seen as a promising approach for the 
treatment of diseases and conditions with an imbalance of the RAS system, insufficient 
natural ACE2 activity, and pathologically elevated Ang II levels or decreased Ang (1-7), 
such as is observed in ALI/ARDS [Tom, 2001; Idell S, 1987; Santos, 2003; Wenz, 2000] 
and pulmonary hypertension [Maron, 2014].
This study will demonstrate how GSK2586881 modulates the acute HPV response in 
healthy volunteers. 
2.1.
Study Rationale
Hypoxic pulmonary vasoconstriction (HPV) is an acute physiological response that plays 
a fundamental role in maintaining optimal arterial oxygen (PaO2) levels in healthy and in 
pathophysiological settings, such as acute respiratory distress syndrome (ARDS) by 
facilitating re-distribution of pulmonary blood flow to areas of ventilated lung.  However, 
in many ARDS patients with pulmonary microvascular injury and dystonia, the normal 
HPV reflex is compromised resulting in the mismatching of perfusion (Q) and ventilation 
(VA) and formation of areas of low perfusion to ventilated alveoli (high VA/Q; 
physiological deadspace), or perfusion of alveoli with minimal or no ventilation (low 
V/Q; physiological shunt).  
The literature is conflicting as to the role of the RAS in modulating the HPV response; 
however, the majority of reports support a role for the RAS in driving acute HPV (Cargil, 
1996; Kiely, 1996). While there is a strong biological rationale for modulation of the 
RAS in the treatment of ARDS patients, therapeutic strategies aimed at RAS may have 
unintended, negative consequences for ARDS patients if they impact on PaO2 and 
produce a blunted HPV response. Surprisingly, there are scant data regarding the effect 
of RAS modulation on HPV, V-Q matching or PaO2 in healthy human volunteers.
Inhibition of the acute HPV response would be expected to promote blood flow to areas 
of poorly-ventilated lung resulting in an increase in venous admixture and a reduction in 
PaO2 levels. In the context of acute lung injury, correction of any V/Q mismatch would 
be expected to be beneficial with respect to maintaining and improving PaO2 levels. 
Conversely, inhibition of HPV by pharmacological agents might be expected to worsen 
V/Q matching and compromise PaO2 levels. Thus, from a safety (and efficacy) 
perspective it is vital to understand the impact of modulation of the RAS system on the 
acute HPV response and subsequent PaO2.
Recombinant human ACE2 (rhACE2) delivered intravenously to pigs inhibits the HPV 
response to acute hypoxic challenge assessed by inhibition of mean pulmonary artery 
pressures and pulmonary vascular resistance. There was also a strong trend to increased 
shunt with administration of rhACE2; however PaO2 was not significantly affected. The 
authors concluded that the increased shunt may not have been sufficient to result in a 
reduction in PaO2 (Kleinsasser, 2012). 
An elegant study by Wagner and colleagues demonstrated the importance of end arterial 
capillary diffusion limitations on PaO2 levels in healthy volunteers during hypoxia ± 
exercise (Torre-Bueno, 1985). Diffusion limitation made a significant contribution to 
PaO2 levels particularly under conditions where exercise and hypoxia were combined. In 
 
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addition, V/Q mismatching was suggested to increase with the combined stresses of 
exercise and hypoxia resulting in significantly more arterial oxygen desaturation than 
observed with either stressor by itself.
The main goals of this study are to examine whether GSK2586881 modulates the acute 
HPV response in healthy volunteers with a subsequent impact on O2 saturation.  Should 
the application of GSK2586881 lead to accentuated arterial oxygen desaturation, further 
clinical studies to examine the therapeutic efficacy of GSK2586881 in acute lung injury 
should be approached with caution.  Conversely, a reduction in HPV without augmented 
hypoxemia would provide supporting evidence that GSK2586881 could have a positive 
impact in patients with pulmonary hypertension.
2.1.1.
Rationale for Changes to the Study following Interim Analysis
As planned in the original protocol, an interim analysis was conducted when 10 subjects 
had completed both Treatment Periods.  Data from the first 11 subjects were reviewed, 
because Subject 
 was withdrawn during Treatment Period 1 (withdrawn due to 
dizziness – investigator considered that this was unrelated to study treatment, and was 
most likely a vasovagal response to cannulation).  
As planned, a core sub-set of the study team (as defined in Section 6.3) reviewed 
unblinded PASP, oxygen saturation, AE and RAS peptide data (RAS peptide data from 
only 5 subjects, as planned; see Section 9.3.2).  The AE data indicated no safety 
concerns:  in total, 5 AEs were reported, 1 was considered severe (as described above for 
Subject 
 and all were considered by the investigator to be unrelated to study 
treatment.  The RAS peptide data indicated target engagement.  
Review of PASP data indicated that an HPV response could not consistently be detected 
in the first 10 subjects who completed the study.  An increase in PASP at T2 and T3 
compared with baseline was not consistently observed.  A decrease in oxygen saturation 
was observed at T2 (mean ~85%) and a further decrease at T3 (mean ~82%) compared 
with ~96% at baseline (similar in both Treatment Periods).
The study was placed on hold to allow the team to consider the data from the first part of 
the study (Part 1), and decide what changes would be made to the second part of the 
study (Part 2).  The team concluded the following:

In previous studies assessing HPV in healthy volunteers, increases in PASP were 
associated with more significant oxygen desaturation (Ricart, 2005; mean oxygen 
saturation in hypoxia was 79.4%, and simultaneous hypoxia and exercise was 
63.5%).  In Part 1 of the study, the altitude of the hypoxia chamber was 4000 m.  In 
Part 2 of the study, the altitude will be increased to 5000 m in order to induce greater 
oxygen desaturation and associated increases in pulmonary pressures.

It is anticipated that increasing the altitude of the chamber from 4000 to 5000 m will 
reduce oxygen saturation to as low as 65% in some subjects (when concurrently 
exercising).  Therefore, the current individual subject withdrawal criteria of oxygen 
saturation falling below 65% during the hypoxia challenge (see Section 5.4) will be 
reduced to below 60% and a timeframe for the reduction added (persistently for >15 
seconds).  This is justified, because subjects will be continually monitored during the 
 
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challenge, and immediately removed from the chamber should oxygen saturation 
decline to the withdrawal limit.  Oxygen saturation recovery on returning to 
normoxia is very rapid.

The exercise challenge in Part 2 will be modified.  In Part 1 of the study, PASP data 
at the T3 time-point were extremely variable.  Review of the literature shows that 
any exercise-induced increase in PASP will decline to baseline extremely rapidly 
following cessation of exercise (Argiento, 2010).  This likely explains the 
unreliability of data at T3.  In Part 2, the exercise challenge will be conducted on a 
semi-recumbent ergometer, allowing acquisition of echo recordings during (rather 
than after) exercise.  The workload of the exercise challenge will be reduced (from 
70% VO2max to 50% VO2max), because of the increase in chamber altitude.  
Additionally, echo recordings will be taken within 2 minutes of starting exercise, 
rather than after exercise, based on reports that prolonged steady state exercise can 
conversely decrease pulmonary vascular pressures, due to a reduction in pulmonary 
blood volume as the systemic circulation adapts (Naeije, 2018).

In Part 2 of the study, at all time-points, the protocol for echo recordings will be 
modified with the aim of improving data quality and reliability.  The following 
changes will be made:  calculation of PASP (outlined in Section 7.4) will be 
conducted after image acquisition (rather than during the recording); the sonographer 
will aim to capture at least 5 good quality images to estimate PASP; and a physician 
‘over-reader’ process will be introduced.  PASP will be calculated by a primary 
reader (the sonographer) and all echo images/calculations will be reviewed by a 
suitably qualified physician, who will provide a quality statement.  

In Part 2 of the study, an exploratory echo endpoint has been added, which will allow
estimation of pulmonary vascular resistance (PVR).  
 
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3.
OBJECTIVE(S) AND ENDPOINT(S)
Objectives
Endpoints
Primary

To evaluate the effect of a single IV dose of 
GSK2586881 on the HPV response in 
healthy volunteers during exercise under 
hypoxic conditions.

Change from baseline of Pulmonary Artery 
Systolic Pressure (PASP) measured via 
Echocardiography.
Secondary

To evaluate the effect of a single IV dose 
GSK2586881 on RAS peptide responses. 

Effect of GSK2586881 on baseline levels 
and changes in response to hypoxia and 
exercise of RAS peptides (e.g. Ang II, 
Ang(1-7), Ang(1-5)).

To evaluate the safety of a single IV dose of 
GSK2586881 in healthy volunteers.

Vital signs (heart rate, systolic and diastolic 
blood pressure), oxygen saturation, 12-lead 
ECGs, AEs, immunogenicity and clinical 
laboratory assessments and continuous 
pulse oximetry.

To evaluate the pharmacokinetics of a 
single IV dose of GSK2586881. 

Plasma concentrations of GSK2586881 and 
derived pharmacokinetic parameters.
Exploratory 

To evaluate the effect of a single IV dose of
GSK2586881 on ventilatory parameters in 
healthy volunteers during exercise in 
hypoxic conditions.

Change from baseline of oxygen 
consumption (VO2), carbon dioxide 
production (CO2) and other parameters as 
data permit.

To evaluate the pharmacodynamic activity 
of a single IV dose of GSK2586881 in 
healthy volunteers during exercise in 
hypoxic conditions.

Change from baseline in Surfactant Protein 
(SP-D) and/or additional analytes to be 
determined.

To evaluate Pharmacogenetics.

Evaluate I/D polymorphisms in the 
Angiotensin Converting Enzyme (ACE) 
gene and analyse the impact on Ang II (and 
possibly other RAS peptides), hypoxic 
pulmonary vasoconstriction and responses 
to GSK2586881 administration.

To evaluate the effect of a single IV dose of 
GSK2586881 on the HPV response in 
healthy volunteers under hypoxic conditions 
(and during exercise under hypoxic 
conditions).

Estimation of pulmonary vascular resistance 
(PVR) measured via echocardiography.
 
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4.
STUDY DESIGN
4.1.
Overall Design
This is a single-centre, randomised, placebo-controlled and double blind (sponsor open), 
two-period crossover study in healthy subjects. 
An interim analysis was conducted when 10 subjects had completed both Treatment 
Periods (Part 1).  The study was placed on hold to allow the study team to consider the 
data from the first part of the study (Part 1).  The study will now restart, with the 
modifications described in Section 2.1.1, and the second part of the study is designated 
Part 2.
The subjects will be required to attend the unit for a screening visit, Treatment Period 1, 
Treatment Period 2 and a follow up visit.
4.2.
Treatment Arms and Duration
Figure 2
Subject participation flow
The subjects must participate in the procedures detailed in the Time and Events Table 
(Section 7.1) and the timings of the simulated altitude, exercise and echocardiograms is 
shown in Figure 3
 
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Figure 3
Part 1:  Approximate timing of simulated altitude and 
echocardiogram measurements (black arrows) during Treatment 
Periods 1 and 2
Figure 3 is applicable also to Part 2 of the study, with the following modifications:  
simulated altitude will be 5000 m, and the T3 echo will be taken 2 minutes into the 
exercise challenge (rather than at the end of a 10-minute exercise challenge).
There will be a washout period of 3–14 days between treatments to ensure biomarkers 
return to pre-challenge baseline.  Subjects then return to the site and repeat the same 
procedures as above, except that they will receive the treatment (GSK2586881 or Saline) 
that they did not receive in the first period.
4.2.1.
Follow Up
The follow-up visit will occur up to 10 days after the end of the second treatment period.  
During the visit various safety tests will be conducted (see time and events table in 
Section 7.1). 
The total study duration for each subject is expected to be a maximum of 56 days.
4.3.
Type and Number of Subjects
Approximately 25 subjects will be randomised such that approximately 20 evaluable 
subjects complete the study.  Eleven subjects were enrolled into Part 1 of the study 
(before the first interim analysis), and up to 14 subjects will be enrolled into Part 2 of the 
study. The target of 20 evaluable subjects may be revised following the sample size re-
estimation, see Section 9.2.2.
 
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If subjects prematurely discontinue the study, additional replacement subjects will not be 
recruited in order to preserve randomisation integrity.
4.4.
Design Justification
The study design is based on a paper published by Ricart, 2005 and is considered to be 
feasible.  The study will provide important information on whether GSK2586881 
modulates the acute HPV response in healthy volunteers.  In addition, the study will 
include assessments of PK and PD effects of GSK2586881.  This will be achieved by 
assessing blood levels of GSK2586881 and RAS peptide responses throughout the 
duration of the hypoxia challenges.
The study will be placebo controlled (saline) so each subject can be used as their own 
control.
4.5.
Dose Justification
GSK2586881 has been studied in 21 healthy subjects as single, intravenous doses over 
30 minutes from 0.1 mg/kg to 1.2 mg/kg, and in repeated daily doses for up to six days of 
0.4 mg/kg once a day.  In addition, ARDS patients have received four doses of 
GSK2586881: 0.1 mg/kg, 0.2 mg.kg, 0.4 mg/kg and 0.8 mg/kg over a 24 hour period 
(n=5) or 0.4 mg/kg BID twice daily for 3 days (n=19). In a concluded investigator-
sponsored study in Pulmonary Arterial Hypertension (PAH) (Study 204696), 5 subjects 
have received a single dose of either 0.2 mg/kg or 0.4 mg/kg.  There were no SAEs 
associated with the infusion of GSK2586881 or reported within the 2-week period of 
study observation. There were no clinically significant changes in laboratory or vital 
signs measurements for any subject.
A population PK model for GSK2586881 was derived from data obtained in healthy 
subjects and ARDS patients and showed that the systemic PK profile was adequately 
described by a two-compartment first order elimination model and that the PK profile 
was independent of population (healthy subjects or ARDS patients).  Furthermore the 
PK/PD response (AngII) in healthy subjects and ARDS patients was consistent with a 
single direct Emax model after accounting for differences in baseline AngII 
concentrations between healthy subjects and ARDS patients.  
Based on the population PK/PD model described above, single intravenous doses of 
0.4‒1.2 mg/kg GSK2586881 are predicted to reduce elevated levels of AngII (baseline 
AngII consistent with an ARDS population) to levels consistent with that observed in 
healthy subjects for the duration of the hypoxic challenge (approx 2.25 h). The dose of 
0.8 mg/kg has been selected to ensure maximal reduction of AngII levels, whilst 
maintaining dosing volumes within acceptable limits, and will further aid the 
understanding of the PK/PD relationship for GSK2586881.
 
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4.6.
Benefit:Risk Assessment
Summaries of findings from both clinical and non-clinical studies conducted with 
GSK2586881 can be found in the Investigator’s Brochure (GlaxoSmithKline Document 
Number 2010N108777_04, 2017).  The following section outlines the risk assessment 
and mitigation strategy for this protocol:  
 
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4.6.1.
Risk Assessment
Potential Risk of Clinical Significance
Summary of Data/Rationale for Risk
Mitigation Strategy
Investigational Product (IP) [GSK2586881]
Cardiovascular risk
During preclinical testing a brief period of non-
sustained ventricular tachycardia was observed 
in one monkey receiving a dose of 20.8 
mg/kg/day.
The dose used in this study is much lower and 
well below the No observed adverse effect level
(NOAEL) for the 14 day repeat dose cynomolgus 
monkeys of 8 mg/kg/day.  
Potential Reproductive/embryofetal risks
Preclinical studies have not been performed.
Women of childbearing potential will be excluded 
from the study.
Potential for Immunogenicity
There has been no induction of an immune 
response to rhACE2 in either of the clinical 
studies to date in healthy subjects or participants 
with ARDS.
Patients will have routine monitoring of any 
immunological response that may occur.  If an 
immunological response is seen the patient will 
be asked to return for further monitoring and 
assessment(s).
Potential for rash
In study ACE114622, rash was reported more 
frequently in subjects receiving GSK2586881, 
although only one event was considered drug-
related.
Patients will be monitored for rash in the clinical 
trials.
 
 
 
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Potential Risk of Clinical Significance
Summary of Data/Rationale for Risk
Mitigation Strategy
Study Procedures
Effects of hypoxia to study subjects (light 
headiness, headaches, nausea)
The subjects will be exposed to hypoxic 
conditions for approximately 80 minutes with a 
simulated altitude of 5000 m.
The subjects will be continuously observed and 
monitored with telemetry and pulse oximetry.  
Stopping criteria are included in the protocol. 
Effects of hypoxia to staff at the clinical unit (light 
headiness, headaches, nausea)
Clinical site staff performing the assessments 
within the hypoxia chamber will potentially be 
exposed to hypoxic conditions with a simulated 
altitude of 5000 m.
All clinical staff entering the hypoxia chamber will 
be provided with an ambulatory oxygen supply.
 
 
 
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4.6.2.
Benefit Assessment
There will be no intended therapeutic clinical benefit to the subjects taking part in the 
study as it is a healthy volunteer study.  However, subjects will undergo a medical 
evaluation during screening including physical exams, ECGs and laboratory assessments 
which may provide important health information. 
By taking part in this study, the subject will be contributing to the development of 
GSK2586881 for the treatment of pulmonary hypertension and ARDS. 
4.6.3.
Overall Benefit:Risk Conclusion
The design of the study is considered low risk to the subjects and justified based on the 
work carried out by other researchers, the safety information from the nonclinical studies 
and the two previous clinical trials carried out on GSK2586881. 
5.
SELECTION OF STUDY POPULATION AND 
WITHDRAWAL CRITERIA
Specific information regarding warnings, precautions, contraindications, adverse events, 
and other pertinent information on the GSK investigational product or other study 
treatment that may impact subject eligibility is provided in the IB.
Deviations from inclusion and exclusion criteria are not allowed because they can 
potentially jeopardize the scientific integrity of the study, regulatory acceptability or 
subject safety. Therefore, adherence to the criteria as specified in the protocol is essential.
5.1.
Inclusion Criteria
A subject will be eligible for inclusion in this study only if all of the following criteria 
apply:
AGE
1. Between 18 and 40 years of age inclusive, at the time of signing the informed 
consent.
TYPE OF SUBJECT 
2. Healthy as determined by the investigator or medically qualified designee based on a 
medical evaluation including medical history, physical examination, spirometry, 
laboratory tests and cardiac monitoring.
A subject with a clinical abnormality or laboratory parameter(s) which is/are not 
specifically listed in the inclusion or exclusion criteria, outside the reference range for 
the population being studied may be included only if the investigator (in consultation 
with the Medical Monitor if required) agree and document that the finding is unlikely 
to introduce additional risk factors and will not interfere with the study procedures. 
Note:  Screened subjects with laboratory values outside of the normal range may be 
 
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TYPE OF SUBJECT 
repeated once for inclusion into the study at the discretion of the Investigator.
3. Screening echocardiogram of good quality, without clinically significant 
abnormalities, and with mild-moderate tricuspid regurgitation sufficient for the 
reliable estimation of PASP, as determined by the echocardiography core laboratory 
or responsible cardiologist.
Screening PASP within the normal range according to site standards.
4. Subjects have not resided at an altitude >1500 m for more than 7 days in the last 
4 months. 
5. Able to complete all study procedures.
6. Any contraindication (orthopaedic, cardiac etc.) to perform exercise on a bicycle 
ergometer.
WEIGHT
7. Body weight 50‒100 kg (inclusive).
SEX
8. Male or female (non child bearing potential)
Male subjects with female partners of child bearing potential must comply with the 
following contraception requirements from the time of first dose of study medication 
until at least five half-lives of study medication OR for a cycle of spermatogenesis 
following five terminal half-lives after the last dose of study medication.
a. Vasectomy with documentation of azoospermia.  
b. Male condom plus partner use of one of the contraceptive options below:

Contraceptive subdermal implant 

Intrauterine device or intrauterine system 

Oral Contraceptive, either combined or progestogen alone [Hatcher, 2007a] 
Injectable progestogen [Hatcher, 2007a]

Contraceptive vaginal ring [Hatcher, 2007a]

Percutaneous contraceptive patches [Hatcher, 2007a]
This is an all-inclusive list of those methods that meet the following GSK definition of 
highly effective: having a failure rate of less than 1% per year when used consistently and 
correctly and, when applicable, in accordance with the product label. For non-product 
methods (e.g. male sterility), the investigator determines what is consistent and correct 
use. The GSK definition is based on the definition provided by the International 
Conference on Harmonization (ICH) [ICH M3 (R2), 2009].
The investigator is responsible for ensuring that subjects understand how to properly use 
 
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SEX
these methods of contraception.
Females: 
A female subject is eligible to participate if she is not pregnant (as confirmed by a 
negative urine human chorionic gonadotrophin (hCG) test), not lactating, and the 
following condition applies:
Non-reproductive potential defined as:

Pre-menopausal females with one of the following:

Documented tubal ligation

Documented hysteroscopic tubal occlusion procedure with follow-up 
confirmation of bilateral tubal occlusion 

Hysterectomy

Documented Bilateral Oophorectomy

Postmenopausal defined as 12 months of spontaneous amenorrhea [in 
questionable cases a blood sample with simultaneous follicle stimulating 
hormone (FSH) and estradiol levels consistent with menopause (refer to 
laboratory reference ranges for confirmatory levels)].  Females on hormone 
replacement therapy (HRT) and whose menopausal status is in doubt will be 
required to use one of the highly effective contraception methods if they wish to 
continue their HRT during the study.  Otherwise, they must discontinue HRT to 
allow confirmation of post-menopausal status prior to study enrolment.
INFORMED CONSENT
9. Capable of giving signed informed consent as described in Section 7.2, which 
includes compliance with the requirements and restrictions listed in the consent form 
and in this protocol.
5.2.
Exclusion Criteria
A subject will not be eligible for inclusion in this study if any of the following criteria 
apply:
CONCURRENT CONDITIONS/MEDICAL HISTORY (INCLUDES LIVER 
FUNCTION AND QTc INTERVAL) 
1. ALT >1.5x Upper limit of normal (ULN).
2. Bilirubin >1.5xULN (isolated bilirubin >1.5xULN is acceptable if bilirubin is 
fractionated and direct bilirubin <35%).
3. Current or chronic history of liver disease, or known hepatic or biliary abnormalities 
(with the exception of Gilbert's syndrome or asymptomatic gallstones).
 
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CONCURRENT CONDITIONS/MEDICAL HISTORY (INCLUDES LIVER 
FUNCTION AND QTc INTERVAL) 
4. Prior history of altitude sickness.
5. Recently been scuba diving (within 1 week before screening).
6. QTc > 450 msec
NOTES:
The QTc is the QT interval corrected for heart rate according to Bazett’s formula 
(QTcB), Fridericia’s formula (QTcF), and/or another method, machine-read or 
manually over-read.
The specific formula that will be used to determine eligibility and discontinuation 
for an individual subject should be determined prior to initiation of the study. In 
other words, several different formulae cannot be used to calculate the QTc for 
an individual subject and then the lowest QTc value used to include or 
discontinue the subject from the trial.
For purposes of data analysis, QTcB, QTcF, another QT correction formula, or a 
composite of available values of QTc will be used as specified in the Reporting 
and Analysis Plan (RAP).
CONCOMITANT MEDICATIONS
7.
Unable to refrain from prescription or non-prescription drugs, including agents active 
in the central nervous system, vitamins, herbal and dietary supplements (including St 
John’s Wort) within 7 days (or 14 days if the drug is a potential enzyme inducer) or 5 
half-lives (whichever is longer) prior to the first dose of study medication and 
throughout the study, unless in the opinion of the Investigator and/or GSK Medical 
Monitor (if needed) the medication will not interfere with the study procedures or 
compromise subject safety.
RELEVANT HABITS
8.
History of regular alcohol consumption within 6 months of the study defined as:
An average weekly intake of >21 units for males or >14 units for females. One 
unit is equivalent to 8 g of alcohol: a half-pint (~240 mL) of beer, 1 glass 
(125 mL) of wine or 1 (25 mL) measure of spirits.
9.
Urinary cotinine levels indicative of smoking or history or regular use of tobacco- or 
nicotine-containing products within 6 months prior to screening.
CONTRAINDICATIONS 
10. History of sensitivity to any of the study medications, or components thereof or a 
history of drug or other allergy that, in the opinion of the investigator or Medical 
Monitor, contraindicates their participation.
 
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DIAGNOSTIC ASSESSMENTS AND OTHER CRITERIA
11. Presence of hepatitis B surface antigen (HBsAg), positive hepatitis C antibody test
result at screening or within 3 months prior to first dose of study treatment. For 
potent immunosuppressive agents, subjects with presence of hepatitis B core antibody
(HBcAb) should also be excluded.
12. A positive pre-study drug/alcohol screen.
13. A positive test for HIV antibody.
14. Where participation in the study would result in donation of blood or blood products
in excess of 500 mL within 56 days.
15. The subject has participated in a clinical trial and has received an investigational
product within the following time period prior to the first dosing day in the current
study: 30 days, 5 half-lives or twice the duration of the biological effect of the
investigational product (whichever is longer).
16. Exposure to more than four new chemical entities within 12 months prior to the first 
dosing day.
5.3.
Screening/Baseline/Run-in Failures
Screen failures are defined as subjects who consent to participate in the clinical trial but 
are never subsequently randomised. In order to ensure transparent reporting of screen 
failure subjects, meet the Consolidated Standards of Reporting Trials (CONSORT) 
publishing requirements, and respond to queries from Regulatory authorities, a minimal 
set of screen failure information is required including Demography, Screen Failure 
details, Eligibility Criteria, and Serious Adverse Events (Section 7.2.1.4).
Subjects that are not enrolled into the study within the allotted screening window may be 
re-screened once. If re-screening is performed, subjects are assigned a different unique 
subject Identification (ID) number for the re-screening, and all screening procedures must 
be repeated.
See the Study Reference Manual (SRM) for specific details.
5.4.
Withdrawal/Stopping Criteria
Subjects may be withdrawn from the study for any of the following reasons: 

A subject may withdraw from study treatment at any time at his/her own request, or 
may be withdrawn at any time at the discretion of the investigator for safety, 
behavioural or administrative reasons. If a subject withdraws from the study, he/she 
may request destruction of any samples taken, and the investigator must document 
this in the site study records. 

If a subject’s oxygen saturation falls below 60% (persistently for >15 seconds) at any 
point during the hypoxia challenge. 
 
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
If the subject experiences worsening shortness of breath or other symptoms, which in 
the opinion of the investigator are consistent with altitude sickness.

The Sponsor may request a subject withdraw for reasons such as significant protocol 
deviations (after discussion with the investigator).

Study is terminated by the Sponsor.
A subject will be considered to have prematurely withdrawn from the investigational 
product if they do not complete all doses in the treatment phase having received the first 
dose of investigational product, for any reason.
Once a subject has discontinued investigational product the subject may not re-enter the 
study. Dosing of the subjects with the investigational product may be stopped at any 
time, at the request of the subject or at the discretion of the Investigator (i.e. if clinically 
significant adverse events should occur). Withdrawal due to adverse events will be 
distinguished from withdrawal for other reasons.
If a subject decides to withdraw or is withdrawn by the Investigator, the reasons for 
withdrawal and the results of any relevant tests will be recorded in the Case Report Form 
(CRF) and the planned follow-up procedures will be performed, where possible.
The following actions must be taken in relation to a subject who fails to attend the clinic 
for a required study visit:

The site must attempt to contact the subject and re-schedule the missed visit as soon 
as possible. 

The site must counsel the subject on the importance of maintaining the assigned visit 
schedule and ascertain whether or not the subject wishes to and/or should continue in 
the study. 

In cases where the subject is deemed ‘lost to follow up’, the investigator or designee 
must make every effort to regain contact with the subject (where possible, 3 
telephone calls and if necessary a certified letter to the subject’s last known mailing 
address or local equivalent methods). These contact attempts should be documented 
in the subject’s medical record. 

Should the subject continue to be unreachable, only then will he/she be considered to 
have withdrawn from the study with a primary reason of “Lost to Follow-up”.
5.4.1.
Study Stopping Criteria
An interim analysis was conducted when 10 subjects had completed both Treatment 
Periods (Part 1).  The study team decided to continue the study (Part 2), with 
modifications to the protocol (see Section 2.1.1).  In Part 2, an interim analysis will be 
conducted when approximately 3 subjects complete both Treatment Periods, and further 
interim analyses may be conducted (see Section 9.3.2).  The study may be stopped if 
PASP results are highly variable, or if the PASP profile for the placebo group is not as 
expected (indicative of the model not working given the alterations to the study) or if 
review of the safety data suggest a change in benefit-risk profile. The decision to stop the 
study will be made by the core members of the GSK study team.
 
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Safety data that is collected on a continuous basis (oxygen saturation and telemetry) will 
be monitored live on site to determine whether a subject tolerates the hypoxia/exercise 
challenge; study procedures may be aborted on safety grounds if, in the Investigator's 
opinion, any of these measurements reach unsafe levels.  The simulated altitude within 
the chamber may be reduced if too many participants fail to tolerate the challenge, and 
the study may be stopped if participants fail to tolerate the challenge at the minimum 
altitude.  The full criteria for this procedure (which may lead to the study being stopped) 
are described in Section 7.3.
5.4.2.
QTc Stopping Criteria
The same QT correction formula must be used for each individual subject to determine 
discontinuation from the study.  For example, if a subject is eligible for the protocol 
based on QTcB, then QTcB must be used for discontinuation of this individual subject as 
well.
A subject that meets either bulleted criterion below will be withdrawn from the study.

QTcB or QTcF > 500 msec,

Change from baseline: QTc >60 msec
The QTc should be based on single or averaged QTc values of triplicate ECGs obtained 
over a brief (e.g. 5-10 minute) recording period.
5.4.3.
Liver Chemistry Stopping Criteria
Liver chemistry stopping and increased monitoring criteria have been designed to 
assure subject safety and evaluate liver event etiology (in alignment with the Food and 
Drug Administration (FDA) premarketing clinical liver safety guidance). 
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guid
ances/UCM174090.pdf
Study treatment will be discontinued for a subject if liver chemistry stopping criteria are
met.
 
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Phase I Liver Chemistry Stopping Criteria – Liver Stopping Event Algorithm
Continue Study Treatment 
Discontinue Study Treatment 
*INR value not applicable to subjects on anticoagulants 
ALT ≥3xULN 
No
Yes
Must refer to Liver Safety Required Actions and Follow up Assessments  section in the Appendix
Report as an SAE if possible Hy’s Law case: ALT≥3xULN and  Bilirubin≥2xULN (>35% direct)  or 
INR>1.5, if measured*
Liver Safety Required Actions and Follow up Assessments Section can be found in
Appendix 2.
5.4.3.1.
Study Treatment Restart or Rechallenge
Study treatment restart or rechallenge after liver chemistry stopping criteria are met by 
any subject participating in this study is not allowed.
5.5.
Subject and Study Completion
A completed subject is one who has completed all phases of the study including the 
follow-up visit.
The end of the study is defined as the last subject’s last visit.
6.
STUDY TREATMENT
6.1.
Investigational Product and Other Study Treatment
The term ‘study treatment’ is used throughout the protocol to describe any combination 
of products received by the subject as per the protocol design. Study treatment may 
therefore refer to the individual study treatments or the combination of those study 
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Study Treatment
Product name:
(Generic name and trade)
GSK2586881
Placebo
Formulation description:
rhACE2
Normal Saline (0.9%)
Dosage form:
IV
IV
Unit dose strength(s)/Dosage 
level(s):
0.8 mg/kg
Saline Placebo
Route of Administration
Intravenous
Intravenous
Dosing instructions:
Infuse over 3-5 minutes
Infuse over 3-5 minutes
Physical description:
Clear colourless liquid 
Clear colourless liquid
At Screening a unique Subject Number (CRF number) will be assigned to any subject 
who has at least one Screening procedure performed, other than informed consent.  The 
unique Subject Number will be used to identify individual subjects during the course of 
the study.
Subjects who meet screening eligibility criteria will be assigned to one of the sequences 
listed in Table 1 below, in accordance with the randomisation schedule generated by 
Clinical Statistics, prior to the start of the study, using validated internal software. Once 
assigned, this number must not be reassigned to any other subject in the study.
Table 1
Description of sequences
Sequence
Period 1 
Period 2
AB
Saline Placebo
GSK2586881
BA
GSK2586881
Saline Placebo
The subjects will be randomised using a central randomisation procedure created by 
GSK. 
Further details on how and when a subject is allocated a randomisation number and the 
subject numbering convention is in the SRM.
6.2.
Treatment after the End of the Study
Subjects will not receive any additional treatment from GSK after completion of the 
study because only healthy volunteers are eligible for study participation.
6.2.1.
Meals and Dietary Restrictions

No dietary restrictions prior to the first treatment period.
 
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6.2.2.
Caffeine, Alcohol, and Tobacco

During each dosing session, subjects will abstain from caffeine for 12 hours prior to 
the start of dosing until collection of the final pharmacokinetic and or 
pharmacodynamic sample during each session. 

During each dosing session, subjects will abstain from alcohol for 12 hours prior to 
the start of dosing until collection of the final pharmacokinetic and or 
pharmacodynamic sample during each session. 

Use of tobacco products is not allowed as outlined in the exclusion criteria. 
6.2.3.
Activity
Subjects will abstain from strenuous exercise for 24 hours prior to screening and each 
treatment period  Subjects may participate in light recreational activities between the 
planned study procedures (e.g., watch television, read).
6.3.
Planned Dose Adjustments
No dose adjustments are allowed.
 
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6.4.
Blinding
This will be double blind (sponsor open) study.  All study staff involved in clinical 
assessments (which includes the investigator, sub-investigators, other site staff), and the 
subject will be blinded to the treatment allocated to individual subjects.  An unblinded 
qualified staff member will be required at site to prepare the study treatment for dosing.  
The unblinded staff member is not permitted to communicate the subject’s treatment 
allocation to blinded site staff.  Selected study team members working for the sponsor 
(and delegates if programming activities are outsourced) will be unblinded to perform the 
interim analysis.  This will include the medical monitor, study statistician, study 
programmer (and delegates) and study pharmacokineticist.  Access to unblinded data will 
be kept to the minimum set of individuals required to implement any interim analyses but 
may include GSK management/review committees if alterations to the study conduct are 
required.  Details of who were unblinded to what data and when will be included in the 
clinical study report.
The following will apply: 

The investigator or treating physician may unblind a subject’s treatment 
assignment only in the case of an emergency OR in the event of a serious 
medical condition when knowledge of the study treatment is essential for the 
appropriate clinical management or welfare of the subject as judged by the 
investigator. 

Investigators have direct access to the subject’s individual study treatment. 

It is preferred (but not required) that the investigator first contacts the Medical 
Monitor or appropriate GSK study personnel to discuss options before unblinding 
the subject’s treatment assignment. 

If GSK personnel are not contacted before the unblinding, the investigator must 
notify GSK as soon as possible after unblinding, but without revealing the 
treatment assignment of the unblinded subject, unless that information is 
important for the safety of subjects currently in the study. 

The date and reason for the unblinding must be fully documented in the  CRF 
A subject whose treatment sequence assignment is unblinded for emergency reasons (as 
described above) will not be permitted to continue in the study (due to the emergency 
requiring unblinding rather than the unblinding itself).  The event or condition that led to 
the unblinding will be recorded in the CRF as the primary reason for discontinuation.
A subject whose treatment sequence assignment is inadvertently unblinded (either to 
investigative staff or the subject themselves) will be permitted to remain in the study, 
although the accidental unblinding will be recorded as a protocol deviation and hence the 
subject will be subject to review as to their inclusion in analyses as per the procedures set 
out in Section 9.3.1.
 
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6.5.
Packaging and Labeling
The contents of the label will be in accordance with all applicable regulatory 
requirements.
6.6.
Preparation/Handling/Storage/Accountability
A description of the methods and materials required for GSK2586881 will be detailed in 
a Study Specific Technical Agreement/Memo (TTS) or Pharmacy Section of the SRM, 
which will be accompanied by a Quality Agreement.

The investigator or designee must confirm appropriate temperature conditions 
have been maintained during transit for all study treatment received and any 
discrepancies are reported and resolved before use of the study treatment.

Only subjects enrolled in the study may receive study treatment and only 
authorized site staff may supply or administer study treatment.  All study 
treatments must be stored in a secure environmentally controlled and monitored 
(manual or automated) area in accordance with the labelled storage conditions 
with access limited to the investigator and authorized site staff. 

The investigator, institution, or the head of the medical institution (where 
applicable) is responsible for study treatment accountability, reconciliation, and 
record maintenance (i.e. receipt, reconciliation and final disposition records).  

Further guidance and information for final disposition of unused study treatment 
are provided in the SRM. 

Under normal conditions of handling and administration, study treatment is not 
expected to pose significant safety risks to site staff.  Take adequate precautions to 
avoid direct eye or skin contact and the generation of aerosols or mists. In the 
case of unintentional occupational exposure notify the monitor, Medical Monitor 
and/or GSK study contact.

A Material Safety Data Sheet (MSDS)/equivalent document describing 
occupational hazards and recommended handling precautions either will be 
provided to the investigator, where this is required by local laws, or is available 
upon request from GSK.
6.7.
Compliance with Study Treatment Administration
When the individual dose for a subject is prepared from a bulk supply, the preparation of 
the dose will be confirmed by a second member of the study site staff. 
Subjects will be dosed at the site, and they will receive study treatment directly from the 
investigator or designee, under medical supervision.  The date and time of each dose 
administered in the clinic will be recorded in the source documents.  The dose of study 
treatment and study subject identification will be confirmed at the time of dosing by a 
member of the study site staff other than the person administering the study treatment.  
 
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GSK2586881 and the saline placebo will be intravenously administered to subjects at the 
site.  Administration will be documented in the source documents and reported in the 
CRF.
6.8.
Treatment of Study Treatment Overdose
For this study, any dose of GSK2586881 > 1.5 mg/kg within a 24 hour time period will 
be considered an overdose.
GSK does not recommend specific treatment for an overdose. The investigator will use 
clinical judgment to treat any overdose.
In the event of an overdose the investigator or treating physician should:
1.
contact the Medical Monitor immediately
2.
closely monitor the subject for adverse events (AEs)/serious adverse events (SAEs) 
and laboratory abnormalities until GSK2586881can no longer be detected 
systemically (at least 3 days for GSK2586881).
3.
obtain a plasma sample for pharmacokinetic (PK) analysis within 1 day from the date 
of the last dose of study treatment if requested by the Medical Monitor (determined 
on a case-by-case basis).
4.
document the quantity of the excess dose as well as the duration of the overdosing in 
the CRF.
Decisions regarding dose interruptions or modifications will be made by the investigator 
in consultation with the Medical Monitor based on the clinical evaluation of the subject.
6.9.
Concomitant Medications and Non-Drug Therapies
6.9.1.
Permitted Medications and Non-Drug Therapies
Paracetamol, at doses of 2 grams/day is permitted for use any time during the study. 
Other concomitant medication may be considered on a case by case basis by the 
investigator in consultation with the Medical Monitor if required.
6.9.2.
Prohibited Medications and Non-Drug Therapies
Subjects must abstain from taking prescription or non-prescription drugs (including 
vitamins and dietary or herbal supplements), within 7 days (or 14 days if the drug is a 
potential enzyme inducer) or 5 half-lives (whichever is longer) prior to the first dose of 
study medication until completion of the follow-up visit, unless in the opinion of the 
Investigator and sponsor the medication will not interfere with the study.
 
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7.
STUDY ASSESSMENTS AND PROCEDURES
Protocol waivers or exemptions are not allowed with the exception of immediate safety 
concerns. Therefore, adherence to the study design requirements, including those 
specified in the Time and Events Table, are essential and required for study conduct.
This section lists the procedures and parameters of each planned study assessment.  The 
exact timing of each assessment is listed in the Time and Events Table Section 7.1
The following points must be noted: 

If assessments are scheduled for the same nominal time, THEN the assessments 
should occur in the following order:
1.
Ventilatory parameters
2.
Echocardiograms
3.
12-lead ECG
4.
vital signs
5.
blood draws  
Note: The timing of the assessments should allow the echocardiogram to be 
performed as close as possible to the nominal time.

The timing and number of planned study assessments, including: safety,
echocardiogram, pharmacokinetic, pharmacodynamic/biomarker or other 
assessments may be altered during the course of the study based on newly available 
data (e.g. to obtain data closer to the time of peak plasma concentrations) to ensure 
appropriate monitoring. 

The change in timing or addition of time points for any planned study assessments 
must be documented in a Note to File which is approved by the relevant GSK study 
team member and then archived in the study sponsor and site study files, but this will 
not constitute a protocol amendment. 

The Institutional Review Board (IRB)/IEC will be informed of any safety issues that 
require alteration of the safety monitoring scheme or amendment of the Informed 
Consent Form. 

No more than 500 mL of blood will be collected over the duration of the study, 
including any extra assessments that may be required.
 
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7.1.
Time and Events Table
7.1.1.
Screening and Follow up
Procedure 
Screening1
(up to 28 days prior to 
Treatment Period 1, Day 1)
Follow up
(7-10 days post 
last dose)
Notes
Informed consent
X
Inclusion and exclusion criteria
X
Demography
X
Full physical exam, including height and weight
X
X
Height and weight to be measured at screening only.  Weight at screening will 
be used for dosing calculation.
Alcohol, Drugs of Abuse, Smoking test
X
Medical history (includes substance usage 
[and family history of premature CV disease])
X
Substances: Drugs, Alcohol, tobacco
Past and current medical conditions [including 
cardiovascular medical history]
X
Serum OR urine pregnancy test (WCBP)
X
HIV, Hep B and Hep C screen
X
Laboratory assessments (include liver 
chemistries)
X
X
Non-Fasting
Immunogenicity
X
12-lead ECG
X
X
Triplicate ECG required at screening.
Vital signs
X
X
Triplicate vital signs required at screening. 
Spirometry
X
Echocardiogram
X
Concomitant Medication review 
X
X
Hypoxia chamber plus exercise 
X
Part 1:  Tolerance to 4000m for 10 mins followed by incremental exercise 
testing to determine maximum oxygen uptake (VO2max) and calculate 70% of 
VO2max (to be used for the exercise challenge during the Treatment Periods).  
Part 2:  Tolerance to 5000m for 10 mins followed by incremental exercise 
testing to determine maximum oxygen uptake (VO2max) and calculate 50% of 
VO2max (to be used for the exercise challenge during the Treatment Periods)
Pharmacogenetic sample (PGx)
X
Can be taken any time after consent has been signed. Only required once and 
is optional. 
 
 
 
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Procedure 
Screening1
(up to 28 days prior to 
Treatment Period 1, Day 1)
Follow up
(7-10 days post 
last dose)
Notes
AE/SAE review
X
X
As per timings detailed in Section 7.2.1.1
1.
Screening assessments are allowed to be conducted on more than one day
 
 
 
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7.1.2.
Treatment Period 1 and 2
Procedure
Treatment Period 1 and 2 (Washout 3-14 days)
Notes
Times relative to start 
of dosing
Hypoxic Challenge ~80 min 
(Times relative to entry to 
Chamber)
Pre-dose
0h
15 min
15-45 min
0-60 min
60 min
60-70 min
Immediately after 
exercise
On exit from 
chamber
After 30 min rest
60 min after exit 
from Chamber 
Randomisation
X
Treatment Period 1 only.  Randomisation can 
occur up to the day before the first treatment 
period
Brief physical exam 
X
Vital signs
X
X
X5
X
Immunogenicity
X
12-lead ECG
X
X
X
Echocardiogram
X
X
X
X6 below
X
Subject enters chamber
X
Subject enters chamber approximately 30 min 
after study treatment
Study Treatment (Dosing) 
X
Subject leaves chamber
X
Subject leaves chamber after the fourth 
echocardiogram, blood samples and vital signs 
have been taken.
Exercise challenge
X
Part 1:  exercise at 70% VO2 max for ~5-10 min.  
Echo conducted immediately after.
Part 2:  exercise at 50% VO2 max for 2 min.  
Echo started at 2 min into the challenge, and the 
subject continues exercising.
Ventilatory parameters
X
X
X
X
Measurements to be taken 2 min before 
echocardiograms.
 
 
 
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Procedure
Treatment Period 1 and 2 (Washout 3-14 days)
Notes
Times relative to start 
of dosing
Hypoxic Challenge ~80 min 
(Times relative to entry to 
Chamber)
Pre-dose
0h
15 min
15-45 min
0-60 min
60 min
60-70 min
Immediately after 
exercise
On exit from 
chamber
After 30 min rest
60 min after exit 
from Chamber 
Pulse Oximetry
(O2 saturation)
================================================================
Will be continuously monitored for safety. A 
measurement should be recorded at the time of 
each echocardiogram and databased.
Part 2:  when the echo is recorded during the 
exercise challenge, pulse oximetry will be 
recorded immediately prior to initiation of the 
echo at 2 minutes into exercise.
Telemetry
================================================================
Will be continuously monitored for safety.
RAS Biomarkers
X
X1
X2
X3
X2
X2
X4
X2
SP-D
X
X1
X2
X3
X2
X2
X4
X2
PK sampling
X
X1
X2
X3
X2
X2
X4
X2
AE/SAE review
============================================================
Concomitant medication review
X
1.
Take at the end of the infusion
2.
Taken immediately after echocardiogram 
3.
Immediately before entering the chamber
4.
To be taken as soon as possible after leaving chamber
5.
On this occasion ONLY, vital signs to be taken after the blood draw.
6.
In Part 2, echo at this time-point taken 2 minutes into the exercise challenge (not immediately after exercise).
 
 
 
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After written informed consent, screening assessments will be performed as outlined in 
the Time and Events Table (Section 7.1).
The following demographic parameters will be captured: year of birth, sex, race and 
ethnicity.
Medical/medication/family history will be assessed as related to the inclusion/exclusion 
criteria listed in Section 5.
Cardiovascular medical history/risk factors (as detailed in the CRF) will be assessed at 
screening.
Cardiorespiratory fitness during bicycle exercise and hypoxia tolerance will be assessed.
Procedures conducted as part of the subject’s routine clinical management (e.g. blood 
count) and obtained prior to signing of informed consent may be utilized for Screening or 
baseline purposes provided the procedure meets the protocol-defined criteria and has 
been performed in the timeframe of the study.
7.2.
Safety
Planned time points for all safety assessments are listed in the Time and Events Table 
(Section 7.1).  Additional time points for safety tests such as vital signs, physical exams 
and laboratory safety tests may be added during the course of the study based on newly 
available data to ensure appropriate safety monitoring.
7.2.1.
Adverse Events (AE) and Serious Adverse Events (SAEs)
The definitions of an AE or SAE can be found in Appendix 4.
The investigator and their designees are responsible for detecting, documenting and 
reporting events that meet the definition of an AE or SAE. 
7.2.1.1.
Time period and Frequency for collecting AE and SAE information

Any SAEs assessed as related to study participation (e.g., protocol-mandated 
procedures, invasive tests, or change in existing therapy) or related to a GSK product 
will be recorded from the time a subject consents to participate in the study up to and 
including any follow-up contact. 

AEs will be collected from the start of Study Treatment until the follow-up contact 
(see Section 7.2.1.3), at the time-points specified in the Time and Events Table 
(Section 7.1).

Medical occurrences that begin prior to the start of study treatment but after 
obtaining informed consent may be recorded on the Medical History/Current 
Medical Conditions section of the CRF.

All SAEs will be recorded and reported to GSK within 24 hours, as indicated in 
Appendix 4.
 
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
Investigators are not obligated to actively seek AEs or SAEs in former study 
subjects. However, if the investigator learns of any SAE, including a death, at any 
time after a subject has been discharged from the study, and he/she considers the 
event reasonably related to the study treatment or study participation, the investigator 
must promptly notify GSK.
NOTE: The method of recording, evaluating and assessing causality of AEs and SAEs 
plus procedures for completing and transmitting SAE reports to GSK are provided in 
Appendix 4.
7.2.1.2.
Method of Detecting AEs and SAEs
Care will be taken not to introduce bias when detecting AEs and/or SAEs. Open-ended 
and non-leading verbal questioning of the subject is the preferred method to inquire about 
AE occurrence.  Appropriate questions include:

“How are you feeling?” 

“Have you had any (other) medical problems since your last visit/contact?” 

“Have you taken any new medicines, other than those provided in this study, since 
your last visit/contact?” 
7.2.1.3.
Follow-up of AEs and SAEs
After the initial AE/SAE report, the investigator is required to proactively follow each 
subject at subsequent visits/contacts.  All SAEs will be followed until resolution, until the 
condition stabilizes, until the event is otherwise explained, or until the subject is lost to 
follow-up (as defined in Section 5.4). Further information on follow-up procedures is 
given in Appendix 4.
7.2.1.4.
Regulatory Reporting Requirements for SAEs
Prompt notification by the investigator to GSK of SAEs related to study treatment (even 
for non- interventional post-marketing studies) is essential so that legal obligations and 
ethical responsibilities towards the safety of subjects and the safety of a product under 
clinical investigation are met. 
GSK has a legal responsibility to notify both the local regulatory authority and other 
regulatory agencies about the safety of a product under clinical investigation.  GSK will 
comply with country specific regulatory requirements relating to safety reporting to the 
regulatory authority, Institutional Review Board (IRB)/Independent Ethics Committee 
(IEC) and investigators.
Investigator safety reports are prepared for suspected unexpected serious adverse 
reactions according to local regulatory requirements and GSK policy and are forwarded 
to investigators as necessary.
An investigator who receives an investigator safety report describing a SAE(s) or other 
specific safety information (e.g., summary or listing of SAEs) from GSK will file it with 
the IB and will notify the IRB/IEC, if appropriate according to local requirements.
 
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7.2.2.
Physical Exams

A complete physical examination will include, at a minimum, assessment of the 
Cardiovascular, Respiratory, Gastrointestinal and Neurological systems. Height and 
weight will also be measured and recorded, at screening only. 

A brief physical examination will include, at a minimum assessments of the skin,
lungs, cardiovascular system, and abdomen (liver and spleen).  To be carried out at 
the start of each period. 

Investigators should pay special attention to clinical signs related to previous serious 
illnesses.
7.2.3.
Vital Signs

Vital signs will be measured in semi-supine position after 5 minutes rest and will 
include temperature, systolic and diastolic blood pressure and pulse rate. 

Triplicate measurements will be taken at screening, and single measurements at other 
time-points.  The first reading should be rejected.  Second and third readings should 
be averaged to give the measurement to be recorded in the CRF.
7.2.4.
Electrocardiogram (ECG)

Triplicate 12-lead ECGs will be obtained at screening.  At all other time-points, 
single 12-lead ECGs will be obtained using an ECG machine that automatically 
calculates the heart rate and measures PR, QRS, QT, and QTc intervals.  Refer to 
Section 5.4.2 for QTc withdrawal criteria and additional QTc readings that may be 
necessary.

ECG to be measured in a semi-supine position after 5 minutes rest.

The same QT correction formula must be used for each individual subject for all QTc 
data being collected for data analysis.  Safety ECGs and other non-protocol specified 
ECGs are an exception.
7.2.5.
Clinical Safety Laboratory Assessments
All protocol required laboratory assessments, as defined in Table 2, must be conducted in 
accordance with the Protocol Time and Events Schedule. Laboratory requisition forms 
must be completed and samples must be clearly labelled. Details for the preparation and 
shipment of samples will be provided by the laboratory. Reference ranges for all safety 
parameters will be provided to the site by the laboratory responsible for the assessments.
If additional non-protocol specified laboratory assessments are performed at the 
institution’s local laboratory and result in a change in subject management or are 
considered clinically significant by the investigator (e.g., SAE or AE or dose 
modification) the results must be recorded in the CRF.
Haematology, clinical chemistry, urinalysis and additional parameters to be tested are 
listed in Table 2. 
 
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Table 2
Protocol Required Safety Laboratory Assessments
Laboratory 
Assessments
Parameters
Haematology
Platelet Count
RBC Indices:
WBC count with Differential:
RBC Count
MCV
Neutrophils
Hemoglobin
MCH
Lymphocytes
Hematocrit
Monocytes
Eosinophils
Basophils
Clinical 
Chemistry 1
BUN
Potassium
AST (SGOT)
Total and direct bilirubin
Urea
Sodium
ALT (SGPT)
Total Protein
Creatinine
Calcium
Alkaline phosphatise
Albumin
Glucose 
Routine 
Urinalysis

Specific gravity

pH, glucose, protein, blood and ketones by dipstick

Microscopic examination (if blood or protein is abnormal)
Other 
Screening 
Tests

HIV

Hepatitis B (HBsAg)

Hepatitis C (Hep C antibody)

Alcohol, smoking and drug screen (to include at minimum: 
amphetamines, barbiturates, cocaine, opiates, cannabinoids, 
benzodiazepines and cotinine) performed at site

Urine hCG Pregnancy test (as needed) 2
NOTES:
1.
Details of Liver Chemistry Stopping Criteria and Required Actions and Follow-Up 
Assessments after liver stopping or monitoring event are given in Section 5.4.2 and 
Appendix 2.
2.
Local urine testing will be standard for the protocol unless serum testing is required 
by local regulation or ethics committee.
All laboratory tests with values that are considered clinically significantly abnormal 
during participation in the study or within 3 days after the last dose of study treatment 
should be repeated until the values return to normal or baseline.  If such values do not 
return to normal within a period judged reasonable by the investigator, the etiology
should be identified and the sponsor notified.
7.3.
Hypoxia Challenge
7.3.1.
Part 1
Each subject will be inside the hypoxia chamber for approximately 80 minutes per
period, during which time they will be under the full 4000 m ± 10% hypoxic conditions.  
 
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If three or more subjects do not tolerate the hypoxic challenge, either due to symptoms or 
O2 saturation of <65%, then the simulated altitude will be adjusted in decrements of 
500 m (i.e. from 4000 m to 3500 m) for all remaining subjects to a minimum of 3000 m.
7.3.2.
Part 2
Each subject will be inside the hypoxia chamber for approximately 80 minutes per 
period, during which time they will be under the full 5000 m ± 10% hypoxic conditions.  
If three or more subjects do not tolerate the hypoxic challenge, either due to symptoms or 
O2 saturation of <60% (persistently for >15 seconds), then the simulated altitude will be 
adjusted in decrements of 500 m (i.e. from 5000 m to 4500 m) for all remaining subjects 
to a minimum of 4000 m.
Further detail about the hypoxia challenge is detailed in the SRM. 
7.4.
Exercise Challenge
7.4.1.
Part 1
Subjects will perform an exercise challenge at 70% of maximum VO2 uptake on an 
upright cycle ergometer within the hypoxia chamber for 10 minutes.
Subjects must complete a minimum of 5 minutes exercise at 70% of maximumVO2 
uptake (calculated from the incremental exhaustive exercise test at the screening visit).
7.4.2.
Part 2
Subjects will perform an exercise challenge at 50% of maximum VO2 uptake on a semi-
recumbent cycle ergometer within the hypoxia chamber (calculated from the incremental 
exhaustive exercise test at the screening visit).  Two minutes into the exercise challenge, 
the echo recording will be initiated.  The subject will exercise for a minimum of 
5 minutes (or until the echo recording is completed, if the recording exceeds 5 minutes).
Further detail about the exercise challenge is detailed in the SRM. 
7.5.
Echocardiogram
Echocardiograms will be taken as detailed in the Time and Events table (Section 7.1). 
Echocardiograms will be obtained with the subject resting supine or lying on their left 
side. In Part 2, the echo during the exercise challenge will be conducted with the subject 
on a semi-recumbent cycle ergometer tilted by 30-40 degrees.  The subject will continue 
exercising during the echo recording.
PASP will be measured and recorded.  PASP will be determined by measuring maximal 
tricuspid regurgitation velocity and applying the modified Bernoulli equation to convert 
this value into pressure values.  Estimated right atrial pressure (RAP) must be added to 
this obtained value.
 
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In Part 2, the sonographer’s priority will be to collect good quality images of the tricuspid 
regurgitation jet, allowing accurate calculation of PASP once image acquisition is 
completed.  The sonographer will aim to collect at least 5 cardiac cycles.  Once 
estimation of tricuspid regurgitation velocity is completed, the sonographer will measure 
the right ventricular outflow tract (RVOT) time velocity integral, which (along with the 
peak tricuspid regurgitant velocity) will allow an estimation of PVR (Rudski, 2010).
In Part 2, the sonographer conducting the echo will be considered the primary reader.  All 
echo images/calculations will be reviewed by a suitably qualified physician (physician 
‘over-reader’).  Any discrepancies will be discussed between the primary reader and 
physician over-reader, and an agreement reached.  The physician over-reader will provide 
a quality statement for each echo.  For the first 3 subjects in Part 2, the physician review 
will occur immediately following completion of each echo.  If quality issues are 
identified, the sonographer and physician will consider if the echo should be repeated.  If 
no echo quality issues are identified for the first 3 subjects, subsequent reviews will occur 
within a few hours.
In Part 2, when the echo recording is conducted during the exercise challenge, the 
sonographer will begin positioning the echo probe as soon as exercise is initiated.  Image 
acquisition will occur at 2 minutes into the exercise challenge.  The sonographer will aim 
to complete image acquisition within approximately 1–2 minutes.
Further details about the echo recording is detailed in the SRM. 
Additional echocardiograms may be obtained for each subject as needed (in the 
judgement of the Investigator and GSK Medical Monitor, if required).
7.6.
Ventilatory parameters
Ventilatory parameters will be measured as detailed in the Time and Events table 
(Section 7.1). 
Ventilatory parameters will be recorded for 2 minutes before echocardiograms.  The 
second minute of the recording will be averaged and used for data analysis.
Measurements may include change from baseline of oxygen consumption (VO2), carbon 
dioxide production (CO2), total tidal volume, inspiratory tidal volume, expiratory tidal 
volume, total respiratory time, inspiratory time, expiratory time, duty cycle, mean
respiratory flow and respiratory rate, as data permit.
7.7.
Pulse Oximetry
Oxygen saturation will be monitored continuously via pulse oximetry as detailed in the 
SRM.  Measurements will be taken at the same time as the echocardiograms and recorded 
in the eCRF.
7.8.
Telemetry
Continuous ECG monitoring will occur via telemetry during both treatment periods.
 
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7.9.
Pharmacokinetics
7.9.1.
Blood Sample Collection
Blood samples for pharmacokinetic (PK) analysis of GSK2586881 will be collected at 
the time points indicated in the Time and Events Table (Section 7.1).  The actual date and 
time of each blood sample collection will be recorded.  
The timing of PK samples may be altered and/or PK samples may be obtained at 
additional time points to ensure thorough PK monitoring.  
Details of PK blood sample collection (including volume to be collected), processing, 
storage and shipping procedures are provided in the SRM.
7.9.2.
Sample Analysis
Plasma analysis will be performed under the control of PTS, In Vitro/In Vivo 
Translations (IVIVT) Department and Third Party Resourcing (TPR), GlaxoSmithKline. 
The details of the Bioanalytical Laboratory will be included in the SRM. Concentrations 
of GSK2586881 will be determined in plasma samples using the currently approved 
bioanalytical methodology. Raw data will be archived at the Bioanalytical Site 
(Bioanalytical Site to be detailed in the SRM).
7.10.
Biomarker(s)/Pharmacodynamic Markers
Blood samples for biomarker/PD analysis will be collected at the time points indicated in 
the Time and Events Table (Section 7.1).  The actual date and time of each blood sample 
collection will be recorded.  The timing of biomarker/PD samples may be altered and/or 
samples may be obtained at additional time points to ensure thorough monitoring.  
Details of biomarker/PD blood sample collection (including volume to be collected), 
processing, storage and shipping procedures are provided in the SRM.
7.10.1.
Renin-angiotensin system biomarkers
RAS peptides including, but not limited to, AngII, Ang(1-7) and Ang(1-5) may be 
analysed as data permit.  Raw data will be archived at the Bioanalytical Site 
(Bioanalytical Site detailed in the SRM).  
7.10.2.
Surfactant Protein-D and other biomarkers
SP-D will be analysed.  Raw data will be archived at the Bioanalytical Site (Bioanalytical 
Site to be detailed in the SRM).  Additional analytes may be analysed, as data permit.  
7.11.
Genetics
Information regarding genetic research is included in Appendix 3.
Genetic sampling is optional.  Subjects can refuse genetic sampling, but will still be 
allowed to participate in the study. 
 
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7.11.1.
Blood sample collection
A blood sample to investigate the association between the loss of function polymorphism 
rs1799752, representing the I/D polymorphism, in intron 16 of the Angiotensin 
Converting Enzyme (ACE) gene and Ang II (and possibly other RAS peptides) and 
hypoxic pulmonary vasoconstriction will be collected as specified in the Time and Events 
Table (Section 7.1). 
Further information for blood sample collection, processing, storage and shipping 
procedures are provided in the SRM. 
Information regarding genetic research is included in Appendix 3.
7.12.
Immunogenicity
7.12.1.
Sample collection
Blood samples for immunogenicity analysis will be collected at the time points indicated 
in Section 7.1, Time and Events Table. Additional visits to obtain immunogenicity 
samples may be required in the unlikely event that subjects develop a clinically relevant 
immunoglobulin response to the drug as described in the SRM.
Details of immunogenicity blood sample collection (including volume to be collected), 
processing, storage and shipping procedures are provided in the SRM.
7.12.2.
Sample analysis
Immunogenicity analysis will be performed under the management of Clinical 
Immunology, Biopharm R&D, GlaxoSmithKline. All pre-dose and post-dose samples 
will be first tested for Anti-ACE2 binding antibodies by screening and confirmation assay 
steps. The post-dose samples tested positive for anti-ACE2 binding antibodies will be 
further characterized for anti-ACE2 neutralizing antibodies. Both positive incidences for 
anti-ACE2 binding and neutralizing antibodies will be reported.
8.
DATA MANAGEMENT

For this study subject data will be entered into GSK defined CRFs, transmitted 
electronically to GSK or designee and combined with data provided from other 
sources in a validated data system.  

Management of clinical data will be performed in accordance with applicable GSK 
standards and data cleaning procedures to ensure the integrity of the data, e.g. 
removing errors and inconsistencies in the data.

Adverse events and concomitant medications terms will be coded using MedDRA 
(Medical Dictionary for Regulatory Activities) and an internal validated medication 
dictionary, GSKDrug.  

CRFs (including queries and audit trails) will be retained by GSK, and copies will be 
sent to the investigator to maintain as the investigator copy.  Subject initials and 
 
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day/month of birth will not be collected or transmitted to GSK according to GSK 
policy.
9.
STATISTICAL CONSIDERATIONS AND DATA 
ANALYSES
9.1.
Hypotheses
The focus of this study is on the exploration of the effect of GSK2586881 on a range of 
echocardiography, pulse oximetry, biomarker, safety and PK endpoints, when subjecting 
healthy volunteers to an exercise challenge under hypoxic conditions.  No formal 
statistical hypotheses are being tested.  A Bayesian statistical analysis framework with 
non-informative priors for model parameters (unless otherwise specified) will be used to 
obtain posterior distributions for effects of interest for Part 1 and Part 2 of the study.  
These posterior distributions will be used to obtain a number of probability statements 
about the magnitude of treatment effects (e.g. Probability of any treatment related 
reduction in PASP, or Probability that the treatment related reduction in PASP 5 
mmHg).
A rule of thumb for end of “study success” is if the probability of any treatment related 
reduction in PASP (T3-T0) exceeds 0.95 (success is also conditional on the probability of 
(absolute) treatment related reductions in oxygen saturation exceeding 5%, being small).
9.2.
Sample Size Considerations
The sample size of 20 evaluable patients is based on logistical considerations and is not 
based on formal sample size calculations.  However, estimates of precision for the 
treatment difference in the primary endpoint are presented for context (Note: precision in 
this context is defined as one half of the width of the 95% confidence interval).  A sample 
size re-estimation was planned after 10 subjects, see Section 9.2.2. 
9.2.1.
Sample Size Assumptions
The precision of the primary treatment comparison (change from baseline PASP to 
hypoxic/exercise PASP) was estimated using simulation.  PASP data points were 
simulated for each subject: normoxic at rest, and hypoxic after exercise, each for two 
study periods, giving a total of four PASP measurements for each subject. The four PASP 
measurements were drawn from a multivariate normal distribution to allow for different 
levels of within-subject correlation. One simulated study with a given sample size (N) 
was created by repeating this process of generating individual subject data N times, 
randomly allocating each subject to a treatment sequence in a 1:1 ratio, and calculating 
the half-width of the confidence interval of the treatment difference in change from 
baseline in PASP from that simulated dataset (using a linear mixed effects model 
including period baseline, subject baseline, treatment and period as fixed effects, and 
subject as a random effect).  A full simulation run consisted of 1000 iterations of 
simulated studies, and a final estimate for precision was calculated as the mean precision 
across the 1000 iterations.
 
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The following assumptions were made regarding the mean and Standard Deviation (SD) 
of PASP based on data from Ricart, 2005: 

Mean PASP was 30 mmHg at baseline (i.e. normoxic and at rest) and 45 mmHg 
under hypoxia and exercise

SD of PASP was 2.81 mmHg at baseline and 4.30 mmHg under hypoxia and exercise

As the purpose of this simulation was to estimate precision by evaluating the SD of 
the treatment difference rather than the mean, there was no treatment effect assumed 
in the simulations

The within-subject correlation of PASP was unknown, therefore four different 
scenarios of within-subject correlation were evaluated: zero correlation, low 
correlation (0.3), high correlation (0.6) and very high correlation (0.9).

A range of sample sizes was considered: from 5 to 10 in increments of 1, and then up 
to 40 in increments of 5.  Table 3 below shows a subset of these; the figure includes 
them all.
Based on these assumptions, the estimated precisions for these sample sizes and under 
these scenarios of within-subject correlation were as follows (smaller number for 
precision denotes more precise estimates):
Table 3
Estimated precision of treatment comparisons of change from 
baseline in PASP (mmHg) for a range of sample sizes and within-
subject correlation scenarios
Within-subject correlation
Sample size (N)
0
0.3
0.6
0.9
10
4.35
3.83
2.92
1.48
20
2.76
2.40
1.83
0.91
30
2.22
1.91
1.46
0.72
40
1.91
1.63
1.23
0.62
Figure 4 illustrates precision estimates under the full range of sample sizes considered 
(from 5 to 40), and for all within-subject correlation scenarios. The red line at 5 mmHg is 
superimposed to indicate a rough guide to the magnitude of a clinically meaningful 
difference.
 
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Figure 4
Sensitivity of study precision to sample size and within subject 
correlation of PASP
9.2.2.
Sample Size Re-estimation
A sample size re-estimation was to be conducted at the interim analysis for Part 1 (see 
Section 9.3.2.1). The purpose of the sample size re-estimation was to determine whether 
the total number of subjects can be reduced below the anticipated 20, based on treatment 
comparison between GSK2586881 and Placebo in change from pre-dose PASP to 
hypoxic/exercised PASP (i.e. T3-T0). The sample size re-estimation was to be considered 
advisory, and taken into account together with other considerations. These were to
include:

ensuring sufficient data is collected on secondary endpoints,

non-conclusive safety data at the time of interim analysis (e.g. a weak signal of a 
reduction in oxygen saturation data that would require the full set of remaining 
subjects to be able to reach a conclusion),

speed of recruitment.
An interim analysis was conducted when 10 subjects had completed Treatment Periods 1 
and 2 (Part 1), and the following data were reviewed:  PASP, oxygen saturation, 
AE/SAE, and RAS peptide.  The decision was taken to continue the study with 
modifications to the protocol (Part 2), see Section 2.1.1.
 
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9.3.
Data Analysis Considerations
Data will be listed and summarised according to GSK integrated data standards library 
(IDSL) reporting standards where applicable.  Complete details will be provided in the 
Reporting and Analysis Plan (RAP).
The key endpoints referred to in the text below comprise PASP measured by 
echocardiography, oxygen saturation measured by continuous pulse oximetry, RAS 
peptides and safety data.
9.3.1.
Analysis Populations
All Subjects Screened Population: This population contains all subjects that complete at 
least one Visit 1 (Screening) procedure. This population will be used for the summary of 
subject disposition (including reasons for screening failures, run-in failures, and 
stabilization failures) and for the listing of AEs and SAEs for non-randomised subjects.
Modified Intent-to-Treat (mITT) Population: This population will comprise all 
randomised subjects, excluding those who were randomised in error. A subject who is 
recorded as a screen failure, but is randomised and does not receive a dose of study 
treatment, is considered to be randomised in error. Any other subject who receives a 
randomisation number will be considered to have been randomised. This will constitute 
the primary population for all safety and pharmacodynamic analyses.
Modified Intent-to-Treat (mITT1) Population Part 1: This population will include all 
subjects in the mITT population, who were randomised into Part 1 of the study (planned 
4000 m altitude).
Modified Intent-to-Treat (mITT2) Population Part 2: This population will include all 
subjects in the mITT population, who were randomised into Part 2 of the study (planned 
5000 m altitude)
Pharmacokinetic (PK) Population Part 1: This population will comprise all subjects in 
the mITT Population, randomised in Part 1 of the study, for whom a PK sample was 
obtained and analysed and on active treatment.
Pharmacokinetic (PK) Population Part 2: This population will comprise all subjects in 
the mITT Population, randomised in Part 2 of the study, for whom a PK sample was 
obtained and analysed and on active treatment.
In addition to the above populations, the effect of important protocol violations, including 
any subjects who failed the inclusion/exclusion criteria, may be assessed by means of 
sensitivity analyses. A blind review of all protocol violations will be performed prior to 
DBF in order to identify any important deviations and consequently identify any subjects 
who will be excluded from such sensitivity analyses.
 
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9.3.2.
Interim Analysis
9.3.2.1.
Part 1
The details below are in reference to the completed interim analysis for Part 1 of the 
study.  Following review of the data from Part 1, the study was modified before restarting 
Part 2.  Section 9.3.2.2 details interim plans for Part 2 of the study.
An interim analysis is planned after 10 subjects have completed the following critical 
assessments:

PASP at T0 and T3 for both study periods

Oxygen saturation at T0 and T3 for both study periods

Adverse events 
The interim analysis will use the following study data:

PASP at time T0 and T3 for both periods, for the first 10 subjects

Oxygen saturation at T0 and T3 for both periods, for the first 10 subjects

Adverse events for the first 10 subjects

RAS peptide concentrations for the first 5 subjects (to allow time for the samples 
to be analysed by the external lab).
The interim analysis will use a data snapshot that has been cleaned to the best extent 
allowed by the timeframes (i.e. the interim data will not be fully cleaned or fully QC’d 
data and there will not be a locked database).
The aims of the interim analysis, and the endpoints to be used to address them, are as 
follows:

Using the primary endpoint (treatment differences between GSK2586881 and 
Placebo in change from pre-dose PASP to hypoxic/exercised PASP [T3-T0]):
o
To decide whether to continue the study or stop based on futility, and
o
to conduct an advisory sample-size re-estimation with the view to 
potentially reduce the number of subjects participating in the study below 
20.

Using secondary endpoints:
o
to estimate treatment differences between GSK2586881 and Placebo in 
change from pre-dose oxygen saturation to hypoxic/exercised oxygen 
saturation [T3-T0], with a view to stopping the study if there is evidence 
that GSK2586881 causes a reduction in oxygen saturation in healthy 
 
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volunteers. As a non-binding guide high posterior probability of observing 
5% absolute differences in mean oxygenation saturation values between 
placebo and active arms would be of concern; but clinical judgement 
would override any statistical methods if, for example, the majority of 
subjects displayed consistent patterns of reductions e.g. between 2-3%).
o
to compare adverse events within the two treatment groups and explore 
any potential safety signals that may emerge
To assess the operating characteristics of the interim analysis decisions to be made based 
on the primary endpoint, a simulation was carried out to estimate the relative proportion 
of studies reaching conclusions to stop for futility, continue with no change to the sample 
size, and to continue with a reduced sample size, under various different scenarios of the 
true treatment effect. Broadly speaking, the aim of the simulation was to confirm that (in 
an overwhelming majority of cases) a decision to stop for futility would be reached in the 
case of no true treatment effect and a decision to continue (perhaps with reduced sample 
size) would be reached in the case of a true treatment effect.
Simulated datasets of PASP at baseline (i.e. normoxic and at rest) and under hypoxia and 
exercise for 10 subjects, each receiving both treatments in sequence, were generated 
using the following assumptions:

10 simulated subjects were randomised to one of the two available treatment 
sequences (see Section 6.2) using block randomisation with block size of 4 records

PASP at baseline and under hypoxia and exercise for both treatment groups (a total of 
four PASP measurements per subject) were sampled from a multivariate normal 
distribution, using values for mean PASP, standard deviation of PASP and within-
subject correlation of PASP as described below.

Mean PASP was 30 mmHg at baseline (i.e. normoxic and at rest) for both treatments,
and 45 mmHg under hypoxia and exercise for Placebo (as in Section 9.2.1). For 
GSK2586881, mean PASP under hypoxia and exercise was (45 - Δ) mmHg, where Δ 
(the mean treatment difference) was varied according to four different scenarios:
o
no treatment difference (Δ = 0 mmHg)
o
weak treatment difference of a magnitude of half the clinically meaningful 
difference (Δ = 2.5 mmHg)
o
minimum clinically meaningful difference (Δ = 5 mmHg)
o
overwhelming treatment difference one-and-a-half times the clinically 
meaningful difference (Δ = 7.5 mmHg)

SD of PASP was 2.81 mmHg at baseline and 4.30 mmHg under hypoxia and 
exercise, for both treatment groups (as in Section 9.2.1) 
 
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
The within-subject correlation of PASP was unknown, therefore four different 
scenarios of within-subject correlation were evaluated: zero correlation, low 
correlation (0.3), high correlation (0.6) and very high correlation (0.9) (as in Section 
9.2.1). Within-subject correlation of PASP was assumed to be compound symmetric 
(i.e. the same correlation was used for each of the six possible pairs of the four PASP 
measurements within each subject).

It was assumed that there would be no effect of period in the simulation, i.e. it was 
assumed that it would make no difference if the measurement was taken from the first 
or second chronological period in the treatment sequence.
Modelling took on a three-step process, with decisions after each. Firstly, the treatment 
difference and its associated standard error was then estimated for the dataset of 10 
simulated subjects using a mixed effects linear regression model, including covariates for 
period, treatment, period baseline and subject baseline (the mean of the two period 
baselines) as fixed effects and subject as a random effect. If the sign of treatment 
difference arising from the simulated data was in the wrong direction (i.e. the simulated 
outcome for GSK2586881 was worse than for Placebo), then the simulated study was 
stopped for futility.
Secondly, in the alternative case that the simulated treatment difference was in favour of 
GSK2586881 over Placebo, a posterior probability of success (where success was defined 
as a 97.5% posterior probability of the treatment difference being in favour of 
GSK2586881 over Placebo) was evaluated for 20 subjects. This was evaluated using a t-
distribution, with the mean and standard deviation taken as the treatment difference and 
standard error (multiplied by a factor of the square root of 10 to estimate the standard 
deviation) from step one, respectively.  If this posterior probability was less than 0.2, then 
the study was stopped for futility as being unlikely to show any benefit of GSK2586881 
over Placebo.
Thirdly, provided that the simulated study hadn't been stopped for futility in either of the 
first two steps, posterior probabilities of success were calculated for N ranging from 10 to 
19 subjects. If any of these posterior probabilities of success were greater than or equal to 
0.9, then the study was continued with a reduced sample size equal to the lowest N at 
which that threshold was reached. Otherwise, the conclusion from the simulated interim 
analysis would be to continue the study with unchanged sample size.
This whole process (simulating data for 10 subjects, modelling the treatment difference, 
evaluating posterior probabilities of success and simulating the decision-making process) 
was replicated 10000 times for each scenario, with the decision ("futile", "no change to 
N" or "reduce N") recorded for each iteration. Each combination of the four treatment 
difference scenarios and the four correlation scenarios was evaluated for a total of 16 
scenarios in all.
The estimated proportions of each decision being reached under each of the 16 scenarios 
are presented in Table 4.
 
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Table 4
Operating characteristics of interim analysis at N=10 under four 
scenarios of treatment effect and four scenarios of within-subject 
correlation
Frequency of decisions (%)
Treatment 
effect 
Scenario
Within-subject 
correlation of PASP
Futile
Continue with 20 
subjects
Continue with 
reduced sample 
size
Δ=0 mmHg (no treatment difference)
0.0
85%
15%
1%
0.3
85%
15%
1%
0.6
85%
15%
1%
0.9
85%
14%
1%
Δ=2.5 mmHg (weak treatment effect, less than clinically meaningful difference)
0.0
44%
50%
6%
0.3
36%
56%
9%
0.6
21%
63%
16%
0.9
1%
31%
68%
Δ=5 mmHg (good treatment effect, at threshold of clinical meaningful difference)
0.0
9%
60%
31%
0.3
4%
54%
42%
0.6
1%
31%
68%
0.9
0%
0%
100%
Δ=7.5 mmHg (very strong treatment effect)
0.0
1%
32%
67%
0.3
0%
18%
82%
0.6
0%
3%
96%
0.9
0%
0%
100%
These results suggest primarily that if there is no true treatment difference between 
GSK2586881 and Placebo, the study would be stopped for futility 85% of the time 
(irrespective of within-subject correlation of PASP). A drug with a weak treatment effect 
would most likely result in the study being continued without change or stopped for 
futility (except in the case where within-subject correlation is 0.9, which is presented here 
as an extreme case, unlikely to occur in practice). If the true treatment effect is at the 
clinically relevant threshold of 5 mmHg, then the study is unlikely to be stopped for 
futility and may indicate being reduced in sample size.
Secondarily, it should be noted that the higher the within-subject correlation, then the 
higher the probability of success. This is because the more correlation there is in 
measurements within the same individual, the less variability there will be in change from 
baseline. Results for correlations of 0.0 and 0.9 are presented as extreme cases unlikely to 
occur in practice, though the exact strength of within-subject correlation of PASP 
(particularly under different stressed conditions) is not known.
Full details of the interim analysis will be supplied in the RAP.
 
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9.3.2.2.
Part 2
Part 2 of the study will be based on modifications as detailed in Section 2.1.1.  Two 
interim analysis reviews are planned when approximately 3 and 6 subjects, respectively 
have completed treatment periods 1 and 2.  
The aims of the interim analyses are to assess the effectiveness of the Part 2 
modifications on critical assessments (PASP, oxygen saturation and AEs) and the 
potential benefit/risk impact on subjects.  
At each review, the study may be stopped for futility if PASP results are highly variable, 
or if the PASP profile for the placebo group is not as expected (indicative of the model 
not working given the alterations to the study) or if review of the safety data suggests a 
change in the benefit-risk profile.  If clear criteria for stopping the study are not met, the 
study will continue to the next interim analysis review, or on to the planned maximum 
number of evaluable subjects.
If data suggest a further interim analysis review of data would be beneficial, then this will 
be documented.
Interim analysis reviews are planned as follows:
1. Review of PASP, oxygen saturation and AE data when approximately 3 subjects 
have completed Treatment Periods 1 and 2.  Critical timepoints for PASP and 
oxygen saturation are T0 and T3 (a review of additional timepoints will also take 
place)
2. Review of PASP, oxygen saturation and AE data when approximately 6 subjects 
have completed Treatment Periods 1 and 2.  Critical timepoints for PASP and 
oxygen saturation are T0 and T3 (a review of additional timepoints will also take 
place).  Note that this second review may not be required and will be dependent 
on data observed during the first interim review.  The timing of this review may 
be altered as necessary dependent on subject recruitment.
Each interim analysis will use a data snapshot that has been cleaned to the best extent 
allowed by the timeframes (i.e. the interim data will not be fully cleaned or fully QC’d 
data and there will not be a locked database).
9.3.3.
Multiple Comparisons and Multiplicity
As this is an early-phase exploratory study, no adjustment for multiple comparisons will 
be made. Treatment comparisons will be presented as effect sizes with 95% confidence 
intervals.
9.4.
Key Elements of Analysis Plan
Each subject will undergo two treatment periods in this crossover study, each one of 
which being subdivided into five key sub-epochs (labelled T0-T4) as follows:
 
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
T0: Pre-dose (period baseline)

T1: Post-dose, normoxic, at rest, pre-challenge

T2: Hypoxic, at rest

T3: Hypoxic, immediately after exercise (for Part 2, echo data will be measured 
during exercise)

T4: Post-challenge, normoxic, at rest
This follows the principle illustrated in the diagram of echocardiograph measurements 
(Figure 2).
PASP and Oxygen Saturation will be assigned to T0 thru T4 timepoints based on when 
they happened relative to the sequence of events that the subject undertakes during the 
course of the study day.  Biomarkers will be collected at times T0 thru T4, plus additional 
timepoints.
Pharmacokinetic endpoints will be timed based on elapsed time since dose 
administration.
In addition to T0 being defined as the period baseline, an overall subject baseline will be 
defined as the mean of the two T0 measurements (one from each period).
Change from baseline at time points T1 - T4 will be calculated as the difference between 
the measurement at the time point in question and the period baseline.  Separate statistical 
analyses will be conducted for subjects in Part 1 and Part 2 of the study.  In general, 
statistical modelling of changes from baseline will be done using a Bayesian mixed 
effects regression model, including covariates for period, treatment, period baseline and 
subject baseline (the mean of the two period baselines).  Subject will be fitted as a 
random effect and non-informative priors will be used for model parameters. An 
unstructured covariance structure within each subject-period-treatment cell will be 
assumed to account for repeated measurements.
Bayesian mixed effects regression models (as described above) will be fitted (using non-
informative priors for the model parameters), and an estimate of the mean change from 
baseline in PASP for each treatment group and post-baseline timepoint, together with its 
95% credible interval, will be obtained.  Estimates for treatment differences will also be 
presented. Data may be log-transformed if necessary.
PASP data will be summarized separately by Part 1 and Part 2 by treatment and time-
point in tabular and graphical format.
Details of the analysis of other endpoints will be described in the RAP.
 
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9.4.1.
Pharmacokinetic Analyses
Pharmacokinetic analysis will be performed by, or under the auspices, of Clinical 
Pharmacology Modelling and Simulation Department within GlaxoSmithKline.  Plasma 
GSK2586881 concentration-time data will be analysed by non-compartmental methods 
with WinNonLin V6.3 or greater.  Calculations will be based on the actual sampling 
times recorded during the study.
From the plasma concentration-time data, the following pharmacokinetic parameters will 
be determined, as data permit: maximum observed plasma concentration (Cmax), time to 
Cmax (tmax), area under the plasma concentration-time curve over the study period 
[nominally AUC(0-2.5h) post-dose], AUC over the hypoxia challenge (nominally 
AUC(0.5-2.0h post-dose), plasma clearance (CL), volume of distribution (V) and 
apparent terminal phase half-life (t1/2), if data permit.  Other PK parameters may also be 
determined.
Pharmacokinetic data will be presented in graphical and/or tabular form and will be
summarized descriptively by Part 1 and Part 2. All pharmacokinetic data will be stored in 
the Archives, GlaxoSmithKline Pharmaceuticals, R&D. 
The relationship between the RAS biomarkers and other pharmacodynamic endpoints 
(echocardiography and pulse oximetry) and GSK2586881 concentrations and/or PK 
parameters may also be explored for Part 2, if appropriate.
If appropriate, a population PK analysis may also be conducted, in addition the plasma 
concentration-time data may be merged with historical data and analysed as part of a 
population PK meta-analysis.
10.
STUDY GOVERNANCE CONSIDERATIONS
10.1.
Posting of Information on Publicly Available Clinical Trial 
Registers
Study information from this protocol will be posted on publicly available clinical trial 
registers before enrollment of subjects begins.
10.2.
Regulatory and Ethical Considerations, Including the 
Informed Consent Process
Prior to initiation of a site, GSK will obtain favourable opinion/approval from the 
appropriate regulatory agency to conduct the study in accordance with ICH Good Clinical 
Practice (GCP) and applicable country-specific regulatory requirements.
The study will be conducted in accordance with all applicable regulatory requirements, 
and with GSK policy.
The study will also be conducted in accordance with ICH Good Clinical Practice (GCP), 
all applicable subject privacy requirements, and the guiding principles of the current 
version of the Declaration of Helsinki.  This includes, but is not limited to, the following:
 
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
IRB/IEC review and favorable opinion/approval of the study protocol and 
amendments as applicable

Obtaining signed informed consent

Investigator reporting requirements (e.g. reporting of AEs/SAEs/protocol 
deviations to IRB/IEC)

GSK will provide full details of the above procedures, either verbally, in writing, 
or both.

Signed informed consent must be obtained for each subject prior to participation 
in the study

The IEC/IRB, and where applicable the regulatory authority, approve the clinical 
protocol and all optional assessments, including genetic research.  

Optional assessments (including those in a separate protocol and/or under separate 
informed consent) and the clinical protocol should be concurrently submitted for 
approval unless regulation requires separate submission.  

Approval of the optional assessments may occur after approval is granted for the 
clinical protocol where required by regulatory authorities.  In this situation, 
written approval of the clinical protocol should state that approval of optional 
assessments is being deferred and the study, with the exception of the optional 
assessments, can be initiated.
10.3.
Quality Control (Study Monitoring)

In accordance with applicable regulations including GCP, and GSK procedures, 
GSK monitors will contact the site prior to the start of the study to review with the 
site staff the protocol, study requirements, and their responsibilities to satisfy 
regulatory, ethical, and GSK requirements.  

When reviewing data collection procedures, the discussion will also include 
identification, agreement and documentation of data items for which the CRF will 
serve as the source document.

Source documents provide evidence for the existence of the participant and 
substantiate the integrity of the data collected. Source documents are filed at the 
investigator’s site.

Data entered in the eCRFs that are transcribed from source documents must be 
consistent with the source documents or the discrepancies must be explained. The 
investigator may need to request previous medical records or transfer records, 
depending on the study; also current medical records must be available.
GSK will monitor the study and site activity to verify that the:

Data are authentic, accurate, and complete.

Safety and rights of subjects are being protected.

Study is conducted in accordance with the currently approved protocol and any 
other study agreements, GCP, and all applicable regulatory requirements.
 
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The investigator and the head of the medical institution (where applicable) agrees to 
allow the monitor direct access to all relevant documents
10.4.
Quality Assurance

To ensure compliance with GCP and all applicable regulatory requirements, GSK 
may conduct a quality assurance assessment and/or audit of the site records, and 
the regulatory agencies may conduct a regulatory inspection at any time during or 
after completion of the study.

In the event of an assessment, audit or inspection, the investigator (and institution) 
must agree to grant the advisor(s), auditor(s) and inspector(s) direct access to all 
relevant documents and to allocate their time and the time of their staff to discuss 
the conduct of the study, any findings/relevant issues and to implement any 
corrective and/or preventative actions to address any findings/issues identified.
10.5.
Study and Site Closure

Upon completion or premature discontinuation of the study, the GSK monitor will 
conduct site closure activities with the investigator or site staff, as appropriate, in 
accordance with applicable regulations including GCP, and GSK Standard 
Operating Procedures.

GSK reserves the right to temporarily suspend or prematurely discontinue this 
study at any time for reasons including, but not limited to, safety or ethical issues 
or severe non-compliance. For multicenter studies, this can occur at one or more 
or at all sites.  

If GSK determines such action is needed, GSK will discuss the reasons for taking 
such action with the investigator or the head of the medical institution (where 
applicable).  When feasible, GSK will provide advance notification to the 
investigator or the head of the medical institution, where applicable, of the 
impending action.

If the study is suspended or prematurely discontinued for safety reasons, GSK will 
promptly inform all investigators, heads of the medical institutions (where 
applicable) and/or institution(s) conducting the study. GSK will also promptly 
inform the relevant regulatory authorities of the suspension or premature 
discontinuation of the study and the reason(s) for the action.  

If required by applicable regulations, the investigator or the head of the medical 
institution (where applicable) must inform the IRB/IEC promptly and provide the 
reason for the suspension or premature discontinuation.
10.6.
Records Retention

Following closure of the study, the investigator or the head of the medical 
institution (where applicable) must maintain all site study records (except for 
those required by local regulations to be maintained elsewhere), in a safe and 
secure location.  
 
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
The records must be maintained to allow easy and timely retrieval, when needed 
(e.g., for a GSK audit or regulatory inspection) and must be available for review 
in conjunction with assessment of the facility, supporting systems, and relevant 
site staff.  

Where permitted by local laws/regulations or institutional policy, some or all of 
these records can be maintained in a format other than hard copy (e.g., microfiche, 
scanned, electronic); however, caution needs to be exercised before such action is 
taken.  

The investigator must ensure that all reproductions are legible and are a true and 
accurate copy of the original and meet accessibility and retrieval standards, 
including re-generating a hard copy, if required.  Furthermore, the investigator 
must ensure there is an acceptable back-up of these reproductions and that an 
acceptable quality control process exists for making these reproductions.

GSK will inform the investigator of the time period for retaining these records to 
comply with all applicable regulatory requirements.  The minimum retention time 
will meet the strictest standard applicable to that site for the study, as dictated by 
any institutional requirements or local laws or regulations, GSK 
standards/procedures, and/or institutional requirements.  

The investigator must notify GSK of any changes in the archival arrangements, 
including, but not limited to, archival at an off-site facility or transfer of 
ownership of the records in the event the investigator is no longer associated with 
the site.
10.7.
Provision of Study Results to Investigators, Posting of 
Information on Publically Available Clinical Trials Registers 
and Publication
Where required by applicable regulatory requirements, an investigator signatory will be 
identified for the approval of the clinical study report.  The investigator will be provided 
reasonable access to statistical tables, figures, and relevant reports and will have the 
opportunity to review the complete study results at a GSK site or other mutually-
agreeable location.
GSK will also provide the investigator with the full summary of the study results.  The 
investigator is encouraged to share the summary results with the study subjects, as 
appropriate.
GSK will provide the investigator with the randomisation codes for their site only after 
completion of the full statistical analysis.
The procedures and timing for public disclosure of the results summary and for 
development of a manuscript for publication will be in accordance with GSK Policy.
A manuscript will be progressed for publication in the scientific literature if the results 
provide important scientific or medical knowledge.
 
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11.
REFERENCES
Abraham WT, Raynolds MV, Badesch DB, Wynne KM, Groves BM, Roden RL,et al..
Angiotensin-converting enzyme DD genotype in patients with primary pulmonary 
hypertension: increased frequency and association with preserved haemodynamics.  J 
Renin Angiotensin Aldosterone Syst. 2003 Mar;4(1):27-30.
Argiento P, Chesler N, Mulè M, D’Alto M, Bossone E, Unger P, Naeije R. Exercise 
stress echocardiography for the study of the pulmonary circulation.  Eur Respir J. June 
2010, 35 (6):1273 – 1278.
Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, et al. The American-
European consensus conference on ARDS: definitions, mechanisms, relevant outcomes, 
and clinical trial coordination. Am J Respir Crit Care Med. 1994;49:818-822. 
Cargil RI, Lipworth BJ. Lisinopril attenuates acute hypoxic pulmonary vasoconstriction 
in humans. Chest. 1996 Feb;109(2):424-9/
GlaxoSmithKline Document Number 2010N108777_04 Study ID GSK2586881. 
Investigator's Brochure for GSK2586881 (formerly known as APN01)– A Soluble 
Recombinant Human Angiotensin Converting Enzyme 2 (rhACE2). Report Date 28-
NOV-2017. 
Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F, Kowal D, editors. 
Contraceptive Technology. 19th edition. New York: Ardent Media, 2007(a): 24. Table 3-
2.
Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F, Kowal D, editors. 
Contraceptive Technology. 19th edition. New York: Ardent Media, 2007(b): 28.
ICH Topic M3 (R2)  Non-clinical safety studies for the conduct of human clinical trials 
and marketing authorisation for pharmaceuticals, 2009
Idell S, Kueppers, F, Lippmann, M, Rosen, H, Niederman, M, Fein, A. ACE elevated in 
ARDS BAL. Angiotensin converting enzyme in bronchoalveolar lavage in ARDS. Chest. 
1987;91:52-56.
Kiely DG, Cargill RI, Lipworth BJ. Effects of hypercapnia on hemodynamic, inotropic, 
lusitropic, and electrophysiologic indices in humans. Chest. 1996; 109:1215–1221
Kiely DG1, Cargill RI, Wheeldon NM, Coutie WJ, Lipworth BJ. Haemodynamic and 
endocrine effects of type 1 angiotensin II receptor blockade in patients with hypoxaemic 
cor pulmonale. Cardiovasc Res. 1997 Jan;33(1):201-8.
Kleinsasser A1, Pircher I, Treml B, Schwienbacher M, Schuster M, Janzek E, Loibner H, 
Penninger JM, Loeckinger A. Recombinant angiotensin-converting enzyme 2 suppresses 
pulmonary vasoconstriction in acute hypoxia. Wilderness Environ Med. 2012 
Mar;23(1):24-30
 
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Maron BA, Leopold JA. The role of the renin-angiotensin-aldosterone system in the 
pathobiology of pulmonary arterial hypertension. 2013 Grover Conference series. Pulm 
Circ. 2014 Jun;4(2):200-10. doi: 10.1086/675984  
Marshall RP, Webb S, Bellingan GJ, Montgomery HE, Chaudhari B, Chambers RJ, , GJ
et al. Angiotensin converting enzyme insertion/deletion polymorphism is associated with 
susceptibility and outcome in acute respiratory distress syndrome. Am. J. Resp. Crit. Care 
Med. 2002;166:646-650. 
Naeije R, Saggar R, Badesch D, Rajagopalan S, Gargani L, Rischard F, et al. Exercise 
induced pulmonary hypertension: Translating pathophysiological concepts into clinical 
practice. Chest. 2018; 3692(18)30161-2.
Paul M, Bachmann J, Ganten D. Angiotensin II-induced vasoconstriction and sodium 
resorption. The Tissue Renin-Angiotensin System in Cardiovascular Disease. Trends 
Cardiovasc. Med. 1992;2:94-99. 
Ricart A, Maristany J, Fort N, Leal C, Pagés T, Viscor G. Effects of sildenafil on the 
human response to acute hypoxia and exercise. High Alt Med Biol. 2005 Spring;6(1):43-
9.
Rubenfeld GD, Caldwell E, Peabody E. Incidence and Outcomes of Acute Lung Injury. N 
Engl J Med. 2005;353:1685-1693. 
Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, et al. 
Guidelines for the echocardiographic assessment of the right heart in adults: a report from 
the American Society of Echocardiograpy. J am Soc Echocardiogr. 2010; 23: 685 – 713
Santos RA, Ferreira AJ, Pinheiro SVB, Sampaio WO, Touyz R, Campangole-Santos MJ. 
Counter-regulatory effects of ANG (1-7) in ANG II. Angiotensin(1-7) and its receptor as 
potential targets for cardiovascular drugs Expert Op. Investig. Drugs. 2005;1019:1031. 
Santos RA, Simoes e Silva AC, Maric C, Silva DM, Machado RP, de Buhr I, et al. 
Angiotensin (1-7) is an endogenous ligand for the G-protein coupled receptor Mas Proc 
Natl Acad Sci USA. 2003;100:8258-8263. 
Suzuki Y, Ruiz-Ortega, M., Lorenzo, O., Ruperez, M., Esteban, V., Egido, J. 
Inflammation and Angiotensin II. Int J Biochem Cell Biol. 2003;35:881-900. 
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes 
as compared with traditional tidal volumes for acute lung injury and the acute respiratory 
distress syndrome. N Engl J Med. 2000;342:1301-1308. 
The ARDS Network Authors for the ARDS network. Ketoconzaole for Early Treatment 
of Acute Lung Injury and Acute Respiratory Distress Syndrome. JAMA. 2000;283:1995-
2002. 
 
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Tom B, de Vries R, Saxena PR, Danser AHJ. Bradykinin potentiation by angiotensin (1-
7) and ACE inhibitors correlates with C- and N-terminal blockade. Hypertension. 
2001;38:95-99.
Torre-Bueno JR, Wagner PD, Saltzman HA, Gale GE, Moon RE. Diffusion limitation in 
normal humans during exercise at sea level and simulated altitude. J Appl Physiol (1985). 
1985 Mar;58(3):989-95
Wenz M, Hoffmann B, Bohlender J, Kaczmarczyk G. Angiotensin II formation and 
endothelin clearance in ARDS patients in supine and prone positions. Intensive Care 
Med. 2000;26:292-298. 
Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP, deBoisblanc 
B,et al.. Pulmonary-Artery versus Central Venous Catheter to Guide Treatment of Acute 
Lung Injury. N Engl J Med. 2006;25:354(21):2213-24. Epub 2006 May 21.
Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B,et 
al. Comparison of Two Fluid-Management Strategies in Acute Lung Injury. N Engl J 
Med. 2006;354(24):2564-75. Epub 2006 May 21.
 
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12.
APPENDICES
12.1.
Appendix 1: Abbreviations and Trademarks
Abbreviations
ACE2
Angiotensin converting enzyme type 2
AE
Adverse Event
ALI
Acute Lung Injury
ALT
Alanine aminotransferase (SGPT)
Ang II
Angiotensin II
ARDS
Acute respiratory distress syndrome
AST
Aspartate aminotransferase (SGOT)
AUC
Area under concentration-time curve
BID
Bi-Daily
BUN
Blood urea nitrogen
CBP
Child Bearing Potential
CL
Clearance
CO2
Carbon dioxide
CONSORT
Consolidated Standards of Reporting Trials
CRF
Case Report Form
CV
Cardiovascular
DNA
Deoxyribonucleic acid
ECG
Electrocardiogram
eCRF
Electronic case report form
FDA
Food and Drug Administration
FRP
Females of Reproductive Potential
GCP
Good Clinical Practice
GLP
Good Laboratory Practice
GSK
GlaxoSmithKline
HBcAb
Hepatitis B core antibody
HBsAg
Hepatitis B surface antigen
hCG
Human chorionic gonadotropin
HIV
Human Immunodeficiency Virus
HPLC
High performance liquid chromatography
HPV
Hypoxic pulmonary vasoconstriction
IB
Investigator’s Brochure
ICH
International Conference on Harmonization of Technical 
Requirements for Registration of Pharmaceuticals for 
Human Use
ID
Identification
IEC
Independent Ethics Committee
IgG
Immunoglobulin G
IND
Investigational New Drug
IP
Investigational Product
IRB
Institutional Review Board
 
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ITT
Intent-to-Treat
IV
Intravenous
IVIVT
In Vitro/In Vivo Translations
Kg
Kilogram
LDH
Lactate dehydrogenase
LFTs
Liver function tests
m
Meters
MCH
Mean corpuscular hemogloin
MCV
Mean corpuscular volume
MedDRA
Medical Dictionary for Regulatory Activities
mg
Milligrams
mL
Milliliter
MSDS
Material Safety Data Sheet
msec
Milliseconds
NOAEL
No observed adverse effect level
O2
Oxygen
PaO2
Partial Pressure of Oxygen in arterial blood
PAH
Pulmonary Arterial Hypertension
PASP
Pulmonary Artery Systolic Pressure
PD
Pharmacodynamic
PGx
Pharmacogenetics
PK
Pharmacokinetic
PVR
Pulmonary vascular resistance
Q
Perfusion
QC
Quality control
QTcB
QT duration corrected for heart rate by Bazett’s formula
QTcF
QT duration corrected for heart rate by Fridericia’s formula
RAP
Reporting and Analysis Plan
RAS
Renin-Angiotensin System
RBC
Red blood cells
rhACE2
Recombinant human angiotensin converting enzyme type 2
RNA
Ribonucleic acid
RVOT
Right ventricular outflow tract
SAE
Serious adverse event(s)
SD
Standard deviation
SP-D
Surfactant Protein-D
SRM
Study Reference Manual
TPR
Third Party Resourcing
TTS
Technical Terms of Supply
t½
Terminal phase half-life
tmax
Time of occurrence of Cmax
V
Volume of Distribution
VA
Ventilation
VO2
Oxygen Consumption
 
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Trademark Information
Trademarks of the GlaxoSmithKline 
group of companies
Trademarks not owned by the 
GlaxoSmithKline group of companies
NONE
MedDRA
WinNonlin
 
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12.2.
Appendix 2: Liver Safety Required Actions and Follow up 
Assessments
Phase I Liver chemistry stopping criteria have been designed to assure subject safety and 
to evaluate liver event etiology (in alignment with the FDA premarketing clinical liver 
safety guidance).
http://
fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidance
s/UCM174090.pdf.
Phase I liver chemistry stopping criteria and required follow up assessments
Liver Chemistry Stopping Criteria – Liver Stopping Event
ALT-absolute
ALT≥3xULN
If  ALT≥3xULN AND bilirubin1,2 2xULN (>35% direct bilirubin) or  INR >1.5, 
Report as an SAE.
See additional Actions and Follow Up Assessments listed below
Required Actions and Follow up Assessments following Liver Stopping Event
Actions
Follow Up Assessments

Immediately discontinue study treatment

Report the event to GSK within 24 hours

Complete the liver event CRF, and complete 
an SAE data collection tool if the event also 
meets the criteria for an SAE2

Perform liver event follow up assessments 

Monitor the subject until liver chemistries 
resolve, stabilise, or return to within baseline
(see MONITORING below)
MONITORING:
If ALT≥3xULN AND bilirubin 2xULN  or INR 
>1.5

Repeat liver chemistries (include ALT, AST, 
alkaline phosphatase, bilirubin) and perform 
liver event follow up assessments within  24 
hrs

Monitor subjects twice weekly until liver 
chemistries resolve, stabilise or return to 
within baseline

Viral hepatitis serology3

Obtain INR and recheck with each liver 
chemistry assessment until the 
transaminases values show downward 
trend.

Blood sample for PK analysis, obtained 24 
hours after last dose 4

Serum creatine phosphokinase (CPK) and 
lactate dehydrogenase (LDH).

Fractionate bilirubin, if total 
bilirubin2xULN

Obtain complete blood count with 
differential to assess eosinophilia

Record the appearance or worsening of 
clinical symptoms of liver injury, or 
hypersensitivity, on the AE report form

Record use of concomitant medications on 
the concomitant medications report form
including acetaminophen, herbal remedies, 
 
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Liver Chemistry Stopping Criteria – Liver Stopping Event

A specialist or hepatology consultation is 
recommended
If ALT≥3xULN AND bilirubin < 2xULN  and 
INR ≤1.5:

Repeat liver chemistries (include ALT, AST, 
alkaline phosphatase, bilirubin) and perform
liver event follow up assessments within 24-
72 hrs

Monitor subjects weekly until liver 
chemistries resolve, stabilize or return to 
within baseline
other over the counter medications.

Record alcohol use on the liver event 
alcohol intake case report form
If ALT≥3xULN AND bilirubin 2xULN  or 
INR >1.5:

Anti-nuclear antibody, anti-smooth muscle 
antibody, Type 1 anti-liver kidney 
microsomal antibodies, and quantitative 
total immunoglobulin G (IgG or gamma 
globulins).

Serum acetaminophen adduct HPLC assay 
(quantifies potential acetaminophen 
contribution to liver injury in subjects with 
definite or likely acetaminophen use in the 
preceding week [James, 2009]. 

Liver imaging (ultrasound, magnetic 
resonance, or computerised tomography) 
and /or liver biopsy to evaluate liver 
disease; complete Liver Imaging and/or 
Liver Biopsy CRF forms.
1.
Serum bilirubin fractionation should be performed if testing is available. If serum bilirubin fractionation is not 
immediately available, discontinue study treatment for that subject if ALT 3xULN and bilirubin 2xULN. 
Additionally, if serum bilirubin fractionation testing is unavailable, record presence of detectable urinary bilirubin on 
dipstick, indicating direct bilirubin elevations and suggesting liver injury. 
2.
All events of ALT 3xULN and bilirubin 2xULN (>35% direct bilirubin) or ALT 3xULN and INR>1.5, if INR 
measured, which may indicate severe liver injury (possible ‘Hy’s Law’), must be reported as an SAE (excluding 
studies of hepatic impairment or cirrhosis); INR measurement is not required and the threshold value stated will 
not apply to subjects receiving anticoagulants
3.
Includes: Hepatitis A IgM antibody; Hepatitis B surface antigen and Hepatitis B Core Antibody (IgM); Hepatitis C
RNA; Cytomegalovirus IgM antibody;  Epstein-Barr viral capsid antigen IgM antibody (or if unavailable, obtain 
heterophile antibody or monospot testing);  Hepatitis E IgM antibody 
4.
Record the date/time of the PK blood sample draw and the date/time of the last dose of study treatment prior to 
blood sample draw on the CRF. If the date or time of the last dose is unclear, provide the subject’s best 
approximation. If the date/time of the last dose cannot be approximated OR a PK sample cannot be collected in 
the time period indicated above, do not obtain a PK sample. Instructions for sample handling and shipping are in 
the SRM.
References
James LP, Letzig L, Simpson PM, Capparelli E, Roberts DW, Hinson JA,et al.. 
Pharmacokinetics of Acetaminophen-Adduct in Adults with Acetaminophen Overdose 
and Acute Liver Failure. Drug Metab Dispos 2009; 37:1779-1784.
 
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12.3.
Appendix 3: Genetic Research
Genetics – Background
Naturally occurring genetic variation may contribute to inter-individual variability in 
response to medicines, as well as an individual's risk of developing specific diseases. 
Genetic factors associated with disease characteristics may also be associated with 
response to therapy, and could help to explain some clinical study outcomes. For 
example, genetic variants associated with age-related macular degeneration (AMD) are 
reported to account for much of the risk for the condition [Gorin, 2012] with certain 
variants reported to influence treatment response [Chen, 2012]. Thus, knowledge of the 
genetic etiology of disease may better inform understanding of disease and the 
development of medicines. Additionally, genetic variability may impact the 
pharmacokinetics (absorption, distribution, metabolism, and elimination), or 
pharmacodynamics (relationship between concentration and pharmacologic effects or the 
time course of pharmacologic effects) of a specific medicine and/or clinical outcomes 
(efficacy and/or safety) observed in a clinical study.
Genetic Research Objectives and Analyses
The objectives of the genetic research are to investigate the relationship between genetic 
variants and: 

Response to medicine, including [any treatment regimens under investigation in 
this study] or any concomitant medicines;
Genetic data may be generated while the study is underway or following completion of 
the study.  Genetic evaluations may include focused candidate gene approaches and/or 
examination of a large number of genetic variants throughout the genome (whole genome 
analyses). Genetic analyses will utilize data collected in the study and will be limited to 
understanding the objectives highlighted above.  Analyses may be performed using data 
from multiple clinical studies to investigate these research objectives.
Appropriate descriptive and/or statistical analysis methods will be used. A detailed 
description of any planned analyses will be documented in a Reporting and Analysis Plan 
(RAP) prior to initiation of the analysis. Planned analyses and results of genetic 
investigations will be reported either as part of the clinical RAP and study report, or in a 
separate genetics RAP and report, as appropriate.
Study Population
Any subject who is enrolled in the study can participate in genetic research.  Any subject 
who has received an allogeneic bone marrow transplant must be excluded from the 
genetic research.
Study Assessments and Procedures
A key component of successful genetic research is the collection of samples during 
clinical studies. Collection of samples, even when no a priori hypothesis has been 
 
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identified, may enable future genetic analyses to be conducted to help understand 
variability in disease and medicine response.  

A 6 ml blood sample will be taken for Deoxyribonucleic acid (DNA) extraction. 
A blood sample is collected at the baseline visit, after the subject has been 
randomised and provided informed consent for genetic research. Instructions for 
collection and shipping of the genetic sample are described in the laboratory 
manual. The DNA from the blood sample may undergo quality control analyses to
confirm the integrity of the sample. If there are concerns regarding the quality of 
the sample, then the sample may be destroyed. The blood sample is taken on a 
single occasion unless a duplicate sample is required due to an inability to utilize 
the original sample.  
The genetic sample is labelled (or “coded”) with the same study specific number used to 
label other samples and data in the study.   This number can be traced or linked back to 
the subject by the investigator or site staff. Coded samples do not carry personal 
identifiers (such as name or social security number). 
Samples will be stored securely and may be kept for up to 15 years after the last subject 
completes the study, or GSK may destroy the samples sooner.  GSK or those working 
with GSK (for example, other researchers) will only use samples collected from the study 
for the purpose stated in this protocol and in the informed consent form.  Samples may be 
used as part of the development of a companion diagnostic to support the GSK medicinal 
product.
Subjects can request their sample to be destroyed at any time.
Informed Consent
Subjects who do not wish to participate in the genetic research may still participate in the 
study.  Genetic informed consent must be obtained prior to any blood being taken.
Subject Withdrawal from Study
If a subject who has consented to participate in genetic research withdraws from the 
clinical study for any reason other than being lost to follow-up, the subject will be given a 
choice of one of the following options concerning the genetic sample, if already 
collected:

Continue to participate in the genetic research in which case the genetic DNA 
sample is retained

Discontinue participation in the genetic research and destroy the genetic DNA 
sample 
If a subject withdraws consent for genetic research or requests sample destruction for any 
reason, the investigator must complete the appropriate documentation to request sample 
destruction within the timeframe specified by GSK and maintain the documentation in 
the site study records. 
 
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Genotype data may be generated during the study or after completion of the study and 
may be analyzed during the study or stored for future analysis. 

If a subject withdraws consent for genetic research and genotype data has not been 
analyzed, it will not be analyzed or used for future research.  

Genetic data that has been analyzed at the time of withdrawn consent will 
continue to be stored and used, as appropriate. 
Screen and Baseline Failures
If a sample for genetic research has been collected and it is determined that the subject 
does not meet the entry criteria for participation in the study, then the investigator should 
instruct the subject that their genetic sample will be destroyed. No forms are required to 
complete this process as it will be completed as part of the consent and sample 
reconciliation process.  In this instance a sample destruction form will not be available to 
include in the site files.
Provision of Study Results and Confidentiality of Subject’s Genetic Data
GSK may summarize the genetic research results in the clinical study report, or 
separately and may publish the results in scientific journals. 
GSK may share genetic research data with other scientists to further scientific 
understanding in alignment with the informed consent. GSK does not inform the subject, 
family members, insurers, or employers of individual genotyping results that are not 
known to be relevant to the subject’s medical care at the time of the study, unless 
required by law. This is due to the fact that the information generated from genetic 
studies is generally preliminary in nature, and therefore the significance and scientific 
validity of the results are undetermined.  Further, data generated in a research laboratory 
may not meet regulatory requirements for inclusion in clinical care.
Chen H, Yu KD, Xu GZ. Association between Variant Y402H in Age-Related Macular 
Degeneration (AMD) Susceptibility Gene CFH and Treatment Response of AMD: A 
Meta-Analysis. PloS ONE 2012; 7: e42464
Gorin MB. Genetic insights into age-related macular degeneration: Controversies 
addressing risk, causality, and therapeutics. Mol. Asp. Med. 2012; 33: 467-486.
 
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12.4.
Appendix 4: Definition of and Procedures for Recording, 
Evaluating, Follow-Up and Reporting of Adverse Events
12.4.1.
Definition of Adverse Events
Adverse Event Definition:

An AE is any untoward medical occurrence in a patient or clinical investigation 
subject, temporally associated with the use of a medicinal product, whether or not 
considered related to the medicinal product.

NOTE: An AE can therefore be any unfavorable and unintended sign (including an 
abnormal laboratory finding), symptom, or disease (new or exacerbated) temporally 
associated with the use of a medicinal product.
Events meeting AE definition include:

Any abnormal laboratory test results (hematology, clinical chemistry, or urinalysis) 
or other safety assessments (e.g., ECGs, radiological scans, vital signs 
measurements), including those that worsen from baseline, and felt to be clinically 
significant in the medical and scientific judgement of the investigator.

Exacerbation of a chronic or intermittent pre-existing condition including either an 
increase in frequency and/or intensity of the condition.

New conditions detected or diagnosed after study treatment administration even 
though it may have been present prior to the start of the study.

Signs, symptoms, or the clinical sequelae of a suspected interaction.

Signs, symptoms, or the clinical sequelae of a suspected overdose of either study 
treatment or a concomitant medication (overdose per se will not be reported as an 
AE/SAE unless this is an intentional overdose taken with possible suicidal/self-
harming intent.  This should be reported regardless of sequelae).
Events NOT meeting definition of an AE include:

Any clinically significant abnormal laboratory findings or other abnormal safety 
assessments which are associated with the underlying disease, unless judged by the 
investigator to be more severe than expected for the subject’s condition.

The disease/disorder being studied or expected progression, signs, or symptoms of 
the disease/disorder being studied, unless more severe than expected for the subject’s 
condition.

Medical or surgical procedure (e.g., endoscopy, appendectomy): the condition that 
leads to the procedure is an AE.

Situations where an untoward medical occurrence did not occur (social and/or 
 
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convenience admission to a hospital).

Anticipated day-to-day fluctuations of pre-existing disease(s) or condition(s) present 
or detected at the start of the study that do not worsen.
12.4.2.
Definition of Serious Adverse Events
If an event is not an AE per definition above, then it cannot be an SAE even if serious 
conditions are met (e.g., hospitalization for signs/symptoms of the disease under study, 
death due to progression of disease, etc).
Serious Adverse Event (SAE) is defined as any untoward medical occurrence that, 
at any dose:
a.
Results in death
b.
Is life-threatening
NOTE:
The term 'life-threatening' in the definition of 'serious' refers to an event in which the 
subject was at risk of death at the time of the event.  It does not refer to an event, which 
hypothetically might have caused death, if it were more severe.
c.
Requires hospitalization or prolongation of existing hospitalization
NOTE:

In general, hospitalization signifies that the subject has been detained (usually 
involving at least an overnight stay) at the hospital or emergency ward for 
observation and/or treatment that would not have been appropriate in the physician’s 
office or out-patient setting.  Complications that occur during hospitalization are 
AEs.  If a complication prolongs hospitalization or fulfills any other serious criteria, 
the event is serious.  When in doubt as to whether “hospitalization” occurred or was 
necessary, the AE should be considered serious.

Hospitalization for elective treatment of a pre-existing condition that did not worsen 
from baseline is not considered an AE.
 
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d.
Results in disability/incapacity
NOTE:

The term disability means a substantial disruption of a person’s ability to conduct 
normal life functions.

This definition is not intended to include experiences of relatively minor medical 
significance such as uncomplicated headache, nausea, vomiting, diarrhea, influenza, 
and accidental trauma (e.g. sprained ankle) which may interfere or prevent everyday 
life functions but do not constitute a substantial disruption
e.
Is a congenital anomaly/birth defect
f.
Other situations:

Medical or scientific judgment should be exercised in deciding whether reporting is 
appropriate in other situations, such as important medical events that may not be 
immediately life-threatening or result in death or hospitalization but may jeopardize 
the subject or may require medical or surgical intervention to prevent one of the 
other outcomes listed in the above definition.  These should also be considered 
serious.

Examples of such events are invasive or malignant cancers, intensive treatment in an 
emergency room or at home for allergic bronchospasm, blood dyscrasias or 
convulsions that do not result in hospitalization, or development of drug dependency 
or drug abuse
g.
Is associated with liver injury and impaired liver function defined as:

ALT 3xULN and total bilirubin* 2xULN (>35% direct), or

ALT 3xULN and INR** > 1.5.
* Serum bilirubin fractionation should be performed if testing is available; if unavailable, 
measure urinary bilirubin via dipstick.  If fractionation is unavailable and ALT 3xULN 
and total bilirubin 2xULN, then the event is still to be reported as an SAE.
** INR testing not required per protocol and the threshold value does not apply to 
subjects receiving anticoagulants.  If INR measurement is obtained, the value is to be 
recorded on the SAE form.

Refer to Appendix 2 for the required liver chemistry follow-up instructions
 
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12.4.3.
Definition of Cardiovascular Events
Cardiovascular Events (CV) Definition:
Investigators will be required to fill out the specific CV event page of the CRF for the 
following AEs and SAEs:

Myocardial infarction/unstable angina

Congestive heart failure

Arrhythmias

Valvulopathy

Pulmonary hypertension

Cerebrovascular events/stroke and transient ischemic attack

Peripheral arterial thromboembolism

Deep venous thrombosis/pulmonary embolism

Revascularization
12.4.4.
Recording of AEs and SAEs
AEs and SAE Recording:

When an AE/SAE occurs, it is the responsibility of the investigator to review all 
documentation (e.g., hospital progress notes, laboratory, and diagnostics reports) 
relative to the event.

The investigator will then record all relevant information regarding an AE/SAE in 
the CRF

It is not acceptable for the investigator to send photocopies of the subject’s medical 
records to GSK in lieu of completion of the GSK, AE/SAE CRF page.

There may be instances when copies of medical records for certain cases are 
requested by GSK.  In this instance, all subject identifiers, with the exception of the 
subject number, will be blinded on the copies of the medical records prior to 
submission of to GSK.

The investigator will attempt to establish a diagnosis of the event based on signs, 
symptoms, and/or other clinical information.  In such cases, the diagnosis will be 
documented as the AE/SAE and not the individual signs/symptoms.

Subject-completed Value Evidence and Outcomes questionnaires and the collection 
of AE data are independent components of the study.

Responses to each question in the Value Evidence and Outcomes questionnaire will 
be treated in accordance with standard scoring and statistical procedures detailed by 
the scale’s developer.
 
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
The use of a single question from a multidimensional health survey to designate a 
cause-effect relationship to an AE is inappropriate.
12.4.5.
Evaluating AEs and SAEs
Assessment of Intensity
The investigator will make an assessment of intensity for each AE and SAE reported 
during the study and will assign it to one of the following categories:

Mild:  An event that is easily tolerated by the subject, causing minimal discomfort 
and not interfering with everyday activities.

Moderate:  An event that is sufficiently discomforting to interfere with normal 
everyday activities

Severe:  An event that prevents normal everyday activities. - an AE that is assessed 
as severe will not be confused with an SAE. Severity is a category utilized for rating 
the intensity of an event; and both AEs and SAEs can be assessed as severe.

An event is defined as ‘serious’ when it meets at least one of the pre-defined 
outcomes as described in the definition of an SAE.
Assessment of Causality

The investigator is obligated to assess the relationship between study treatment and 
the occurrence of each AE/SAE.

A "reasonable possibility" is meant to convey that there are facts/evidence or 
arguments to suggest a causal relationship, rather than a relationship cannot be ruled 
out.

The investigator will use clinical judgment to determine the relationship.

Alternative causes, such as natural history of the underlying diseases, concomitant 
therapy, other risk factors, and the temporal relationship of the event to the study 
treatment will be considered and investigated.

The investigator will also consult the Investigator Brochure (IB) and/or Product 
Information, for marketed products, in the determination of his/her assessment.

For each AE/SAE the investigator must document in the medical notes that he/she 
has reviewed the AE/SAE and has provided an assessment of causality.

There may be situations when an SAE has occurred and the investigator has minimal 
information to include in the initial report to GSK.  However, it is very important 
that the investigator always make an assessment of causality for every event 
prior to the initial transmission of the SAE data to GSK.

The investigator may change his/her opinion of causality in light of follow-up 
 
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information, amending the SAE data collection tool accordingly.

The causality assessment is one of the criteria used when determining regulatory 
reporting requirements.
Follow-up of AEs and SAEs

The investigator is obligated to perform or arrange for the conduct of supplemental 
measurements and/or evaluations as may be indicated or as requested by GSK to 
elucidate as fully as possible the nature and/or causality of the AE or SAE.

The investigator is obligated to assist.  This may include additional laboratory tests 
or investigations, histopathological examinations or consultation with other health 
care professionals.

If a subject dies during participation in the study or during a recognized follow-up 
period, the investigator will provide GSK with a copy of any post-mortem findings, 
including histopathology.

New or updated information will be recorded in the originally completed CRF.

The investigator will submit any updated SAE data to GSK within the designated 
reporting time frames.
12.4.6.
Reporting of SAEs to GSK
SAE reporting to GSK via electronic data collection tool

Primary mechanism for reporting SAEs to GSK will be the electronic data collection 
tool

If the electronic system is unavailable for greater than 24 hours, the site will use the 
paper SAE data collection tool and fax it to the Medical Monitor Site will enter the 
serious adverse event data into the electronic system as soon as it becomes available.

The investigator will be required to confirm review of the SAE causality by ticking 
the ‘reviewed’ box at the bottom of the eCRF page within 72 hours of submission of 
the SAE.

After the study is completed at a given site, the electronic data collection tool (e.g., 
InForm system) will be taken off-line to prevent the entry of new data or changes to 
existing data

If a site receives a report of a new SAE from a study subject or receives updated data 
on a previously reported SAE after the electronic data collection tool has been taken 
off-line, the site can report this information on a paper SAE form or to the Medical 
Monitor telephone.

Contacts for SAE receipt can be found at the beginning of this protocol on the 
Sponsor/Medical Monitor Contact Information page.
 
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SAE reporting to GSK via paper CRF

Facsimile transmission of the SAE paper CRF is the preferred method to transmit 
this information to the Medical Monitor

In rare circumstances and in the absence of facsimile equipment, notification by 
telephone is acceptable, with a copy of the SAE data collection tool sent by 
overnight mail

Initial notification via the telephone does not replace the need for the investigator to 
complete and sign the SAE CRF pages within the designated reporting time frames.

Contacts for SAE receipt can be found at this beginning of the protocol on the 
Sponsor/Medical Monitor Contact Information page.
 
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12.5.
Appendix 5: Modified List of Highly Effective Methods for 
Avoiding Pregnancy and Collection of Pregnancy 
Information
12.5.1.
Modified List of Highly Effective Methods for Avoiding Pregnancy
The list does not apply to FRP with same sex partners or for subjects who are and will 
continue to be abstinent from penile-vaginal intercourse on a long term and persistent 
basis, when this is their preferred and usual lifestyle. Periodic abstinence (e.g. calendar, 
ovulation, symptothermal, post-ovulation methods) and withdrawal are not acceptable 
methods of contraception.
1.
Contraceptive subdermal implant
2.
Intrauterine device or intrauterine system
3.
Combined estrogen and progestogen oral contraceptive [Hatcher RA, 2011]
4.
Injectable progestogen [Hatcher RA, 2011]
5.
Contraceptive vaginal ring [Hatcher RA, 2011]
6.
Percutaneous contraceptive patches [Hatcher RA, 2011]
7.
Male partner sterilization with documentation of azoospermia prior to the female 
subject's entry into the study, and this male is the sole partner for that subject 
[Hatcher RA, 2011]. The documentation on male sterility can come from the site 
personnel’s: review of subject’s medical records, medical examination and/or semen 
analysis, or medical history interview provided by her or her partner.
These allowed methods of contraception are only effective when used consistently, 
correctly and in accordance with the product label. The investigator is responsible for 
ensuring that subjects understand how to properly use these methods of contraception.
Contraceptive requirements for male subjects with female partners of reproductive 
potential (when applicable).
Male subjects with female partners of child bearing potential must comply with the 
following contraception requirements from the time of first dose of study medication 
until [at least five half-lives of study medication OR for a cycle of spermatogenesis 
following five terminal half-lives] after the last dose of study medication.
1.
Vasectomy with documentation of azoospermia. The documentation on male sterility 
can come from the site personnel’s: review of subject’s medical records, medical 
examination and/or semen analysis, or medical history interview.
2.
Male condom plus partner use of one of the contraceptive options below that meets 
the Standard Operating Procedure (SOP) effectiveness criteria including a <1% rate 
of failure per year, as stated in the product label:

Contraceptive subdermal implant

Intrauterine device or intrauterine system
 
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
Combined estrogen and progestogen oral contraceptive [Hatcher RA, 2011] 

Injectable progestogen [Hatcher RA, 2011]

Contraceptive vaginal ring [Hatcher RA, 2011]

Percutaneous contraceptive patches [Hatcher RA, 2011]
These allowed methods of contraception are only effective when used consistently, 
correctly and in accordance with the product label. The investigator is responsible for 
ensuring that subjects understand how to properly use these methods of contraception.
12.5.2.
Collection of Pregnancy Information

Investigator will collect pregnancy information on any female subject, who becomes 
pregnant while participating in this study

Information will be recorded on the appropriate form and submitted to GSK within 2 
weeks of learning of a subject's pregnancy.

Subject will be followed to determine the outcome of the pregnancy. The 
investigator will collect follow up information on mother and infant, which will be 
forwarded to GSK.  Generally, follow-up will not be required for longer than 6 to 8 
weeks beyond the estimated delivery date. 

Any termination of pregnancy will be reported, regardless of fetal status (presence or 
absence of anomalies) or indication for procedure.

While pregnancy itself is not considered to be an AE or SAE, any pregnancy 
complication or elective termination of a pregnancy will be reported as an AE or 
SAE.

A spontaneous abortion is always considered to be an SAE and will be reported as 
such.  

Any SAE occurring as a result of a post-study pregnancy which is considered 
reasonably related to the study treatment by the investigator, will be reported to GSK 
as described in Appendix 5. While the investigator is not obligated to actively seek 
this information in former study participants, he or she may learn of an SAE through 
spontaneous reporting.
Any female subject who becomes pregnant while participating

will discontinue study medication or be withdrawn from the study

Investigator will attempt to collect pregnancy information on any female partner of a 
male study subject who becomes pregnant while participating in this study. This 
applies only to subjects who are randomised to receive study medication. 

After obtaining the necessary signed informed consent from the female partner 
directly, the investigator will record pregnancy information on the appropriate form 
and submit it to GSK within 2 weeks of learning of the partner’s pregnancy
 
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
Partner will also be followed to determine the outcome of the pregnancy.  
Information on the status of the mother and child will be forwarded to GSK. 

Generally, follow-up will be no longer than 6 to 8 weeks following the estimated 
delivery date.  Any termination of the pregnancy will be reported regardless of fetal 
status (presence or absence of anomalies) or indication for procedure.
12.5.3.
References
Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F, Kowal D, Policar MS, 
editors. Contraceptive Technology. 20th edition. Atlanta, Georgia: Ardent Media, Inc., 
2011: 50. Table 3-2.
 
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12.6.
Appendix 6:  Protocol Changes
12.6.1.
Protocol Amendment 01 (24-Feb-2017) from Original Protocol 
(23-Sep-2016)
This is a global amendment.
12.6.1.1.
Summary of Changes and Rationale for Amendment
Additional Inclusion Criteria (Section 5.2) and Subject Stopping Criteria (Section 5.4) 
added in response to comments from BfArM.
12.6.1.2.
List of Specific Changes
Title Page, Author (s)
Rationale for change:  Addition and removal of author(s).
 
 
Sponsor Signatory
Rationale for change:  Change in sponsor signatory
Dr Richard Marshall Dr Aili Lazaar
Vice President, Fibrosis & Lung Injury Discovery Performance Unit (DPU) Head, 
Respiratory Therapy Area Unit Director, Discovery Medicine
Project Physician Leader, Respiratory Therapy Area
Section 5.2:  Exclusion Criteria
Rationale for change: Addition of exclusion criteria number 4 and 5.
CONCURRENT CONDITIONS/MEDICAL HISTORY (INCLUDES LIVER 
FUNCTION AND QTc INTERVAL) 
1. ALT >1.5x Upper limit of normal (ULN).
2. Bilirubin >1.5xULN (isolated bilirubin >1.5xULN is acceptable if bilirubin is 
fractionated and direct bilirubin <35%).
3. Current or chronic history of liver disease, or known hepatic or biliary abnormalities 
(with the exception of Gilbert's syndrome or asymptomatic gallstones).
4. Prior history of altitude sickness.
5. Recently been scuba diving (within 1 week before screening).
 
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6. QTc > 450 msec
NOTES:

The QTc is the QT interval corrected for heart rate according to Bazett’s 
formula (QTcB), Fridericia’s formula (QTcF), and/or another method, machine-
read or manually over-read.

The specific formula that will be used to determine eligibility and 
discontinuation for an individual subject should be determined prior to initiation 
of the study. In other words, several different formulae cannot be used to 
calculate the QTc for an individual subject and then the lowest QTc value used 
to include or discontinue the subject from the trial.

For purposes of data analysis, QTcB, QTcF, another QT correction formula, or a 
composite of available values of QTc will be used as specified in the Reporting 
and Analysis Plan (RAP).
Section 5.4:  Withdrawal/Stopping Criteria
Rationale for change: Addition of withdrawal criteria.
Subjects may be withdrawn from the study for any of the following reasons:

A subject may withdraw from study treatment at any time at his/her own request, 
or may be withdrawn at any time at the discretion of the investigator for safety, 
behavioural or administrative reasons. If a subject withdraws from the study, 
he/she may request destruction of any samples taken, and the investigator must 
document this in the site study records. 

If a subjects oxygen saturation falls below 65% at any point during the hypoxia 
challenge. 

If the subject experiences worsening shortness of breath or other symptoms, 
which in the opinion of the investigator are consistent with altitude sickness.

The Sponsor may request a subject withdraw for reasons such as significant 
protocol deviations (after discussion with the investigator).

Study is terminated by the Sponsor.
A subject will be considered to have prematurely withdrawn from the investigational 
product if they do not complete all doses in the treatment phase having received the first 
dose of investigational product, for any reason.
 
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12.6.2.
Protocol Amendment 02 (07-Mar-2017) from Protocol Amendment 
01 (24-Feb-2017)
This is a global amendment.
12.6.2.1.
Summary of Changes and Rationale for Amendment
This is a substantial protocol amendment to:

Reduce the number of participants in the study from approximately 35 healthy 
volunteers to approximately 25 healthy volunteers.
This is a non-substantial protocol amendment to:

Remove some of the exploratory biomarkers.

Add a spirometry assessment at screening.

Add a pre-dose pulse oximetry assessment.

Add continuous ECG telemetry.

Move the immunogenicity screening sample to Pre-dose in Treatment Period 1.

Remove height and weight assessments from the follow-up visit.

Clarify the sequence and priority of assessments.  

Correct typographical errors.
See Section 12.6.2.2 below for a rationale for each change.
12.6.2.2.
List of Specific Changes
Protocol synopsis for study 204987
Protocol synopsis updated to reflect changes in the main body of the protocol.
Section 3:  Objectives/Endpoints
Rationale for change:  Removal of some of the exploratory biomarkers.  SP-D will be 
analysed and reported, and additional biomarkers may be analysed, as data permit.
 
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Objectives
Endpoints
Exploratory 

To evaluate the effect of a single IV 
dose of GSK2586881 on ventilatory 
parameters in healthy volunteers during 
exercise in hypoxic conditions.

Change from baseline of oxygen 
consumption (VO2), carbon dioxide 
production (CO2) and other parameters 
as data permit.

To evaluate the effect of a single IV 
dose of GSK2586881 on peptide 
hormone responses to hypoxia and 
exercise.

Baseline levels and changes in response 
to hypoxia and exercise in kinins (e.g. 
des-Arg-bradykinin), apelins (e.g. 
Apelin 13, pyr1-Apelin, 13) and other 
systems (e.g. dynorphin A) as data 
permit.

To evaluate the pharmacodynamic 
activity of a single IV dose of 
GSK2586881 in healthy volunteers 
during exercise in hypoxic conditions.

Change from baseline in other  
biomarkers which may include Atrial 
Naturetic peptide (ANP), Brain 
Naturetic Peptide (NT-proBNP), 
Troponin I, Surfactant Protein D (SP-
D) , IL-6 and/or additional analytes to 
be determined.

To evaluate Pharmacogenetics.

Evaluate I/D polymorphisms in the 
Angiotensin Converting Enzyme 
(ACE) gene and analyse the impact on 
Ang II (and possibly other RAS 
peptides), hypoxic pulmonary 
vasoconstriction and responses to 
GSK2586881 administration.
Section 4.3:  Type and Number of Subjects
Rationale for change: The removal of some exploratory biomarkers, led to a re-
assessment of the sample size; given that the larger prior sample size was to optimise 
data collection to include exploratory biomarkers. The sample size has been reduced 
from 35 to 25 enrolled subjects (30 to 20 completed subjects), because precision 
estimates show that a difference of between 3 and 5 mmHg in PASP (the primary 
endpoint) could be detected with an acceptable level of precision based on 20 completed 
subjects (see Section 9.2).
Approximately 35 25 subjects healthy volunteers will be randomised such that 
approximately 30 20 evaluable subjects complete the study (the target of 30 20 may be 
revised following the sample size re-estimation, see Section 9.2.2).
 
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Section 4.5:  Dose Justification
Rationale for change:  Additional subjects have been dosed with GSK2586881 since the 
protocol was finalised in September 2016.
GSK2586881 has been studied in 21 healthy subjects as single, intravenous doses over 
30 minutes from 0.1 mg/kg to 1.2 mg/kg, and in repeated daily doses for up to six days of
0.4 mg/kg once a day.  In addition, ARDS patients have received four doses of 
GSK2586881: 0.1 mg/kg, 0.2 mg.kg, 0.4 mg/kg and 0.8 mg/kg over a 24 hour period 
(n=5) or 0.4 mg/kg BID twice daily for 3 days (n=19). In a concluded (but not yet 
reported) investigator-sponsored study in Pulmonary Arterial Hypertension (PAH) 
(Study 204696), 5 subjects have received a single dose of either 0.2 mg/kg or 0.4 
mg/kgOne subject with Pulmonary Arterial Hypertension (PAH) has received a single 
dose of 0.2 mg/kg.
Section 5.1:  Inclusion Criteria
Rationale for change:  Addition of a spirometry test at screening to ensure normal lung 
function before hypoxic challenge and exercise test.
TYPE OF SUBJECT 
2. Healthy as determined by the investigator or medically qualified designee based on a 
medical evaluation including medical history, physical examination, spirometry,
laboratory tests and cardiac monitoring.
Section 5.1:  Inclusion Criteria
Rationale for change:  Correction of typographical errors.
SEX
8. Male or female (non child bearing potential)
Male subjects with female partners of child bearing potential must comply with the 
following contraception requirements from the time of first dose of study medication 
until at least five half-lives of study medication OR for a cycle of spermatogenesis 
following five terminal half-lives after the last dose of study medication.
h. Vasectomy with documentation of azoospermia.  
i. Male condom plus partner use of one of the contraceptive options below:

Contraceptive subdermal implant 

Intrauterine device or intrauterine system 

Oral Contraceptive, either combined or progestogen alone [Hatcher, 2007a] 
Injectable progestogen [Hatcher, 2007a]
 
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
Contraceptive vaginal ring [Hatcher, 2007a]

Percutaneous contraceptive patches [Hatcher, 2007a]
This is an all-inclusive list of those methods that meet the following GSK definition of 
highly effective: having a failure rate of less than 1% per year when used consistently and 
correctly and, when applicable, in accordance with the product label. For non-product 
methods (e.g. male sterility), the investigator determines what is consistent and correct 
use. The GSK definition is based on the definition provided by the International 
Conference on Harmonization (ICH) [ICH, M3 (R2) 2009].
The investigator is responsible for ensuring that subjects understand how to properly use 
these methods of contraception.
This is an all-inclusive list of those methods that meet the following GSK definition of 
highly effective: having a failure rate of less than 1% per year when used consistently and 
correctly and, when applicable, in accordance with the product label.  For non-product 
methods (e.g. male sterility), the investigator determines what is consistent and correct 
use.  The GSK definition is based on the definition provided by the International 
Conference on Harmonization (ICH) [ICH, M3 (R2) 2009].
The investigator is responsible for ensuring that subjects understand how to properly use 
these methods of contraception.
Females: 
A female subject is eligible to participate if she is not pregnant (as confirmed by a 
negative urine human chorionic gonadotrophin (hCG) test), not lactating, and the 
following condition applies:
Non-reproductive potential defined as:

Pre-menopausal females with one of the following:

Documented tubal ligation

Documented hysteroscopic tubal occlusion procedure with follow-up 
confirmation of bilateral tubal occlusion 

Hysterectomy

Documented Bilateral Oophorectomy

Postmenopausal defined as 12 months of spontaneous amenorrhea [in 
questionable cases a blood sample with simultaneous follicle stimulating 
hormone (FSH) and estradiol levels consistent with menopause (refer to 
laboratory reference ranges for confirmatory levels)].  Females on hormone 
replacement therapy (HRT) and whose menopausal status is in doubt will be 
required to use one of the highly effective contraception methods if they wish to 
continue their HRT during the study.  Otherwise, they must discontinue HRT to 
allow confirmation of post-menopausal status prior to study enrolment.
The investigator is responsible for ensuring that subjects understand how to properly use 
 
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these methods of contraception.
Section 5.4.1:  Study Stopping Criteria
Rationale for change:  The overall sample size has been reduced from 35 to 25 enrolled
subjects (30 to 20 completed subjects), so the interim analysis will now be completed 
after 10 subjects have completed the study, rather than 15.    
An interim analysis is planned after approximately 15 10 subjects have completed 
treatment periods 1 and 2 and the study may be stopped if a reasonable change in PASP 
is not observed after dosing with GSK2586881 or if review of the safety data suggests a 
change in the benefit-risk profile. The decision to stop the study will be made by the core 
members of the GSK study team.
Section 5.4.2:  QTc Stopping Criteria
Rationale for change:  QTc Stopping Criteria removed from Section 7.2.5, and inserted 
into Section 5.4 with the other subject stopping criteria.
The same QT correction formula must be used for each individual subject to 
determine discontinuation from the study.  For example, if a subject is eligible for 
the protocol based on QTcB, then QTcB must be used for discontinuation of this 
individual subject as well.
A subject that meets either bulleted criterion below will be withdrawn from the 
study.

QTcB or QTcF >500 msec,

Change from baseline: QTc >60 msec
The QTc should be based on single or averaged QTc values of triplicate ECGs 
obtained over a brief (e.g. 5-10 minute) recording period.
Section 6.1:  Investigational Product and Other Study Treatment
Rationale for change:  Order of treatment sequences altered to reflect GSK’s standard 
practice to list placebo first.
Table 1
Description of sequences
Sequence
Period 1 
Period 2
AB
GSK2586881Saline Placebo
Saline PlaceboGSK2586881
BA
Saline PlaceboGSK2586881
GSK2586881Saline Placebo
 
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Section 7:  Study Assessments and Procedures
Rationale for change:  Addition of ventilatory parameters to the list of assessments, and 
clarification that echocardiograms should be taken as close as possible to the nominal 
time-point (rather than blood draws), because they are the primary endpoint.

If assessments are scheduled for the same nominal time, THEN the assessments 
should occur in the following order:
1.
Ventilatory parameters
2.
Echocardiograms
3.
12-lead ECG
4.
vital signs
5.
blood draws  
Note: The timing of the assessments should allow the blood draw to occur at the 
exact echocardiogram to be performed as close as possible to the nominal time.
Section 7.1:  Time and Events Table
Rationale for change: 

Height and weight removed at follow-up (not required).

Spirometry added at screening (see justification in Section 5.1).

Immunogenicity moved from screening to Day 1, Treatment Period 1.

Removal of exploratory ventilatory parameters after exercise, as this assessment 
would delay the echocardiogram, which is the primary endpoint.

Addition of telemetry throughout the treatment periods.

Correction of typographical errors.
 
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Section 7.1.1:  Screening and Follow up
Procedure 
Screening1
(up to 28 days prior to 
Treatment Period 1, Day 1)
Follow up
(7-10 days post 
last dose)
Notes
Informed consent
X
Inclusion and exclusion criteria
X
Demography
X
Full physical exam, including height and weight
X
X
Height and weight to be measured at screening only.  Weight at screening 
will be used for dosing calculation.
Alcohol, Drugs of Abuse, Smoking test
X
Medical history (includes substance usage  
[and family history of premature CV disease])
X
Substances: Drugs, Alcohol, tobacco
Past and current medical conditions [including 
cardiovascular medical history]
X
Serum OR urine pregnancy test (WCBP)
X
HIV, Hep B and Hep C screen
X
Laboratory assessments (include liver 
chemistries)
X
X
Non Fasting 
Immunogenicity
X
X
12-lead ECG
X
X
Triplicate ECG required at screening.
Vital signs
X
X
Triplicate vital signs required at screening. 
Spirometry
X
Echocardiogram
X
Concomitant Medication review 
X
X
Hypoxia chamber plus exercise 
X
Tolerance to 4000m for 10 mins followed by followed by incremental exercise 
testing to determine maximum oxygen uptake (VO2max) and calculate 70% of 
VO2max for the (to be used for the exercise challenge during the 
Treatment Periods).  
Pharmacogenetic sample (PGx)
X
Can be taken any time after consent has been signed. Only required once and 
is optional. 
AE/SAE review
X
X
As per timings detailed in Section 7.2.1.1
1.
Screening assessments are allowed to be conducted on more than one day
 
 
 
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Section 7.1.2:  Treatment Period 1 and 2
Procedure
Treatment Period 1 and 2 (Washout 3-14 days)
Notes
Times relative to 
start of dosing
Hypoxic Challenge ~80 min
(Times relative to entry to 
Chamber)
Pre-dose
0h
15 min
15-45 min
0-60 min
60 min
60-70 min
Immediately after 
exercise
30m rest On exit 
from chamber
After 30 min rest
60 min after exit 
from Chamber 
Randomisation
X
Randomisation can occur up to the day before 
the first treatment period
Brief physical exam 
X
Vital signs
X
X
X5
X
Immunogenicity
X
Treatment period 2 only 
12-lead ECG
X
X
X
Echocardiogram
X
X
X
X
X
Echocardiogram duration approx 5 min
Subject enters chamber
X
Subject enters chamber approximately 30 min 
after study treatment
Study Treatment (Dosing) 
X
Subject leaves chamber
X
Subject leaves chamber after the fourth 
echocardiogram, blood samples and vital signs 
have been taken.
Exercise challenge
X
For approx 5-10 minutes
Ventilatory parameters
X
X
X
X1
X
Measurements to be taken at the same time as
the2 min before echocardiograms. During the 
exercise challenge, an ECG integrated with the 
ventilatory assessment will be carried out.
Pulse Oximetry
(O2 saturation)
--------------------------------------------------------------------------------------------------------
Will be continuously monitored for safety. A 
measurement should be recorded at time of each 
echocardiogram post-treatment and databased.
Telemetry
--------------------------------------------------------------------------------------------------------
Will be continuously monitored for safety.
 
 
 
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Procedure
Treatment Period 1 and 2 (Washout 3-14 days)
Notes
Times relative to 
start of dosing
Hypoxic Challenge ~80 min
(Times relative to entry to 
Chamber)
Pre-dose
0h
15 min
15-45 min
0-60 min
60 min
60-70 min
Immediately after 
exercise
30m rest On exit 
from chamber
After 30 min rest
60 min after exit 
from Chamber 
RAS Biomarkers
X
X1
X2
X3
X2
X2
X4
X2
Other BiomarkersSP-D
X
X1
X2
X3
X2
X2
X4
X2
PK sampling
X
X1
X2
X3
X2
X2
X4
X2
AE/SAE review
============================================================
Concomitant medication review
X
1.
To be taken at the end of exercise Take at the end of the infusion
2.
Taken immediately after echocardiogram.
3.
Immediately before entering the chamber
4.
To be taken as soon as possible after leaving chamber
5.
On this occasion ONLY, vital signs to be taken after the blood draw.
 
 
 
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Section 7.2.1.3:  Follow-up of AEs and SAEs
Rationale for change:  Deletion of reference to AEs of special interest, as no AEs of 
special interest have been defined in the protocol.
After the initial AE/SAE report, the investigator is required to proactively follow each 
subject at subsequent visits/contacts.  All SAEs, and non-serious AEs of special interest 
(as defined in Section 4.6.1) will be followed until resolution, until the condition 
stabilizes, until the event is otherwise explained, or until the subject is lost to follow-up 
(as defined in Section 5.4). Further information on follow-up procedures is given in 
Appendix 4.
Section 7.2.2:  Physical Exams
Rationale for change:  Height and Weight removed from follow-up visit, as not required.

A complete physical examination will include, at a minimum, assessment of the 
Cardiovascular, Respiratory, Gastrointestinal and Neurological systems. Height and 
weight will also be measured and recorded, at screening only. This will be carried 
out at screening and follow up. 
Section 7.2.3:  Vital Signs
Rationale for change:  Correction of typographical errors.

Triplicate measurements will be taken at screening, and single measurements at 
other time-points.  Three readings of blood pressure and pulse rate will be taken.
The first reading should be rejected.  Second and third readings should be averaged 
to give the measurement to be recorded in the CRF. (Triplicate measurements will 
only be taken at screening and single measurements to be taken after that).
Section 7.2.4:  Electrocardiogram (ECG)
Rationale for change:  QTc Stopping Criteria removed from Section 7.2.5, and inserted 
into Section 5.4 with the other subject stopping criteria.

Triplicate 12-lead ECGs will be obtained at screening.  At all other time-points, a 
single 12-lead ECGs will be obtained at each time point during the study using an 
ECG machine that automatically calculates the heart rate and measures PR, QRS, 
QT, and QTc intervals.  Refer to Section 5.4.2 for QTc withdrawal criteria and 
additional QTc readings that may be necessary.

ECG to be measured in a semi-supine position after 5 minutes rest.

The same QT correction formula must be used for each individual subject for all 
QTc data being collected for data analysis.  Safety ECGs and other non-
protocol specified ECGs are an exception.
 
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7.2.5 QTc Stopping Criteria

The same QT correction formula must be used for each individual subject to 
determine eligibility for and discontinuation from the study.  This formula may not 
be changed or substituted once the subject has been enrolled.

For example, if a subject is eligible for the protocol based on QTcB, then QTcB must 
be used for discontinuation of this individual subject as well.

Once the QT correction formula has been chosen for a subject’s eligibility, the same 
formula must continue to be used for that subject for all QTc data being collected for 
data analysis.  Safety ECGs and other non-protocol specified ECGs are an exception.  

The QTc should be based on single or averaged QTc values of triplicate 
electrocardiograms obtained over a brief (e.g. 5-10 minute) recording period.
A subject that meets either bulleted criterion below will be withdrawn from the study.

QTcB or QTcF > 500 msec,

Change from baseline: QTc >60 msec
Section 7.2.5:  Clinical Safety Laboratory Assessments
Rationale for change:  Correction of typographical errors.  Addition of urea to clinical 
chemistry parameters, to allow the calculation of BUN.
All protocol required laboratory assessments, as defined in Table 2, must be conducted in 
accordance with the Protocol Time and Events Schedule. Laboratory requisition forms 
must be completed and samples must be clearly labelled with the subject number, 
protocol number, site/centre number, and visit date. Details for the preparation and 
shipment of samples will be provided by the laboratory and are detailed in the laboratory 
manual. Reference ranges for all safety parameters will be provided to the site by the 
laboratory responsible for the assessments.
If additional non-protocol specified laboratory assessments are performed at the 
institution’s local laboratory and result in a change in subject management or are 
considered clinically significant by the investigator (e.g., SAE or AE or dose 
modification) the results must be recorded in the CRF.
Refer to the SRM for appropriate processing and handling of samples to avoid duplicate 
and/or additional blood draws.
Haematology, clinical chemistry, urinalysis and additional parameters to be tested are 
listed in Table 2. 
 
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Table 2
Protocol Required Safety Laboratory Assessments
Laboratory 
Assessments
Parameters
Haematology
Platelet Count
RBC Indices:
WBC count with Differential:
RBC Count
MCV
Neutrophils
Hemoglobin
MCH
Lymphocytes
Hematocrit
Monocytes
Eosinophils
Basophils
Clinical 
Chemistry 1
BUN
Potassium
AST (SGOT)
Total and direct bilirubin
Urea
Sodium
ALT (SGPT)
Total Protein
Creatinine
Calcium
Alkaline phosphatise
Albumin
Glucose 
Routine 
Urinalysis

Specific gravity

pH, glucose, protein, blood and ketones by dipstick

Microscopic examination (if blood or protein is abnormal)
Other 
Screening 
Tests

HIV

Hepatitis B (HBsAg)

Hepatitis C (Hep C antibody)

Alcohol, smoking and drug screen (to include at minimum: 
amphetamines, barbiturates, cocaine, opiates, cannabinoids, 
benzodiazepines and cotinine) performed at site

Urine hCG Pregnancy test (as needed) 2
NOTES :
1. Details of Liver Chemistry Stopping Criteria and Required Actions and Follow-Up 
Assessments after liver stopping or monitoring event are given in Section 5.4.2 and 
Appendix 2.
2. Local urine testing will be standard for the protocol unless serum testing is required 
by local regulation or ethics committee.
Section 7.3.1:  Exercise Challenge
Rationale for change:  Clarification of exercise test.
Subjects will perform an exercise challenge at 70% of maximum VO2 uptake on a cycle 
ergometer within the hypoxia chamber for 10 minutes as detailed in the SRM.
Subjects must complete a minimum of 5 minutes exercise at 70% of maximumVO2 
uptake (calculated from the incremental exhaustive exercise test at the screening 
visit).
 
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Section 7.5:  Ventilatory parameters 
Rationale for change:  Clarification of ventilatory parameter assessment.
Ventilatory parameters will be measured as detailed in the Time and Events table 
(Section 7.1). 
Ventilatory parameters will be recorded for 2 minutes before echocardiograms.  
The second minute of the recording will be averaged and used for data analysis.
Measurements may include change from baseline of oxygen consumption (VO2), carbon 
dioxide production (CO2), total tidal volume, inspiratory tidal volume, expiratory 
tidal volume, total respiratory time, inspiratory time, expiratory time, duty cycle, 
mean respiratory flow and respiratory rate and other parameters as data permit.
Further details can be found in the SRM
Section 7.7:  Telemetry
Rationale for change:  Addition of telemetry.
Continuous ECG monitoring will occur via telemetry during both treatment 
periods.
Section 7.9.1:  Renin-angiotensin system biomarkers
Rationale for change:  Clarification of archiving procedure.
RAS peptides including, but not limited to, AngII, Ang(1-7) and Ang(1-5) may be 
analysed as data permit.  Raw data will be archived at the Bioanalytical Site 
(Bioanalytical Site detailed in the SRM).  
Section 7.9.2:  Surfactant Protein-D and other biomarkers
Rationale for change:  Removal of some exploratory biomarkers.
SP-D will be analysed.  Raw data will be archived at the Bioanalytical Site 
(Bioanalytical Site to be detailed in the SRM).  Additional analytes may be analysed, 
as data permit.  Peptide hormones such as Kinins (e.g. des-Arg-bradykinin), apelins 
(e.g. Apelin 13, pyr1-Apelin, 13) and other systems (e.g. dynorphin A) may be analysed 
as data permit.
Atrial Naturetic peptide (ANP), Brain Naturetic Peptide (NT-proBNP), Troponin I, 
Surfactant Protein D, IL-6 and/or additional analytes to be determined may also be 
analysed as data permit.
 
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Section 9.2:  Sample Size Considerations
Rationale for change:  Refer to rationale stated for Section 4.3 and Section 5.4.1.
The sample size of 30 20 patients is based on logistical considerations and is not based on 
formal sample size calculations.  However, estimates of precision for the treatment 
difference in the primary endpoint are presented for context (Note: precision in this 
context is defined as one half of the width of the 95% confidence interval).  A sample 
size re-estimation is planned after 15 10 subjects. 
Section 9.2.2:  Sample Size Re-estimation
Rationale for change:  Refer to rationale stated for Section 4.3 and Section 5.4.1.
A sample size re-estimation will be conducted at the interim analysis (see Section 9.3.2). 
The purpose of the sample size re-estimation is to determine whether the total number of 
subjects can be reduced below the anticipated 3020, based on treatment comparison 
between GSK2586881 and Placebo in change from pre-dose PASP to hypoxic/exercised 
PASP (i.e. T3-T0). The sample size re-estimation is to be considered advisory, and taken
into account together with other considerations.
Section 9.3.1:  Analysis Populations
Rationale for change:  Correction of typographical errors.
Intent-to-Treat (ITT) Population: This population will comprise all randomised subjects, 
excluding those who were randomised in error. A subject who is recorded as a screen 
failure, run-in failure, or stabilisation failure, but is randomised and does not receive a 
dose of study treatment, is considered to be randomised in error. Any other subject who 
receives a randomisation number will be considered to have been randomised. This will 
constitute the primary population for all efficacy and safety and pharmacodynamic
analyses.
Section 9.3.2:  Interim Analysis
Rationale for change:  Refer to rationale stated for Section 4.3 and Section 5.4.1.
An interim analysis is planned after 15 10 subjects have completed the following critical 
assessments:

PASP at T0 and T3 for both study periods

Oxygen saturation at T0 and T3 for both study periods

Adverse events 
The interim analysis will use the following study data:

PASP at time T0 and T3 for both periods, for the first 15 10 subjects
 
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
Oxygen saturation at T0 and T3 for both periods, for the first 15 10 subjects

Adverse events for the first 15 10 subjects

Angiotensin biomarkerRAS peptide concentrations for the first 5 subjects (to 
allow time for the samples to be analysed by the external lab).
The interim analysis will use a data snapshot that has been cleaned to the best extent 
allowed by the timeframes (i.e. the interim data will not be fully cleaned or fully QC’d 
data and there will not be a locked database).
The aims of the interim analysis, and the endpoints to be used to address them, are as 
follows:

Using the primary endpoint (treatment differences between GSK2586881 and 
Placebo in change from pre-dose PASP to hypoxic/exercised PASP [T3-T0]):
o
To decide whether to continue the study or stop based on futility, and
o
to conduct an advisory sample-size re-estimation with the view to 
potentially reduce the number of subjects participating in the study below 
3020.

Using secondary endpoints:
o
to estimate treatment differences between GSK2586881 and Placebo in 
change from pre-dose oxygen saturation to hypoxic/exercised oxygen 
saturation [T3-T0], with a view to stopping the study if there is evidence 
that GSK2586881 causes a reduction in oxygen saturation in healthy 
volunteers. As a non-binding guide high posterior probability of observing 
5% absolute differences in mean oxygenation saturation values between 
placebo and active arms would be of concern; but clinical judgement 
would override any statistical methods if, for example, the majority of 
subjects displayed consistent patterns of reductions e.g. between 2-3%).
o
to compare adverse events within the two treatment groups and explore 
any potential safety signals that may emerge
To assess the operating characteristics of the interim analysis decisions to be made based 
on the primary endpoint, a simulation was carried out to estimate the relative proportion 
of studies reaching conclusions to stop for futility, continue with no change to the sample 
size, and to continue with a reduced sample size, under various different scenarios of the 
true treatment effect. Broadly speaking, the aim of the simulation was to confirm that (in 
an overwhelming majority of cases) a decision to stop for futility would be reached in the 
case of no true treatment effect and a decision to continue (perhaps with reduced sample 
size) would be reached in the case of a true treatment effect.
 
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Simulated datasets of PASP at baseline (i.e. normoxic and at rest) and under hypoxia and 
exercise for 15 10 subjects, each receiving both treatments in sequence, were generated 
using the following assumptions:

15 10 simulated subjects were randomised to one of the two available treatment 
sequences (see Section 6.2) using block randomisation with block size of 4 records

PASP at baseline and under hypoxia and exercise for both treatment groups (a total of 
four PASP measurements per subject) were sampled from a multivariate normal 
distribution, using values for mean PASP, standard deviation of PASP and within-
subject correlation of PASP as described below.

Mean PASP was 30 mmHg at baseline (i.e. normoxic and at rest) for both treatments, 
and 45 mmHg under hypoxia and exercise for Placebo (as in Section 9.2.1). For 
GSK2586881, mean PASP under hypoxia and exercise was (45 - Δ) mmHg, where Δ 
(the mean treatment difference) was varied according to four different scenarios:
o
no treatment difference (Δ = 0 mmHg)
o
weak treatment difference of a magnitude of half the clinically meaningful 
difference (Δ = 2.5 mmHg)
o
minimum clinically meaningful difference (Δ = 5 mmHg)
o
overwhelming treatment difference one-and-a-half times the clinically 
meaningful difference (Δ = 7.5 mmHg)

SD of PASP was 2.81 mmHg at baseline and 4.30 mmHg under hypoxia and 
exercise, for both treatment groups (as in Section 9.2.1) 

The within-subject correlation of PASP was unknown, therefore four different 
scenarios of within-subject correlation were evaluated: zero correlation, low 
correlation (0.3), high correlation (0.6) and very high correlation (0.9) (as in Section 
9.2.1). Within-subject correlation of PASP was assumed to be compound symmetric 
(i.e. the same correlation was used for each of the six possible pairs of the four PASP 
measurements within each subject).

It was assumed that there would be no effect of period in the simulation, i.e. it was 
assumed that it would make no difference if the measurement was taken from the first 
or second chronological period in the treatment sequence.
Modelling took on a three-step process, with decisions after each. Firstly, the treatment 
difference and its associated standard error was then estimated for the dataset of 15 10
simulated subjects using a mixed effects linear regression model, including covariates for 
period, treatment, period baseline and subject baseline (the mean of the two period 
baselines) as fixed effects and subject as a random effect. If the sign of treatment 
difference arising from the simulated data was in the wrong direction (i.e. the simulated 
outcome for GSK2586881 was worse than for Placebo), then the simulated study was 
stopped for futility.
 
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Secondly, in the alternative case that the simulated treatment difference was in favour of 
GSK2586881 over Placebo, a posterior probability of success (where success was defined 
as a 97.5% posterior probability of the treatment difference being in favour of 
GSK2586881 over Placebo) was evaluated for 30 20 subjects. This was evaluated using a 
t-distribution, with the mean and standard deviation taken as the treatment difference and 
standard error (multiplied by a factor of the square root of 15 10  to estimate the standard 
deviation) from step one, respectively.  If this posterior probability was less than 0.2, then 
the study was stopped for futility as being unlikely to show any benefit of GSK2586881 
over Placebo.
Thirdly, provided that the simulated study hadn't been stopped for futility in either of the 
first two steps, posterior probabilities of success were calculated for N ranging from 15
10 to 29 19 subjects. If any of these posterior probabilities of success were greater than or 
equal to 0.9, then the study was continued with a reduced sample size equal to the lowest 
N at which that threshold was reached. Otherwise, the conclusion from the simulated 
interim analysis would be to continue the study with unchanged sample size.
This whole process (simulating data for 15 10 subjects, modelling the treatment 
difference, evaluating posterior probabilities of success and simulating the decision-
making process) was replicated 10000 times for each scenario, with the decision ("futile", 
"no change to N" or "reduce N") recorded for each iteration. Each combination of the 
four treatment difference scenarios and the four correlation scenarios was evaluated for a 
total of 16 scenarios in all.
The estimated proportions of each decision being reached under each of the 16 scenarios 
are presented in Table 4.
Table 4 Operating characteristics of interim analysis at N=10 under four scenarios 
of treatment effect and four scenarios of within-subject correlation
Frequency of decisions (%)
Treatment 
effect 
Scenario
Within-subject 
correlation of PASP
Futile
Continue with 20
30 subjects
Continue with 
reduced sample 
size
Δ=0 mmHg (no treatment difference)
0.0
87 85%
13 15%
0 1%
0.3
87 85%
13 15%
1%
0.6
85%
15%
0 1%
0.9
86 85%
14%
0 1%
Δ=2.5 mmHg (weak treatment effect, less than clinically meaningful difference)
0.0
4431%
50 60%
9 6%
0.3
3624%
56 65%
11 9%
0.6
2110%
63 66%
25 16%
0.9
1 0%
319%
91 68%
Δ=5 mmHg (good treatment effect, at threshold of clinical meaningful difference)
0.0
9 2%
60 46%
31 52%
0.3
4 1%
54 35%
42 64%
0.6
1 0%
31 11%
68 89%
 
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Frequency of decisions (%)
Treatment 
effect 
Scenario
Within-subject 
correlation of PASP
Futile
Continue with 20
30 subjects
Continue with 
reduced sample 
size
0.9
0%
0%
100%
Δ=7.5 mmHg (very strong treatment effect)
0.0
1 0%
32 10%
67 90%
0.3
0%
18 2%
82 98%
0.6
0%
3 0%
96 100%
0.9
0%
0%
100%
These results suggest primarily that if there is no true treatment difference between 
GSK2586881 and Placebo, the study would be stopped for futility 8587% of the time 
(irrespective of within-subject correlation of PASP). A drug with a weak treatment effect 
would most likely result in the study being continued without change or stopped for 
futility (except in the case where within-subject correlation is 0.9, which is presented here 
as an extreme case, unlikely to occur in practice). If the true treatment effect is at the 
clinically relevant threshold of 5 mmHg, then the study is highly unlikely to be stopped 
for futility and may indicate being reduced in sample size.
Section 9.4:  Key Elements of Analysis Plan
Rationale for change:  Correction of typographical errors.
Each subject will undergo two treatment periods in this crossover study, each one of 
which being subdivided into five key sub-epochs (labelled T0-T4) as follows:

T0: Pre-dose (period baseline)

T1: Post-dose, normoxic, at rest, pre-challenge

T2: Hypoxic, at rest

T3: Hypoxic, immediately after exercise

T4: Post-challenge, normoxic, at rest
This follows the principle illustrated in the diagram of echocardiograph measurements 
(Figure 2).
Pharmacodynamic endpoints PASP and Oxygen Saturation will be assigned to T0 thru 
T4 timepoints based on when they happened relative to the sequence of events that the 
subject undertakes during the course of the study day.  Biomarkers will be collected at 
times T0 thru T4, plus additional time-points.
Pharmacokinetic endpoints will be timed based on elapsed time since dose 
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In addition to T0 being defined as the period baseline, an overall subject baseline will be 
defined as the mean of the two T0 measurements (one from each period).
Change from baseline at time points T1 - T4 will be calculated as the difference between 
the measurement at the time point in question and the period baseline.  In general, 
statistical modelling of changes from baseline will be done using a Bayesian mixed 
effects regression model, including covariates for period, treatment, period baseline and 
subject baseline (the mean of the two period baselines).  as fixed effects and s Subject 
will be fitted as a random effect and non-informative priors will be used for model 
parameters. A compound symmetric covariance structure within each subject-period-
treatment cell will be assumed to account for repeated measurements a) inherent in the 
two-period crossover design and b) due to the four post-baseline timepoints within each 
treatment period.
Section 12.2:  Appendix 2: Liver Safety Required Actions and Follow up Assessments
Rationale for change:  Correction of typographical error.
Footnote 4:  PK sample may not be required for subjects known to be receiving placebo or non-GSK comparator 
treatments. Record the date/time of the PK blood sample draw and the date/time of the last dose of study treatment 
prior to blood sample draw on the CRF. If the date or time of the last dose is unclear, provide the subject’s best 
approximation. If the date/time of the last dose cannot be approximated OR a PK sample cannot be collected in the 
time period indicated above, do not obtain a PK sample. Instructions for sample handling and shipping are in the SRM.
Section 12.4.1:  Definition of Adverse Events
Rationale for change:  Removal of AE definitions related to efficacy, because this is not a 
patient study.
Events meeting AE definition include:

Any abnormal laboratory test results (hematology, clinical chemistry, or urinalysis) 
or other safety assessments (e.g., ECGs, radiological scans, vital signs 
measurements), including those that worsen from baseline, and felt to be clinically 
significant in the medical and scientific judgement of the investigator.

Exacerbation of a chronic or intermittent pre-existing condition including either an 
increase in frequency and/or intensity of the condition.

New conditions detected or diagnosed after study treatment administration even 
though it may have been present prior to the start of the study.

Signs, symptoms, or the clinical sequelae of a suspected interaction.

Signs, symptoms, or the clinical sequelae of a suspected overdose of either study 
treatment or a concomitant medication (overdose per se will not be reported as an 
AE/SAE unless this is an intentional overdose taken with possible suicidal/self-
harming intent.  This should be reported regardless of sequelae).

"Lack of efficacy" or "failure of expected pharmacological action" per se will not be 
reported as an AE or SAE.  However, the signs and symptoms and/or clinical 
sequelae resulting from lack of efficacy will be reported if they fulfil the definition 
 
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of an AE or SAE.

The signs and symptoms and/or clinical sequelae resulting from lack of efficacy will 
be reported if they fulfil the definition of an AE or SAE.  Also, "lack of efficacy" or 
"failure of expected pharmacological action" also constitutes an AE or SAE.
 
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12.6.3.
Protocol Amendment 03 (06-Mar-2018) from Protocol Amendment 
02 (07-Mar-2017)
This is a global amendment.
12.6.3.1.
Summary of Changes and Rationale for Amendment
This is a substantial protocol amendment to restart the trial following a temporary halt.  
The trial was halted following the planned interim analysis (when 10 subjects had 
completed both Treatment Periods) to allow the study team time to consider the data from 
the first part of the study (Part 1), and decide what changes would be made to the second 
part of the study (Part 2).  The study team made the following changes to the study in 
Part 2:

Increasing the altitude of the hypoxia chamber (Part 1: 4000 m, and Part 2: 5000 m).  

Changing the individual subject withdrawal criteria for oxygen saturation threshold 
during the hypoxia challenge (Part 1: below 65%; and Part 2:  below 60%
persistently for >15 seconds).

Modification of the exercise challenge:  
Changing from an upright ergometer (Part 1) to a semi-recumbent ergometer (Part 
2).  
Echo recordings taken during exercise (Part 2), rather than after exercise (Part 1).
Changing the workload of the exercise challenge, due to the change in chamber 
altitude (Part 1: 70% VO2 max to Part 2: 50% VO2 max).  

Modification of the echo recording procedure:  calculation of pulmonary artery 
systolic pressure (PASP) conducted after image acquisition in Part 2 (rather than 
during the recording, Part 1); and the addition of a physician ‘over-reader’ in Part 2 
to review all echo images/calculations and provide a quality statement (not used in 
Part 1).  

Addition of an exploratory echo endpoint in Part 2 allowing estimation of pulmonary 
vascular resistance.
See Section 12.6.3.2 below for a rationale for each change.
12.6.3.2.
List of Specific Changes
Title Page, Author (s)
Rationale for change:  Addition and removal of author(s).
 
Sponsor Signatory
Rationale for change:  Change in sponsor signatory.
 
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Dr Aili Lazaar Dr Tony Cahn
Director, Discovery Medicine, Project Physician Leader, Respiratory Therapy Area
Medical Monitor/SAE Contact Information: 
Rationale for change: Switch in primary and secondary medical monitor roles.
Role
Name
Day Time Phone 
Number and email 
address
After-hours 
Phone/Cell/
Pager Number
Fax 
Number
Site Address
Primary 
Medical 
Monitor
709 Swedeland 
Road
UW2531
King of Prussia, 
PA  19406 USA
Gunnels 
Wood Road, 
Stevenage, 
Hertfordshire, 
SG1 2NY, UK
Secondary 
Medical 
Monitor 
Gunnels Wood 
Road, 
Stevenage, 
Hertfordshire, 
SG1 2NY, UK
709 Swedeland 
Road
UW2531
King of 
Prussia, PA  
19406 USA
SAE
contact
information
[Medical
monitor
as 
above]
Protocol synopsis for study 204987:
Protocol synopsis updated to reflect changes in the main body of the protocol.
 
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Section 2.1.1: Rationale for changes to the study following interim analysis:
Rationale for change: Clarification of the rationale behind protocol changes following 
interim analysis.
As planned in the original protocol, an interim analysis was conducted when 10 
subjects had completed both Treatment Periods.  Data from the first 11 subjects 
were reviewed, because Subject 
 was withdrawn during Treatment Period 1 
(withdrawn due to dizziness – investigator considered that this was unrelated to 
study treatment, and was most likely a vasovagal response to cannulation).  
As planned, a core sub-set of the study team (as defined in Section 6.3) reviewed 
unblinded PASP, oxygen saturation, AE and RAS peptide data (RAS peptide data 
from only 5 subjects, as planned; see Section 9.3.2).  The AE data indicated no safety 
concerns:  in total, 5 AEs were reported, 1 was considered severe (as described 
above for Subject 
 and all were considered by the investigator to be unrelated to 
study treatment.  The RAS peptide data indicated target engagement.  
Review of PASP data indicated that an HPV response could not consistently be 
detected in the first 10 subjects who completed the study.  An increase in PASP at 
T2 and T3 compared with baseline was not consistently observed.  A decrease in 
oxygen saturation was observed at T2 (mean ~85%) and a further decrease at T3 
(mean ~82%) compared with ~96% at baseline (similar in both Treatment Periods).
The study was placed on hold to allow the team to consider the data from the first 
part of the study (Part 1), and decide what changes would be made to the second 
part of the study (Part 2).  The team concluded the following:

In previous studies assessing HPV in healthy volunteers, increases in PASP were 
associated with more significant oxygen desaturation (Ricart, 2005; mean 
oxygen saturation in hypoxia was 79.4%, and simultaneous hypoxia and 
exercise was 63.5%).  In Part 1 of the study, the altitude of the hypoxia chamber 
was 4000 m.  In Part 2 of the study, the altitude will be increased to 5000 m in 
order to induce greater oxygen desaturation and associated increases in 
pulmonary pressures.

It is anticipated that increasing the altitude of the chamber from 4000 to 5000 m 
will reduce oxygen saturation to as low as 65% in some subjects (when 
concurrently exercising).  Therefore, the current individual subject withdrawal 
criteria of oxygen saturation falling below 65% during the hypoxia challenge 
(see Section 5.4) will be reduced to below 60% and persistently for >15 seconds 
added as a timeframe.  This is justified, because subjects will be continually 
monitored during the challenge, and immediately removed from the chamber 
should oxygen saturation decline to the withdrawal limit.  Oxygen saturation 
recovery on returning to normoxia is very rapid.

The exercise challenge in Part 2 will be modified.  In Part 1 of the study, PASP 
data at the T3 time-point were extremely variable.  Review of the literature
shows that any exercise-induced increase in PASP will decline to baseline 
extremely rapidly following cessation of exercise (Argiento, 2010).  This likely 
 
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explains the unreliability of data at T3.  In Part 2, the exercise challenge will be 
conducted on a semi-recumbent ergometer, allowing acquisition of echo 
recordings during (rather than after) exercise.  The workload of the exercise 
challenge will be reduced (from 70% VO2max to 50% VO2max), because of the 
increase in chamber altitude.  Additionally, echo recordings will be taken within 
2 minutes of starting exercise, rather than after exercise, based on reports that 
prolonged steady state exercise can conversely decrease pulmonary vascular 
pressures, due to a reduction in pulmonary blood volume as the systemic 
circulation adapts (Naeije, 2018).

In Part 2 of the study, at all time-points, the protocol for echo recordings will be 
modified with the aim of improving data quality and reliability.  The following 
changes will be made:  calculation of PASP (outlined in Section 7.4) will be 
conducted after image acquisition (rather than during the recording); the 
sonographer will aim to capture at least 5 good quality images to estimate 
PASP; and a physician ‘over-reader’ process will be introduced.  PASP will be 
calculated by a primary reader (the sonographer) and all echo 
images/calculations will be reviewed by a suitably qualified physician, who will 
provide a quality statement.  

In Part 2 of the study, an exploratory echo endpoint has been added, which will 
allow the estimation of pulmonary vascular resistance (PVR).  
Section 3: Objectives and Endpoints:
Rationale for change:  Addition of PVR as an exploratory endpoint.
Objectives
Endpoints
Primary

To evaluate the effect of a single IV dose of 
GSK2586881 on the HPV response in 
healthy volunteers during exercise under 
hypoxic conditions.

Change from baseline of Pulmonary Artery 
Systolic Pressure (PASP) measured via 
Echocardiography.
Secondary

To evaluate the effect of a single IV dose 
GSK2586881 on RAS peptide responses. 

Effect of GSK2586881 on baseline levels 
and changes in response to hypoxia and 
exercise of RAS peptides (e.g. Ang II, 
Ang(1-7), Ang(1-5)).

To evaluate the safety of a single IV dose of 
GSK2586881 in healthy volunteers.

Vital signs (heart rate, systolic and diastolic 
blood pressure), oxygen saturation, 12-lead 
ECGs, AEs, immunogenicity and clinical 
laboratory assessments and continuous 
pulse oximetry.

To evaluate the pharmacokinetics of a 
single IV dose of GSK2586881. 

Plasma concentrations of GSK2586881 and 
derived pharmacokinetic parameters.
 
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Objectives
Endpoints
Exploratory 

To evaluate the effect of a single IV dose of 
GSK2586881 on ventilatory parameters in 
healthy volunteers during exercise in 
hypoxic conditions.

Change from baseline of oxygen 
consumption (VO2), carbon dioxide 
production (CO2) and other parameters as 
data permit.

To evaluate the pharmacodynamic activity 
of a single IV dose of GSK2586881 in 
healthy volunteers during exercise in 
hypoxic conditions.

Change from baseline in Surfactant Protein 
(SP-D) and/or additional analytes to be 
determined.

To evaluate Pharmacogenetics.

Evaluate I/D polymorphisms in the 
Angiotensin Converting Enzyme (ACE) 
gene and analyse the impact on Ang II (and 
possibly other RAS peptides), hypoxic 
pulmonary vasoconstriction and responses 
to GSK2586881 administration.

To evaluate the effect of a single IV dose 
of GSK2586881 on the HPV response in 
healthy volunteers under hypoxic 
conditions (and during exercise under 
hypoxic conditions).

Estimation of pulmonary vascular
resistance (PVR) measured via 
echocardiography.
Section 4.1: Overall Design
Rationale for change: Clarification of the change in study design following interim 
analysis
This is a single-centre, randomised, placebo-controlled and double blind (sponsor open), 
two-period crossover study in healthy subjects. 
An interim analysis was conducted when 10 subjects had completed both Treatment 
Periods (Part 1).  The study was placed on hold to allow the study team to consider 
the data from the first part of the study (Part 1).  The study will now restart, with 
the modifications described in Section 2.1.1, and the second part of the study is 
designated Part 2.
The subjects will be required to attend the unit for a screening visit, Treatment Period 1, 
Treatment Period 2 and a follow up visit.
Section 4.2: Treatment arms and duration:
Rationale for change:  Clarification to distinguish between Part 1 and Part 2 of the 
study.
 
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Figure 3
Part 1:  Approximate timing of simulated altitude and echocardiogram 
measurements (black arrows) during Treatment Periods 1 and 2
Figure 3 is applicable also to Part 2 of the study, with the following modifications:  
simulated altitude will be 5000 m, and the T3 echo will be taken 2 minutes into the 
exercise challenge (rather than at the end of a 10-minute exercise challenge).
There will be a washout period of 3–14 days between treatments to ensure biomarkers 
return to pre-challenge baseline.  Subjects then return to the site and repeat the same 
procedures as above, except that they will receive the treatment (GSK2586881 or Saline) 
that they did not receive in the first period.
Section 4.3:  Type and Number of Subjects:
Rationale for change:  Clarification to distinguish between Part 1 and Part 2 of the 
study.
Approximately 25 subjects healthy volunteers will be randomised such that 
approximately 20 evaluable subjects complete the study.  Eleven subjects were enrolled 
into Part 1 of the study (before the first interim analysis), and up to 14 subjects will 
be enrolled into Part 2 of the study.  The target of 20 evaluable subjects (the target of 
20 may be revised following the sample size re-estimation, see Section 9.2.2.
If subjects prematurely discontinue the study, additional replacement subjects will not be 
recruited in order to preserve randomisation integrity.
Section 4.5: Dose Justification:
 
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Rationale for change:  Study 204696 has been completed and reported since the protocol 
was amended in March 2017.
GSK2586881 has been studied in 21 healthy subjects as single, intravenous doses over
30 minutes from 0.1 mg/kg to 1.2 mg/kg, and in repeated daily doses for up to six days of 
0.4 mg/kg once a day.  In addition, ARDS patients have received four doses of 
GSK2586881: 0.1 mg/kg, 0.2 mg.kg, 0.4 mg/kg and 0.8 mg/kg over a 24 hour period 
(n=5) or 0.4 mg/kg BID twice daily for 3 days (n=19). In a concluded (but not yet 
reported) investigator-sponsored study in Pulmonary Arterial Hypertension (PAH) (Study 
204696), 5 subjects have received a single dose of either 0.2 mg/kg or 0.4 mg/kg.  There 
were no SAEs associated with the infusion of GSK2586881 or reported within the 2-
week period of study observation.  There were no clinically significant changes in 
laboratory or vital signs measurements for any subject.
 
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Section 4.6.1: Risk Assessment:
Rationale for change:  Inclusion of hypoxia risk and mitigation to clinical unit staff.
Potential Risk of Clinical Significance
Summary of Data/Rationale for Risk
Mitigation Strategy
Investigational Product (IP) [GSK2586881]
Cardiovascular risk
During preclinical testing a brief period of non-
sustained ventricular tachycardia was observed 
in one monkey receiving a dose of 20.8 
mg/kg/day.
The dose used in this study is much lower and 
well below the No observed adverse effect level
(NOAEL) for the 14 day repeat dose cynomolgus 
monkeys of 8 mg/kg/day.  
Potential Reproductive/embryofetal risks
Preclinical studies have not been performed.
Women of childbearing potential will be excluded 
from the study.
Potential for Immunogenicity
There has been no induction of an immune 
response to rhACE2 in either of the clinical 
studies to date in healthy subjects or participants 
with ARDS.
Patients will have routine monitoring of any 
immunological response that may occur.  If an 
immunological response is seen the patient will 
be asked to return for further monitoring and 
assessment(s).
Potential for rash
In study ACE114622, rash was reported more 
frequently in subjects receiving GSK2586881, 
although only one event was considered drug-
related.
Patients will be monitored for rash in the clinical 
trials.
 
 
 
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Potential Risk of Clinical Significance
Summary of Data/Rationale for Risk
Mitigation Strategy
Study Procedures
Effects of hypoxia to study subjects (light 
headiness, headaches, nausea)
The subjects will be exposed to hypoxic 
conditions for approximately 80 minutes with a 
simulated altitude of 4000 m5000 m.
The subjects will be continuously observed and 
monitored with telemetry and pulse oximetry.  
Stopping criteria are included in the protocol. 
Effects of hypoxia to staff at the clinical unit 
(light headiness, headaches, nausea)
Clinical site staff performing the 
assessments within the hypoxia chamber will 
potentially be exposed to hypoxic conditions 
with a simulated altitude of 5000 m.
All clinical staff entering the hypoxia 
chamber will be provided with an ambulatory 
oxygen supply.
 
 
 
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Section 5.4: Withdrawal/Stopping Criteria
Rationale for change: Change in oxygen saturation withdrawal criteria.
Subjects may be withdrawn from the study for any of the following reasons: 

A subject may withdraw from study treatment at any time at his/her own request, or 
may be withdrawn at any time at the discretion of the investigator for safety, 
behavioural or administrative reasons. If a subject withdraws from the study, he/she 
may request destruction of any samples taken, and the investigator must document 
this in the site study records. 

If a subject’s oxygen saturation falls below 65%60% (persistently for >15 seconds)
at any point during the hypoxia challenge. 

If the subject experiences worsening shortness of breath or other symptoms, which in 
the opinion of the investigator are consistent with altitude sickness.

The Sponsor may request a subject withdraw for reasons such as significant protocol 
deviations (after discussion with the investigator).

Study is terminated by the Sponsor.
Section 5.4.1 Study Stopping Criteria
Rationale for change: Clarification to distinguish between Part 1 and Part 2 of the 
study.
An interim analysis is planned after approximately 10 subjects have completed treatment 
periods 1 and 2 and the study may be stopped if a reasonable change in PASP is not 
observed after dosing with GSK 2586881 or if review of the safety data suggests a 
change in the benefit-risk profile.  The decision to stop the study will be made by the core 
members of the GSK study team.An interim analysis was conducted when 10 subjects 
had completed both Treatment Periods (Part 1).  The study team decided to 
continue the study (Part 2), with modifications to the protocol (see Section 2.1.1).  In 
Part 2, an interim analysis will be conducted when approximately 3 subjects 
complete both Treatment Periods, and further interim analyses may be conducted 
(see Section 9.3.2).  The study may be stopped if PASP results are highly variable, or 
if the PASP profile for the placebo group is not as expected (indicative of the model 
not working given the alterations to the study) or if review of the safety data suggest 
a change in benefit-risk profile.  The decision to stop the study will be made by the 
core members of the GSK study team.
Safety data that is collected on a continuous basis (oxygen saturation and telemetry) will 
be monitored live on site to determine whether a subject tolerates the hypoxia/exercise 
challenge; study procedures may be aborted on safety grounds if, in the Investigator's 
opinion, any of these measurements reach unsafe levels.  The simulated altitude within 
the chamber may be reduced if too many participants fail to tolerate the challenge, and 
the study may be stopped if participants fail to tolerate the challenge at the minimum 
altitude.  The full criteria for this procedure (which may lead to the study being stopped) 
are described in Section 7.3.
 
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In addition, the study may be stopped at the interim analysis for a safety signal in oxygen 
saturation under hypoxia and exercise, combined with a lack of evidence of mechanistic 
effect on Angiotensin biomarkers (Ang II, Ang 1-7 and Ang 1-5).  Full details on 
stopping criteria are described together with the full procedure for the interim analysis in 
Section 9.3.2.
Section 7.1: Time and Events Table:
Rationale for change:

Clarification to distinguish between Part 1 and Part 2 of the study.

Change of echo and pulse oximetry recording from timepoint “immediately after 
exercise” to “2 minutes into exercise”
 
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Section 7.1.1: Screening and Follow up:
Procedure 
Screening1
(up to 28 days prior to 
Treatment Period 1, Day 1)
Follow up
(7-10 days post 
last dose)
Notes
Informed consent
X
Inclusion and exclusion criteria
X
Demography
X
Full physical exam, including height and weight
X
X
Height and weight to be measured at screening only.  Weight at screening will 
be used for dosing calculation.
Alcohol, Drugs of Abuse, Smoking test
X
Medical history (includes substance usage 
[and family history of premature CV disease])
X
Substances: Drugs, Alcohol, tobacco
Past and current medical conditions [including 
cardiovascular medical history]
X
Serum OR urine pregnancy test (WCBP)
X
HIV, Hep B and Hep C screen
X
Laboratory assessments (include liver 
chemistries)
X
X
Non-Fasting 
Immunogenicity
X
12-lead ECG
X
X
Triplicate ECG required at screening.
Vital signs
X
X
Triplicate vital signs required at screening. 
Spirometry
X
Echocardiogram
X
Concomitant Medication review 
X
X
Hypoxia chamber plus exercise 
X
Part 1:  Tolerance to 4000m for 10 mins followed by incremental exercise 
testing to determine maximum oxygen uptake (VO2max) and calculate 70% of 
VO2max (to be used for the exercise challenge during the Treatment Periods).  
Part 2:  Tolerance to 5000m for 10 mins followed by incremental exercise 
testing to determine maximum oxygen uptake (VO2max) and calculate 
50% of VO2max (to be used for the exercise challenge during the 
Treatment Periods)
Pharmacogenetic sample (PGx)
X
Can be taken any time after consent has been signed. Only required once and 
is optional. 
AE/SAE review
X
X
As per timings detailed in Section 7.2.1.1
3.
Screening assessments are allowed to be conducted on more than one day
 
 
 
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Section 7.1.2: Treatment Period 1 and 2:
Procedure
Treatment Period 1 and 2 (Washout 3-14 days)
Notes
Times relative to start 
of dosing
Hypoxic Challenge ~80 min 
(Times relative to entry to 
Chamber)
Pre-dose
0h
15 min
15-45 min
0-60 min
60 min
60-70 min
Immediately after 
exercise
On exit from 
chamber
After 30 min rest
60 min after exit 
from Chamber 
Randomisation
X
Treatment Period 1 only.  Randomisation can 
occur up to the day before the first treatment 
period
Brief physical exam 
X
Vital signs
X
X
X5
X
Immunogenicity
X
12-lead ECG
X
X
X
Echocardiogram
X
X
X
X6
X
Echocardiogram duration approx 5 min
Subject enters chamber
X
Subject enters chamber approximately 30 min 
after study treatment
Study Treatment (Dosing) 
X
Subject leaves chamber
X
Subject leaves chamber after the fourth 
echocardiogram, blood samples and vital signs 
have been taken.
Exercise challenge
X
For approx 5-10 min
Part 1:  exercise at 70% VO2 max for ~5-10 
min.  Echo conducted immediately after.
Part 2:  exercise at 50% VO2 max for 2 min.  
Echo started at 2 min into the challenge, and 
the subject continues exercising.
 
 
 
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Procedure
Treatment Period 1 and 2 (Washout 3-14 days)
Notes
Times relative to start 
of dosing
Hypoxic Challenge ~80 min 
(Times relative to entry to 
Chamber)
Pre-dose
0h
15 min
15-45 min
0-60 min
60 min
60-70 min
Immediately after 
exercise
On exit from 
chamber
After 30 min rest
60 min after exit 
from Chamber 
Ventilatory parameters
X
X
X
X
Measurements to be taken 2 min before 
echocardiograms.
Pulse Oximetry
(O2 saturation)
================================================================
Will be continuously monitored for safety. A 
measurement should be recorded at time of 
each echocardiogram and databased.
Part 2:  when the echo is recorded during the 
exercise challenge, pulse oximetry will be 
recorded immediately prior to initiation of the 
echo at 2 minutes into exercise.
Telemetry
================================================================
Will be continuously monitored for safety.
RAS Biomarkers
X
X1
X2
X3
X2
X2
X4
X2
SP-D
X
X1
X2
X3
X2
X2
X4
X2
PK sampling
X
X1
X2
X3
X2
X2
X4
X2
AE/SAE review
============================================================
Concomitant medication review
X
1. Take at the end of the infusion
2. Taken immediately after echocardiogram 
3. Immediately before entering the chamber
4. To be taken as soon as possible after leaving chamber
5. On this occasion ONLY, vital signs to be taken after the blood draw.
6. In Part 2, echo at this time-point taken 2 minutes into the exercise challenge (not immediately after exercise).
 
 
 
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Section 7.3: Hypoxia Challenge
Rationale for change: Clarification of the changes to the hypoxia challenge between 
Part 1 and Part 2 of the study
Section 7.3.1: Part 1
Each subject will be inside the hypoxia chamber for approximately 80 minutes per 
period, during which time they will be under the full 4000 m ± 10% hypoxic conditions.  
If three or more subjects do not tolerate the hypoxic challenge, either due to symptoms or 
O2 saturation of <65%, then the simulated altitude will be adjusted in decrements of 
500 m (i.e. from 4000 m to 3500 m) for all remaining subjects to a minimum of 3000 m.
Section 7.3.2: Part 2
Each subject will be inside the hypoxia chamber for approximately 80 minutes per 
period, during which time they will be under the full 5000 m ± 10% hypoxic
conditions.  
If three or more subjects do not tolerate the hypoxic challenge, either due to 
symptoms or O2 saturation of <60% (persistently for >15 seconds), then the 
simulated altitude will be adjusted in decrements of 500 m (i.e. from 5000 m to 
4500 m) for all remaining subjects to a minimum of 4000 m.
Further detail about the hypoxia challenge is detailed in the SRM. 
Section 7.4: Exercise Challenge
Rationale for change:  Clarification of the changes to the exercise challenge between 
Part 1 and Part 2 of the study
Section 7.4.1: Part 1
Subjects will perform an exercise challenge at 70% of maximum VO2 uptake on an 
upright cycle ergometer within the hypoxia chamber for 10 minutes.
Subjects must complete a minimum of 5 minutes exercise at 70% of maximumVO2
uptake (calculated from the incremental exhaustive exercise test at the screening visit).
Section 7.4.2: Part 2
Subjects will perform an exercise challenge at 50% of maximum VO2 uptake on a 
semi-recumbent cycle ergometer within the hypoxia chamber (calculated from the 
incremental exhaustive exercise test at the screening visit).  Two minutes into the 
exercise challenge, the echo recording will be initiated.  The subject will exercise for 
a minimum of 5 minutes (or until the echo recording is completed, if the recording 
exceeds 5 minutes).
Further detail about the exercise challenge is detailed in the SRM. 
 
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Section 7.5: Echocardiogram
Rationale for change:  

Clarification of the changes to the echocardiogram between Part 1 and Part 2 of the 
study

Addition of an order of priority for echo parameters

Description of physician ‘over-reader’ procedure
Echocardiograms will be taken as detailed in the Time and Events table (Section 7.1). 
Echocardiograms will be obtained with the subject resting supine or lying on their left 
side. In Part 2, the echo during the exercise challenge will be conducted with the 
subject on a semi-recumbent cycle ergometer tilted by 30-40 degrees.  The subject 
will continue exercising during the echo recording.
PASP will be measured and recorded.  PASP will be determined by measuring maximal 
tricuspid regurgitation velocity and applying the modified Bernoulli equation to convert 
this value into pressure values.  Estimated right atrial pressure (RAP) must be added to 
this obtained value.
In Part 2, the sonographer’s priority will be to collect good quality images of the 
tricuspid regurgitation jet, allowing accurate calculation of PASP once image 
acquisition is completed.  The sonographer will aim to collect at least 5 cardiac 
cycles.  Once estimation of tricuspid regurgitation velocity is completed, the 
sonographer will measure the right ventricular outflow tract (RVOT) time velocity 
integral, which (along with the peak tricuspid regurgitant velocity) will allow an 
estimation of PVR (Rudski, 2010).
In Part 2, the sonographer conducting the echo will be considered the primary 
reader.  All echo images/calculations will be reviewed by a suitably qualified 
physician (physician ‘over-reader’).  Any discrepancies will be discussed between 
the primary reader and physician over-reader, and an agreement reached.  The 
physician over-reader will provide a quality statement for each echo.  For the first 3 
subjects in Part 2, the physician review will occur immediately following completion 
of each echo.  If quality issues are identified, the sonographer and physician will 
consider if the echo should be repeated.  If no echo quality issues are identified for 
the first 3 subjects, subsequent reviews will occur within a few hours.
In Part 2, when the echo recording is conducted during the exercise challenge, the 
sonographer will begin positioning the echo probe as soon as exercise is initiated.  
Image acquisition will occur at 2 minutes into the exercise challenge.  The 
sonographer will aim to complete image acquisition within approximately 1–2 
minutes.
Further details about the PASP measurementecho recording is detailed in the SRM. 
 
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Additional echocardiograms may be obtained for each subject as needed (in the 
judgement of the Investigator and GSK Medical Monitor, if required).
Section 9.1: Hypotheses
Rationale for change:  Clarification of statistical analysis for Part 1 and Part 2 of the 
study
The focus of this study is on the exploration of the effect of GSK2586881 on a range of 
echocardiography, pulse oximetry, biomarker, safety and PK endpoints, when subjecting 
healthy volunteers to an exercise challenge under hypoxic conditions.  No formal 
statistical hypotheses are being tested.  A Bayesian statistical analysis framework with 
non-informative priors for model parameters (unless otherwise specified) will be used to 
obtain posterior distributions for effects of interest for Part 1 and Part 2 of the study.  
These posterior distributions will be used to obtain a number of probability statements 
about the magnitude of treatment effects (e.g. Probability of any treatment related 
reduction in PASP, or Probability that the treatment related reduction in PASP 5 
mmHg).
Section 9.2: Sample Size Considerations
Rationale for change:  Correction of typographical errors
The sample size of 20 evaluable patients is based on logistical considerations and is not 
based on formal sample size calculations.  However, estimates of precision for the 
treatment difference in the primary endpoint are presented for context (Note: precision in 
this context is defined as one half of the width of the 95% confidence interval).  A sample 
size re-estimation wasis planned after 10 subjects, see Section 9.2.2.  
Section 9.2.2: Sample Size Re-estimation
Rationale for change:  Description of the completed interim analysis
A sample size re-estimation was to be ill be conducted at the interim analysis for Part 1
(see Section 9.3.2.1). The purpose of the sample size re-estimation wasis to determine 
whether the total number of subjects can be reduced below the anticipated 20, based on 
treatment comparison between GSK2586881 and Placebo in change from pre-dose PASP 
to hypoxic/exercised PASP (i.e. T3-T0). The sample size re-estimation wasis to be 
considered advisory, and taken into account together with other considerations. These 
were towill include:

ensuring sufficient data is collected on secondary endpoints,

non-conclusive safety data at the time of interim analysis (e.g. a weak signal of a 
reduction in oxygen saturation data that would require the full set of remaining 
subjects to be able to reach a conclusion),

speed of recruitment.
An interim analysis was conducted when 10 subjects had completed Treatment 
Periods 1 and 2 (Part 1), and the following data were reviewed:  PASP, oxygen 
 
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saturation, AE/SAE, and RAS peptide.  The decision was taken to continue the 
study with modifications to the protocol (Part 2), see Section 2.1.1.
Section 9.3.1: Analysis Populations
Rationale for change:  Separation of the analysis populations between Part 1 and Part 2 
of the study.
All Subjects Screened Population: This population contains all subjects that complete at 
least one Visit 1 (Screening) procedure. This population will be used for the summary of 
subject disposition (including reasons for screening failures, run-in failures, and 
stabilization failures) and for the listing of AEs and SAEs for non-randomised subjects.
Modified Intent-to-Treat (mITT) Population: This population will comprise all 
randomised subjects, excluding those who were randomised in error. A subject who is 
recorded as a screen failure, run-in failure, or stabilisation failure, but is randomised and 
does not receive a dose of study treatment, is considered to be randomised in error. Any 
other subject who receives a randomisation number will be considered to have been 
randomised. This will constitute the primary population for all safety and 
pharmacodynamic analyses.
Modified Intent-to-Treat (mITT1) Population Part 1: This population will include all 
subjects in the mITT population, who were randomised into Part 1 of the study 
(planned 4000 m altitude).
Modified Intent-to-Treat (mITT2) Population Part 2: This population will include all 
subjects in the mITT population, who were randomised into Part 2 of the study 
(planned 5000 m altitude)
Pharmacokinetic (PK) Population Part 1: This population will comprise all subjects 
in the mITT Population, randomised in Part 1 of the study, for whom a PK sample 
was obtained and analysed and on active treatment.
Pharmacokinetic (PK) Population Part 2: This population will comprise all subjects 
in the mITT Population, randomised in Part 2 of the study, for whom a PK sample 
was obtained and analysed and on active treatment.
Section 9.3.2: Interim Analysis
Rationale for change: Clarification of the differences in interim analysis between Part 1 
and Part 2 of the study
Section 9.3.2.1: Part 1
The details below are in reference to the completed interim analysis for Part 1 of the 
study.  Following review of the data from Part 1, the study was modified before 
restarting Part 2.  Section 9.3.2.2 details interim plans for Part 2 of the study.
 
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An interim analysis is planned after 10 subjects have completed the following critical 
assessments:

PASP at T0 and T3 for both study periods

Oxygen saturation at T0 and T3 for both study periods

Adverse events 
Section 9.3.2.2: Part 2
Part 2 of the study will be based on modifications as detailed in Section 2.1.1.  Two 
interim analysis reviews are planned when approximately 3 and 6 subjects, 
respectively have completed treatment periods 1 and 2.  
The aims of the interim analyses are to assess the effectiveness of the Part 2 
modifications on critical assessments (PASP, oxygen saturation and AEs) and the 
potential benefit/risk impact on subjects.  
At each review, the study may be stopped for futility if PASP results are highly 
variable, or if the PASP profile for the placebo group is not as expected (indicative 
of the model not working given the alterations to the study) or if review of the safety 
data suggests a change in the benefit-risk profile.  If clear criteria for stopping the 
study are not met, the study will continue to the next interim analysis review, or on 
to the planned maximum number of evaluable subjects.
If data suggest a further interim analysis review of data would be beneficial, then 
this will be documented.
Interim analysis reviews are planned as follows:
1.
Review of PASP, oxygen saturation and AE data when approximately 3 subjects 
have completed Treatment Periods 1 and 2.  Critical timepoints for PASP and 
oxygen saturation are T0 and T3 (a review of additional timepoints will also 
take place)
2.
Review of PASP, oxygen saturation and AE data when approximately 6 subjects 
have completed Treatment Periods 1 and 2.  Critical timepoints for PASP and 
oxygen saturation are T0 and T3 (a review of additional timepoints will also 
take place).  Note that this second review may not be required and will be 
dependent on data observed during the first interim review.  The timing of this 
review may be altered as necessary dependent on subject recruitment.
Each interim analysis will use a data snapshot that has been cleaned to the best 
extent allowed by the timeframes (i.e. the interim data will not be fully cleaned or 
fully QC’d data and there will not be a locked database).
 
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Section 9.4: Key Elements of the Analysis Plan
Rationale for change:  Clarification of the differences in statistical analysis between Part 
1 and Part 2 of the study
Each subject will undergo two treatment periods in this crossover study, each one of 
which being subdivided into five key sub-epochs (labelled T0-T4) as follows:

T0: Pre-dose (period baseline)

T1: Post-dose, normoxic, at rest, pre-challenge

T2: Hypoxic, at rest

T3: Hypoxic, immediately after exercise (for Part 2, echo data will be measured 
during exercise)

T4: Post-challenge, normoxic, at rest
This follows the principle illustrated in the diagram of echocardiograph measurements 
(Figure 2).
PASP and Oxygen Saturation will be assigned to T0 thru T4 timepoints based on when 
they happened relative to the sequence of events that the subject undertakes during the 
course of the study day.  Biomarkers will be collected at times T0 thru T4, plus additional 
timepoints.
Pharmacokinetic endpoints will be timed based on elapsed time since dose 
administration.
In addition to T0 being defined as the period baseline, an overall subject baseline will be 
defined as the mean of the two T0 measurements (one from each period).
Change from baseline at time points T1 - T4 will be calculated as the difference between 
the measurement at the time point in question and the period baseline.  Separate 
statistical analyses will be conducted for subjects in Part 1 and Part 2 of the study.  
In general, statistical modelling of changes from baseline will be done using a Bayesian 
mixed effects regression model, including covariates for period, treatment, period 
baseline and subject baseline (the mean of the two period baselines).  Subject will be 
fitted as a random effect and non-informative priors will be used for model parameters. 
An unstructured compound symmetric covariance structure within each subject-period-
treatment cell will be assumed to account for repeated measurements a) inherent in the 
two-period crossover design and b) due to the four post-baseline timepoints within each 
treatment period.
PASP data will be summarized by treatment and time-point in tabular and graphical 
format. A Bayesian mixed effects regression models (as described above) will be fitted 
(using non-informative priors for the model parameters), and an estimate of the mean
change from baseline in PASP for each treatment group and post-baseline timepoint, 
 
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together with its 95% credible interval, will be obtained.  Estimates for treatment 
differences will also be presented. Data may be log-transformed if necessary.
PASP data will be summarized separately by Part 1 and Part 2 by treatment and 
time-point in tabular and graphical format.
Details of the analysis of other endpoints will be described in the RAP.
Section 9.4.1: Pharmacokinetic Analyses
Rationale for change:  Clarification of PK analyses for Part 1 and Part 2 of the study.
Pharmacokinetic analysis will be performed by, or under the auspices, of Clinical 
Pharmacology Modelling and Simulation Department within GlaxoSmithKline.  Plasma 
GSK2586881 concentration-time data will be analysed by non-compartmental methods 
with WinNonLin V6.3 or greater.  Calculations will be based on the actual sampling 
times recorded during the study.
From the plasma concentration-time data, the following pharmacokinetic parameters will 
be determined, as data permit: maximum observed plasma concentration (Cmax), time to 
Cmax (tmax), area under the plasma concentration-time curve over the study period 
[nominally AUC(0-2.5h) post-dose], AUC over the hypoxia challenge (nominally 
AUC(0.5-2.0h post-dose), plasma clearance (CL), volume of distribution (V) and 
apparent terminal phase half-life (t1/2), if data permit.  Other PK parameters may also be 
determined.
Pharmacokinetic data will be presented in graphical and/or tabular form and will be
summarized descriptively by Part 1 and Part 2. All pharmacokinetic data will be stored 
in the Archives, GlaxoSmithKline Pharmaceuticals, R&D. 
The relationship between the RAS biomarkers and other pharmacodynamic endpoints 
(echocardiography and pulse oximetry) and GSK2586881 concentrations and/or PK 
parameters may also be explored for Part 2, if appropriate.
Section 11: References
Rationale for change: Addition of references
Argiento P, Chesler N, Mulè M, D’Alto M, Bossone E, Unger P, Naeije R. Exercise 
stress echocardiography for the study of the pulmonary circulation.  Eur Respir J. 
June 2010, 35 (6):1273 – 1278.
Naeije R, Saggar R, Badesch D, Rajagopalan S, Gargani L, Rischard F, et al. 
Exercise induced pulmonary hypertension: Translating pathophysiological concepts 
into clinical practice. Chest. 2018; 3692(18)30161-2.
Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, 
et al. Guidelines for the echocardiographic assessment of the right heart in adults: a 
 
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report from the American Society of Echocardiograpy. J am Soc Echocardiogr. 
2010; 23: 685 – 713
 
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The GlaxoSmithKline group of companies
204987
1
TITLE PAGE
Division: Worldwide Development
Information Type: Protocol Amendment
Title:
The effects of GSK2586881 on the responses to acute hypoxia 
and exercise
Compound Number:
GSK2586881
Development Phase:
I
Effective Date:
07-MAR-2017
Protocol Amendment Number:  02
Author (s):
 
 
Copyright 2017 the GlaxoSmithKline group of companies.  All rights reserved.  
Unauthorised copying or use of this information is prohibited.
 
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Revision Chronology
GlaxoSmithKline
Document Number
Date
Version
2016N283626_00
2016-SEP-23
Original
2016N283626_01
2017-FEB-24
Amendment No. 1
Additional Inclusion Criteria (Section 5.2) and Subject Stopping Criteria (Section 5.4) 
added in response to comments from BfArM.
A summary of changes is presented in Appendix 6.
2016N283626_02
2017-MAR-07
Amendment No. 2
This is a substantial protocol amendment to:

Reduce the number of participants in the study from approximately 35 healthy 
volunteers to approximately 25 healthy volunteers.
This is a non-substantial protocol amendment to:

Remove some of the exploratory biomarkers.

Add a spirometry assessment at screening.

Add a pre-dose pulse oximetry assessment.

Add continuous ECG telemetry.

Move the immunogenicity screening sample to Pre-dose in Treatment Period 1.

Remove height and weight assessments from the follow-up visit.

Clarify the sequence and priority of assessments.  

Correct typographical errors.
A summary of changes is presented in Appendix 6.
 
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MEDICAL MONITOR/SPONSOR INFORMATION PAGE
Medical Monitor/SAE Contact Information: 
Role
Name
Day Time Phone 
Number and email 
address
After-hours 
Phone/Cell/
Pager Number
Fax 
Number
Site Address
Primary 
Medical 
Monitor 
709 Swedeland 
Road
UW2531
King of Prussia, 
PA  19406 USA
Secondary 
Medical 
Monitor
Gunnels 
Wood Road, 
Stevenage, 
Hertfordshire, 
SG1 2NY, UK
SAE
contact
information
[Medical
monitor
as 
above]
Sponsor Legal Registered Address: 
GlaxoSmithKline Research & Development Limited
980 Great West Road
Brentford
Middlesex, TW8 9GS
UK
In some countries, the clinical trial sponsor may be the local GlaxoSmithKline Affiliate 
Company (or designee). If applicable, the details of the alternative Sponsor and contact 
person in the territory will be provided to the relevant regulatory authority as part of the 
clinical trial application.   
Regulatory Agency Identifying Number(s):  2016-002465-55
 
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INVESTIGATOR PROTOCOL AGREEMENT PAGE
For protocol 204987
I confirm agreement to conduct the study in compliance with the protocol, as amended by 
this protocol amendment.
I acknowledge that I am responsible for overall study conduct. I agree to personally 
conduct or supervise the described study.
I agree to ensure that all associates, colleagues and employees assisting in the conduct of 
the study are informed about their obligations. Mechanisms are in place to ensure that site 
staff receives the appropriate information throughout the study. 
Investigator Name:
Investigator Address:
Investigator Phone Number:
Investigator Signature
Date
 
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TABLE OF CONTENTS
PAGE
1.
PROTOCOL SYNOPSIS FOR STUDY 204987........................................................9
2.
INTRODUCTION....................................................................................................13
2.1.
Study Rationale ..........................................................................................14
3.
OBJECTIVE(S) AND ENDPOINT(S) ......................................................................16
4.
STUDY DESIGN ....................................................................................................17
4.1.
Overall Design ............................................................................................17
4.2.
Treatment Arms and Duration.....................................................................17
4.2.1.
Follow Up.....................................................................................18
4.3.
Type and Number of Subjects.....................................................................18
4.4.
Design Justification.....................................................................................18
4.5.
Dose Justification........................................................................................18
4.6.
Benefit:Risk Assessment ............................................................................19
4.6.1.
Risk Assessment .........................................................................20
4.6.2.
Benefit Assessment.....................................................................22
4.6.3.
Overall Benefit:Risk Conclusion...................................................22
5.
SELECTION OF STUDY POPULATION AND WITHDRAWAL CRITERIA .............22
5.1.
Inclusion Criteria.........................................................................................22
5.2.
Exclusion Criteria........................................................................................24
5.3.
Screening/Baseline/Run-in Failures............................................................26
5.4.
Withdrawal/Stopping Criteria.......................................................................26
5.4.1.
Study Stopping Criteria................................................................27
5.4.2.
QTc Stopping Criteria ..................................................................28
5.4.3.
Liver Chemistry Stopping Criteria ................................................28
5.4.3.1.
Study Treatment Restart or Rechallenge....................29
5.5.
Subject and Study Completion....................................................................29
6.
STUDY TREATMENT ............................................................................................29
6.1.
Investigational Product and Other Study Treatment....................................29
6.2.
Planned Dose Adjustments.........................................................................30
6.3.
Blinding.......................................................................................................31
6.4.
Packaging and Labeling..............................................................................32
6.5.
Preparation/Handling/Storage/Accountability..............................................32
6.6.
Compliance with Study Treatment Administration.......................................32
6.7.
Treatment of Study Treatment Overdose....................................................33
6.8.
Treatment after the End of the Study ..........................................................33
6.8.1.
Meals and Dietary Restrictions ....................................................33
6.8.2.
Caffeine, Alcohol, and Tobacco ...................................................33
6.8.3.
Activity .........................................................................................34
6.9.
Concomitant Medications and Non-Drug Therapies....................................34
6.9.1.
Permitted Medications and Non-Drug Therapies..........................34
6.9.2.
Prohibited Medications and Non-Drug Therapies.........................34
7.
STUDY ASSESSMENTS AND PROCEDURES .....................................................35
7.1.
Time and Events Table...............................................................................36
7.1.1.
Screening and Follow up .............................................................36
 
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7.1.2.
Treatment Period 1 and 2 ............................................................37
7.2.
Safety .........................................................................................................39
7.2.1.
Adverse Events (AE) and Serious Adverse Events (SAEs)..........39
7.2.1.1.
Time period and Frequency for collecting AE 
and SAE information...................................................39
7.2.1.2.
Method of Detecting AEs and SAEs ...........................40
7.2.1.3.
Follow-up of AEs and SAEs........................................40
7.2.1.4.
Regulatory Reporting Requirements for SAEs............40
7.2.2.
Physical Exams ...........................................................................41
7.2.3.
Vital Signs....................................................................................41
7.2.4.
Electrocardiogram (ECG).............................................................41
7.2.5.
Clinical Safety Laboratory Assessments ......................................41
7.3.
Hypoxia Challenge......................................................................................42
7.3.1.
Exercise Challenge......................................................................43
7.4.
Echocardiogram..........................................................................................43
7.5.
Ventilatory parameters................................................................................43
7.6.
Pulse Oximetry ...........................................................................................44
7.7.
Telemetry....................................................................................................44
7.8.
Pharmacokinetics .......................................................................................44
7.8.1.
Blood Sample Collection..............................................................44
7.8.2.
Sample Analysis ..........................................................................44
7.9.
Biomarker(s)/Pharmacodynamic Markers ...................................................44
7.9.1.
Renin-angiotensin system biomarkers .........................................44
7.9.2.
Surfactant Protein-D and other biomarkers..................................45
7.10.
Genetics .....................................................................................................45
7.10.1.
Blood sample collection ...............................................................45
7.11.
Immunogenicity...........................................................................................45
7.11.1.
Sample collection.........................................................................45
7.11.2.
Sample analysis...........................................................................45
8.
DATA MANAGEMENT ...........................................................................................46
9.
STATISTICAL CONSIDERATIONS AND DATA ANALYSES .................................46
9.1.
Hypotheses.................................................................................................46
9.2.
Sample Size Considerations.......................................................................46
9.2.1.
Sample Size Assumptions ...........................................................46
9.2.2.
Sample Size Re-estimation..........................................................48
9.3.
Data Analysis Considerations .....................................................................49
9.3.1.
Analysis Populations....................................................................49
9.3.2.
Interim Analysis ...........................................................................49
9.3.3.
Multiple Comparisons and Multiplicity ..........................................53
9.4.
Key Elements of Analysis Plan ...................................................................54
9.4.1.
Pharmacokinetic Analyses...........................................................55
10. STUDY GOVERNANCE CONSIDERATIONS........................................................55
10.1.
Posting of Information on Publicly Available Clinical Trial Registers............55
10.2.
Regulatory and Ethical Considerations, Including the Informed 
Consent Process ........................................................................................55
10.3.
Quality Control (Study Monitoring) ..............................................................56
10.4.
Quality Assurance.......................................................................................57
10.5.
Study and Site Closure ...............................................................................57
10.6.
Records Retention......................................................................................57
 
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10.7.
Provision of Study Results to Investigators, Posting of Information 
on Publically Available Clinical Trials Registers and Publication .................58
11. REFERENCES.......................................................................................................59
12. APPENDICES........................................................................................................62
12.1.
Appendix 1: Abbreviations and Trademarks................................................62
12.2.
Appendix 2: Liver Safety Required Actions and Follow up 
Assessments ..............................................................................................65
12.3.
Appendix 3: Genetic Research ...................................................................67
12.4.
Appendix 4: Definition of and Procedures for Recording, Evaluating, 
Follow-Up and Reporting of Adverse Events...............................................70
12.4.1.
Definition of Adverse Events........................................................70
12.4.2.
Definition of Serious Adverse Events...........................................71
12.4.3.
Definition of Cardiovascular Events .............................................73
12.4.4.
Recording of AEs and SAEs ........................................................73
12.4.5.
Evaluating AEs and SAEs............................................................74
12.4.6.
Reporting of SAEs to GSK...........................................................75
12.5.
Appendix 5: Modified List of Highly Effective Methods for Avoiding 
Pregnancy and Collection of Pregnancy Information...................................77
12.5.1.
Modified List of Highly Effective Methods for Avoiding 
Pregnancy ...................................................................................77
12.5.2.
Collection of Pregnancy Information ............................................78
12.5.3.
References ..................................................................................79
12.6.
Appendix 6:  Protocol Changes...................................................................80
12.6.1.
Protocol Amendment 01 (24-Feb-2017) from Original 
Protocol  (23-Sep-2016)...............................................................80
12.6.1.1.
Summary of Changes and Rationale for 
Amendment................................................................80
12.6.1.2.
List of Specific Changes .............................................80
12.6.2.
Protocol Amendment 02 (07-Mar-2017) from Protocol 
Amendment 01 (24-Feb-2017).....................................................82
12.6.2.1.
Summary of Changes and Rationale for 
Amendment................................................................82
12.6.2.2.
List of Specific Changes .............................................82
 
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1.
PROTOCOL SYNOPSIS FOR STUDY 204987
Rationale
The purpose of this study is to examine how GSK2586881, a recombinant human ACE2 
peptide, modulates the acute hypoxic pulmonary vasoconstriction (HPV) response in 
healthy volunteers. 
HPV is an acute physiological response that plays a fundamental role in maintaining 
optimal arterial oxygen (PaO2) levels in healthy and in pathophysiological settings, such 
as acute respiratory distress syndrome (ARDS) by facilitating re-distribution of 
pulmonary blood flow to areas of ventilated lung. The literature supports a role for the 
renin angiotensin system (RAS) in driving acute HPV and while there is a strong 
biological rationale for modulation of RAS in the treatment of ARDS patients, 
therapeutic strategies aimed at RAS may have unintended, negative consequences for 
ARDS patients if they blunt the normal HPV response and negatively impact on arterial 
oxygenation (PaO2).  Thus, from a safety (and efficacy) perspective it is important to 
understand the impact of modulation of the RAS system by GSK2586881 on the acute 
HPV response.
 
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Objective(s)/Endpoint(s)
Objectives
Endpoints
Primary

To evaluate the effect of a single IV 
dose of GSK2586881 on the HPV 
response in healthy volunteers during 
exercise under hypoxic conditions.

Change from baseline of Pulmonary 
Artery Systolic Pressure (PASP) 
measured via Echocardiography.
Secondary

To evaluate the effect of a single IV 
dose GSK2586881 on RAS peptide 
responses. 

Effect of GSK2586881 on baseline 
levels and changes in response to 
hypoxia and exercise of RAS peptides 
(e.g. Ang II, Ang(1-7), Ang(1-5)).

To evaluate the safety of a single IV 
dose of GSK2586881 in healthy 
volunteers.

Vital signs (heart rate, systolic and 
diastolic blood pressure), oxygen 
saturation, 12-lead ECGs, AEs, 
immunogenicity and clinical laboratory 
assessments and continuous pulse 
oximetry.

To evaluate the pharmacokinetics of a 
single IV dose of GSK2586881. 

Plasma concentrations of GSK2586881 
and derived pharmacokinetic 
parameters.
Exploratory 

To evaluate the effect of a single IV 
dose of GSK2586881 on ventilatory 
parameters in healthy volunteers during 
exercise in hypoxic conditions.

Change from baseline of oxygen 
consumption (VO2), carbon dioxide 
production (CO2) and other parameters 
as data permit.

To evaluate the pharmacodynamic 
activity of a single IV dose of 
GSK2586881 in healthy volunteers 
during exercise in hypoxic conditions.

Change from baseline in Surfactant 
Protein-D and/or additional analytes to 
be determined.

To evaluate Pharmacogenetics.

Evaluate I/D polymorphisms in the 
Angiotensin Converting Enzyme 
(ACE) gene and analyse the impact on 
Ang II (and possibly other RAS 
peptides), hypoxic pulmonary 
vasoconstriction and responses to 
GSK2586881 administration.
 
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Overall Design
The study will be single-centre, randomised, placebo-controlled and double blind
(sponsor open). Subjects will be randomised to receive a single IV dose of GSK2586881 
or saline in a crossover design. 
A schematic of the study is shown below. Echocardiograms approximate timings are 
indicated by bold arrows.  
Approximate timing of simulated altitude and echocardiogram 
measurements (black arrows) during Treatment Periods 1 and 2.
Treatment Groups, Randomisation Arms and Duration
The study is intended to follow a double blind (sponsor open) two-period cross-over 
design.
Treatment Group A: matching volume of placebo, administered as a single IV dose 
Treatment Group B: GSK2586881 0.8 mg/kg, administered as a single IV dose. 
Subjects will receive both treatments during the course of the study, and will be 
randomised to one of two sequences, each of which describes the order in which those 
treatments are received:
 
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Sequence 1: AB: Placebo in the first period followed by GSK2586881 in the second.
Sequence 2: BA: GSK2586881 in the first period followed by Placebo in the second.
The total study duration for each subject is expected to be a maximum of 56 days.
Type and Number of Subjects
Approximately 25 subjects will be enrolled to ensure that a minimum of 20 subjects 
complete all dosing and critical assessments (the target of 20 may be revised by the 
sample size re-estimation).
If subjects prematurely discontinue the study, additional replacement subjects will not be 
recruited in order to preserve randomisation integrity.  
Analysis
This study is designed to estimate the effect of GSK2586881 relative to placebo on 
change from baseline in PASP following exercise under hypoxic conditions. No formal 
hypothesis will be tested. Point estimates will be calculated together with corresponding 
95% confidence intervals (or credible intervals if utilising a Bayesian framework) for the 
difference between the mean of the test treatment and the mean of the reference 
treatment.
Analysis of PASP: Statistical modelling of changes from baseline (Ti-T0) will be done 
using a Bayesian mixed effects regression model, including covariates for period, 
treatment, period baseline and subject baseline (the mean of the two period baselines).  
Subject will be included as a random effect. A compound symmetric covariance 
structure within each subject-period-treatment cell will be assumed to account for 
repeated measurements a) inherent in the two-period crossover design and b) due to the 
four post-baseline time-points within each treatment period. Non-informative priors will 
be used for the model parameters. Posterior distributions will be obtained for the 
GSK2586881 Vs Placebo comparisons at each of the post dosing time-points (T1-T4). 
These distributions will be used to produce several posterior probability statements; the 
most important being the probability that the change from baseline in PASP is reduced by 
the GSK2586881 at time T3. 
Oxygenation saturation will also be analysed in a similar way; although of interest is the 
posterior probability that the study drug causes (absolute) reductions in oxygenation 
saturation in excess of 5%.
An interim analysis is planned after 10 subjects have completed Treatment Period 1 and 2 
assessments to i) evaluate safety and tolerability (SAE, AE and Oxygenation saturation), 
ii) determine whether the study should stop for futility based on expected PASP 
outcomes if the study were allowed to complete recruitment and iii) re-estimate the 
sample size based using the observed variance parameters.
 
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2.
INTRODUCTION
GSK2586881 is a purified intravenous formulation of soluble recombinant human
angiotensin converting enzyme type 2 (rhACE2), which is expressed in Chinese Hamster
Ovary cells. Angiotensin converting enzyme type 2 (ACE2) is a zinc carboxypeptidase 
involved in the Renin-Angiotensin System (RAS) that controls blood pressure, 
electrolytes, and intravascular fluid volume. A key function of ACE2 is believed to be 
the cleavage of Angiotensin II (Ang II) to Ang (1-7), which have opposing physiological 
roles. Elevated levels of Ang II are associated with vasoconstriction, inflammation, 
fibrosis, vascular leak, and sodium absorption. Ang (1-7) appears to be a counter-
regulatory protein in the RAS; associated with vasodilation, anti-proliferation, anti-
inflammation, and reduced vascular leak, as noted in Figure 1 below [Paul, 1992; Santos, 
2005; Suzuki, 2003].
Figure 1
Renin Angiotensin System
Angiotensinogen
Angiotensin I (1-10)
Angiotensin II(1-8)
Angiotensin (1-9)
Angiotensin (1-7)
Renin
ACE 1
Aldosterone
Vascular leak
Vasoconstriction
Pro-inflammatory
Pro-fibrotic/apoptotic
Sodium/water retention
ACE 1
ACE 2
ACE 2
Reduced vascular leak
Vasodilatation
Anti-inflammatory
Anti-proliferation/apoptotic
Ang II binds to two distinct receptors called AT-1 and AT-2, with the AT-1 receptor 
mediating the vasoconstrictive, proliferative and pro-inflammatory actions of Ang II. 
The function of the AT-2 receptor has not been fully elucidated. Ang (1-7) initiates its 
effects by binding to the Mas-receptor, and also acts by inhibiting the activity of the 
carboxyterminal domain of angiotensin converting enzyme (ACE), which prevents ACE 
from fully acting on its substrates Angiotensin I and bradykinin.
ACE and Angiotensin II has been implicated in the pathogenesis of acute respiratory 
distress syndrome (ARDS), and pulmonary hypertension. It has been observed that 
circulating Ang II levels and lung ACE levels are increased in humans with ARDS and 
pulmonary hypertension. It has also been shown that the DD ACE polymorphism, which 
is associated with higher ACE activity, is associated with susceptibility to development 
of lung injury and worsened outcome (mortality) in patients with ARDS [Marshall, 2002] 
and to the development of pulmonary hypertension [Abraham, 2003].
It is expected that the reduction of Ang II and simultaneous formation of Ang (1-7) 
should have positive impacts in ARDS and on pulmonary haemodynamics in patients 
with pulmonary hypertension. This dual action can be achieved by ACE2, and thus, an 
 
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enhancement of the activity of this enzyme is seen as a promising approach for the 
treatment of diseases and conditions with an imbalance of the RAS system, insufficient 
natural ACE2 activity, and pathologically elevated Ang II levels or decreased Ang (1-7), 
such as is observed in ALI/ARDS [Tom, 2001; Idell S, 1987; Santos, 2003; Wenz, 2000] 
and pulmonary hypertension [Maron, 2014].
This study will demonstrate how GSK2586881 modulates the acute HPV response in 
healthy volunteers. 
2.1.
Study Rationale
Hypoxic pulmonary vasoconstriction (HPV) is an acute physiological response that plays 
a fundamental role in maintaining optimal arterial oxygen (PaO2) levels in healthy and in 
pathophysiological settings, such as acute respiratory distress syndrome (ARDS) by 
facilitating re-distribution of pulmonary blood flow to areas of ventilated lung. However, 
in many ARDS patients with pulmonary microvascular injury and dystonia, the normal 
HPV reflex is compromised resulting in the mismatching of perfusion (Q) and ventilation 
(VA) and formation of areas of low perfusion to ventilated alveoli (high VA/Q; 
physiological deadspace), or perfusion of alveoli with minimal or no ventilation (low 
V/Q; physiological shunt).  
The literature is conflicting as to the role of the RAS in modulating the HPV response; 
however, the majority of reports support a role for the RAS in driving acute HPV (Cargil, 
1996; Kiely, 1996). While there is a strong biological rationale for modulation of the 
RAS in the treatment of ARDS patients, therapeutic strategies aimed at RAS may have 
unintended, negative consequences for ARDS patients if they impact on PaO2 and 
produce a blunted HPV response. Surprisingly, there are scant data regarding the effect 
of RAS modulation on HPV, V-Q matching or PaO2 in healthy human volunteers.
Inhibition of the acute HPV response would be expected to promote blood flow to areas 
of poorly-ventilated lung resulting in an increase in venous admixture and a reduction in 
PaO2 levels. In the context of acute lung injury, correction of any V/Q mismatch would 
be expected to be beneficial with respect to maintaining and improving PaO2 levels. 
Conversely, inhibition of HPV by pharmacological agents might be expected to worsen 
V/Q matching and compromise PaO2 levels. Thus, from a safety (and efficacy) 
perspective it is vital to understand the impact of modulation of the RAS system on the 
acute HPV response and subsequent PaO2.
Recombinant human ACE2 (rhACE2) delivered intravenously to pigs inhibits the HPV 
response to acute hypoxic challenge assessed by inhibition of mean pulmonary artery 
pressures and pulmonary vascular resistance. There was also a strong trend to increased 
shunt with administration of rhACE2; however PaO2 was not significantly affected. The 
authors concluded that the increased shunt may not have been sufficient to result in a 
reduction in PaO2 (Kleinsasser, 2012). 
An elegant study by Wagner and colleagues demonstrated the importance of end arterial 
capillary diffusion limitations on PaO2 levels in healthy volunteers during hypoxia ± 
exercise (Torre-Bueno, 1985). Diffusion limitation made a significant contribution to 
PaO2 levels particularly under conditions where exercise and hypoxia were combined. In 
 
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addition, V/Q mismatching was suggested to increase with the combined stresses of 
exercise and hypoxia resulting in significantly more arterial oxygen desaturation than 
observed with either stressor by itself.
The main goals of this study are to examine whether GSK2586881 modulates the acute 
HPV response in healthy volunteers with a subsequent impact on O2 saturation.  Should 
the application of GSK2586881 lead to accentuated arterial oxygen desaturation, further 
clinical studies to examine the therapeutic efficacy of GSK2586881 in acute lung injury 
should be approached with caution. Conversely, a reduction in HPV without augmented 
hypoxemia would provide supporting evidence that GSK2586881 could have a positive 
impact in patients with pulmonary hypertension.
 
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3.
OBJECTIVE(S) AND ENDPOINT(S)
Objectives
Endpoints
Primary

To evaluate the effect of a single IV 
dose of GSK2586881 on the HPV 
response in healthy volunteers during 
exercise under hypoxic conditions.

Change from baseline of Pulmonary
Artery Systolic Pressure (PASP) 
measured via Echocardiography.
Secondary

To evaluate the effect of a single IV 
dose GSK2586881 on RAS peptide 
responses. 

Effect of GSK2586881 on baseline 
levels and changes in response to 
hypoxia and exercise of RAS peptides 
(e.g. Ang II, Ang(1-7), Ang(1-5)).

To evaluate the safety of a single IV 
dose of GSK2586881 in healthy 
volunteers.

Vital signs (heart rate, systolic and 
diastolic blood pressure), oxygen 
saturation, 12-lead ECGs, AEs, 
immunogenicity and clinical laboratory 
assessments and continuous pulse 
oximetry.

To evaluate the pharmacokinetics of a 
single IV dose of GSK2586881. 

Plasma concentrations of GSK2586881 
and derived pharmacokinetic 
parameters.
Exploratory 

To evaluate the effect of a single IV 
dose of GSK2586881 on ventilatory 
parameters in healthy volunteers during 
exercise in hypoxic conditions.

Change from baseline of oxygen 
consumption (VO2), carbon dioxide 
production (CO2) and other parameters 
as data permit.

To evaluate the pharmacodynamic 
activity of a single IV dose of 
GSK2586881 in healthy volunteers 
during exercise in hypoxic conditions.

Change from baseline in Surfactant 
Protein (SP-D) and/or additional 
analytes to be determined.

To evaluate Pharmacogenetics.

Evaluate I/D polymorphisms in the 
Angiotensin Converting Enzyme 
(ACE) gene and analyse the impact on 
Ang II (and possibly other RAS 
peptides), hypoxic pulmonary 
vasoconstriction and responses to 
GSK2586881 administration.
 
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4.
STUDY DESIGN
4.1.
Overall Design
This is a single-centre, randomised, placebo-controlled and double blind (sponsor open), 
two-period crossover study in healthy subjects. 
The subjects will be required to attend the unit for a screening visit, Treatment Period 1, 
Treatment Period 2 and a follow up visit.
4.2.
Treatment Arms and Duration
Figure 2
Subject participation flow
The subjects must participate in the procedures detailed in the Time and Events Table 
(Section 7.1) and the timings of the simulated altitude, exercise and echocardiograms is 
shown in Figure 3
Figure 3
Approximate timing of simulated altitude and echocardiogram 
measurements (black arrows) during Treatment Periods 1 and 2
 
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There will be a washout period of 3–14 days between treatments to ensure biomarkers 
return to pre-challenge baseline. Subjects then return to the site and repeat the same 
procedures as above, except that they will receive the treatment (GSK2586881 or Saline) 
that they did not receive in the first period.
4.2.1.
Follow Up
The follow-up visit will occur up to 10 days after the end of the second treatment period. 
During the visit various safety tests will be conducted (see time and events table in 
Section 7.1). 
The total study duration for each subject is expected to be a maximum of 56 days.
4.3.
Type and Number of Subjects
Approximately 25 subjects healthy volunteers will be randomised such that 
approximately 20 evaluable subjects complete the study (the target of 20 may be revised 
following the sample size re-estimation, see Section 9.2.2).
If subjects prematurely discontinue the study, additional replacement subjects will not be 
recruited in order to preserve randomisation integrity.
4.4.
Design Justification
The study design is based on a paper published by Ricart, 2005 and is considered to be 
feasible. The study will provide important information on whether GSK2586881 
modulates the acute HPV response in healthy volunteers.  In addition, the study will 
include assessments of PK and PD effects of GSK2586881.  This will be achieved by 
assessing blood levels of GSK2586881 and RAS peptide responses throughout the 
duration of the hypoxia challenges.
The study will be placebo controlled (saline) so each subject can be used as their own 
control.
4.5.
Dose Justification
GSK2586881 has been studied in 21 healthy subjects as single, intravenous doses over 
30 minutes from 0.1 mg/kg to 1.2 mg/kg, and in repeated daily doses for up to six days of 
0.4 mg/kg once a day.  In addition, ARDS patients have received four doses of 
GSK2586881: 0.1 mg/kg, 0.2 mg.kg, 0.4 mg/kg and 0.8 mg/kg over a 24 hour period 
(n=5) or 0.4 mg/kg BID twice daily for 3 days (n=19). In a concluded (but not yet 
reported) investigator-sponsored study in Pulmonary Arterial Hypertension (PAH) (Study 
204696), 5 subjects have received a single dose of either 0.2 mg/kg or 0.4 mg/kg.
A population PK model for GSK2586881 was derived from data obtained in healthy 
subjects and ARDS patients and showed that the systemic PK profile was adequately 
described by a two-compartment first order elimination model and that the PK profile 
was independent of population (healthy subjects or ARDS patients).  Furthermore the 
PK/PD response (AngII) in healthy subjects and ARDS patients was consistent with a 
 
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single direct Emax model after accounting for differences in baseline AngII 
concentrations between healthy subjects and ARDS patients.  
Based on the population PK/PD model described above, single intravenous doses of 
0.4‒1.2 mg/kg GSK2586881 are predicted to reduce elevated levels of AngII (baseline 
AngII consistent with an ARDS population) to levels consistent with that observed in 
healthy subjects for the duration of the hypoxic challenge (approx 2.25 h). The dose of 
0.8 mg/kg has been selected to ensure maximal reduction of AngII levels, whilst 
maintaining dosing volumes within acceptable limits, and will further aid the 
understanding of the PK/PD relationship for GSK2586881.
4.6.
Benefit:Risk Assessment
Summaries of findings from both clinical and non-clinical studies conducted with 
GSK2586881 can be found in the Investigator’s Brochure (GlaxoSmithKline Document 
Number 2010N108777_00, 2015).  The following section outlines the risk assessment 
and mitigation strategy for this protocol:  
 
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4.6.1.
Risk Assessment
Potential Risk of Clinical Significance
Summary of Data/Rationale for Risk
Mitigation Strategy
Investigational Product (IP) [GSK2586881]
Cardiovascular risk
During preclinical testing a brief period of 
non-sustained ventricular tachycardia was 
observed in one monkey receiving a dose of 
20.8 mg/kg/day.
The dose used in this study is much lower 
and well below the No observed adverse 
effect level (NOAEL) for the 14 day repeat 
dose cynomolgus monkeys of 8 mg/kg/day.  
Potential Reproductive/embryofetal risks
Preclinical studies have not been performed.
Women of childbearing potential will be 
excluded from the study.
Potential for Immunogenicity
There has been no induction of an immune 
response to rhACE2 in either of the clinical 
studies to date in healthy subjects or 
participants with ARDS.
Patients will have routine monitoring of any 
immunological response that may occur.  If 
an immunological response is seen the 
patient will be asked to return for further 
monitoring and assessment(s).
Potential for rash
In study ACE114622, rash was reported 
more frequently in subjects receiving 
GSK2586881, although only one event was 
considered drug-related.
Patients will be monitored for rash in the 
clinical trials.
 
 
 
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Potential Risk of Clinical Significance
Summary of Data/Rationale for Risk
Mitigation Strategy
Study Procedures
Effects of hypoxia (light headiness, 
headaches, nausea)
The subjects will be exposed to hypoxic 
conditions for approximately 80 minutes 
with a simulated altitude of 4000 m.
The subjects will be continuously observed 
and monitored with telemetry and pulse 
oximetry. Stopping criteria are included in 
the protocol. 
 
 
 
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4.6.2.
Benefit Assessment
There will be no intended therapeutic clinical benefit to the subjects taking part in the 
study as it is a healthy volunteer study. However, subjects will undergo a medical 
evaluation during screening including physical exams, ECGs and laboratory assessments 
which may provide important health information. 
By taking part in this study, the subject will be contributing to the development of 
GSK2586881 for the treatment of pulmonary hypertension and ARDS. 
4.6.3.
Overall Benefit:Risk Conclusion
The design of the study is considered low risk to the subjects and justified based on the 
work carried out by other researchers, the safety information from the nonclinical studies 
and the two previous clinical trials carried out on GSK2586881. 
5.
SELECTION OF STUDY POPULATION AND 
WITHDRAWAL CRITERIA
Specific information regarding warnings, precautions, contraindications, adverse events, 
and other pertinent information on the GSK investigational product or other study 
treatment that may impact subject eligibility is provided in the IB.
Deviations from inclusion and exclusion criteria are not allowed because they can 
potentially jeopardize the scientific integrity of the study, regulatory acceptability or 
subject safety. Therefore, adherence to the criteria as specified in the protocol is essential.
5.1.
Inclusion Criteria
A subject will be eligible for inclusion in this study only if all of the following criteria 
apply:
AGE
1. Between 18 and 40 years of age inclusive, at the time of signing the informed 
consent.
TYPE OF SUBJECT 
2. Healthy as determined by the investigator or medically qualified designee based on a 
medical evaluation including medical history, physical examination, spirometry, 
laboratory tests and cardiac monitoring.
A subject with a clinical abnormality or laboratory parameter(s) which is/are not 
specifically listed in the inclusion or exclusion criteria, outside the reference range for 
the population being studied may be included only if the investigator (in consultation 
with the Medical Monitor if required) agree and document that the finding is unlikely 
to introduce additional risk factors and will not interfere with the study procedures. 
Note:  Screened subjects with laboratory values outside of the normal range may be 
 
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repeated once for inclusion into the study at the discretion of the Investigator.
3. Screening echocardiogram of good quality, without clinically significant 
abnormalities, and with mild-moderate tricuspid regurgitation sufficient for the 
reliable estimation of PASP, as determined by the echocardiography core laboratory 
or responsible cardiologist.
Screening PASP within the normal range according to site standards.
4. Subjects have not resided at an altitude >1500 m for more than 7 days in the last 
4 months.
5. Able to complete all study procedures.
6. Any contraindication (orthopaedic, cardiac etc.) to perform exercise on a bicycle 
ergometer.
WEIGHT
7. Body weight 50‒100 kg (inclusive).
SEX
8. Male or female (non child bearing potential)
Male subjects with female partners of child bearing potential must comply with the 
following contraception requirements from the time of first dose of study medication 
until at least five half-lives of study medication OR for a cycle of spermatogenesis 
following five terminal half-lives after the last dose of study medication.
a. Vasectomy with documentation of azoospermia.  
b. Male condom plus partner use of one of the contraceptive options below:

Contraceptive subdermal implant 

Intrauterine device or intrauterine system 

Oral Contraceptive, either combined or progestogen alone [Hatcher, 2007a] 
Injectable progestogen [Hatcher, 2007a]

Contraceptive vaginal ring [Hatcher, 2007a]

Percutaneous contraceptive patches [Hatcher, 2007a]
This is an all-inclusive list of those methods that meet the following GSK definition of 
highly effective: having a failure rate of less than 1% per year when used consistently and 
correctly and, when applicable, in accordance with the product label. For non-product 
methods (e.g. male sterility), the investigator determines what is consistent and correct 
use. The GSK definition is based on the definition provided by the International 
Conference on Harmonization (ICH) [ICH M3 (R2), 2009].
The investigator is responsible for ensuring that subjects understand how to properly use 
these methods of contraception.
 
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Females: 
A female subject is eligible to participate if she is not pregnant (as confirmed by a 
negative urine human chorionic gonadotrophin (hCG) test), not lactating, and the 
following condition applies:
Non-reproductive potential defined as:

Pre-menopausal females with one of the following:

Documented tubal ligation

Documented hysteroscopic tubal occlusion procedure with follow-up 
confirmation of bilateral tubal occlusion 

Hysterectomy

Documented Bilateral Oophorectomy

Postmenopausal defined as 12 months of spontaneous amenorrhea [in 
questionable cases a blood sample with simultaneous follicle stimulating 
hormone (FSH) and estradiol levels consistent with menopause (refer to 
laboratory reference ranges for confirmatory levels)].  Females on hormone 
replacement therapy (HRT) and whose menopausal status is in doubt will be 
required to use one of the highly effective contraception methods if they wish to 
continue their HRT during the study.  Otherwise, they must discontinue HRT to 
allow confirmation of post-menopausal status prior to study enrolment.
INFORMED CONSENT
9. Capable of giving signed informed consent as described in Section 7.2, which 
includes compliance with the requirements and restrictions listed in the consent form 
and in this protocol.
5.2.
Exclusion Criteria
A subject will not be eligible for inclusion in this study if any of the following criteria 
apply:
CONCURRENT CONDITIONS/MEDICAL HISTORY (INCLUDES LIVER 
FUNCTION AND QTc INTERVAL) 
1. ALT >1.5x Upper limit of normal (ULN).
2. Bilirubin >1.5xULN (isolated bilirubin >1.5xULN is acceptable if bilirubin is 
fractionated and direct bilirubin <35%).
3. Current or chronic history of liver disease, or known hepatic or biliary abnormalities 
(with the exception of Gilbert's syndrome or asymptomatic gallstones).
4. Prior history of altitude sickness.
5. Recently been scuba diving (within 1 week before screening).
 
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6. QTc > 450 msec
NOTES:
The QTc is the QT interval corrected for heart rate according to Bazett’s formula 
(QTcB), Fridericia’s formula (QTcF), and/or another method, machine-read or 
manually over-read.
The specific formula that will be used to determine eligibility and discontinuation 
for an individual subject should be determined prior to initiation of the study. In 
other words, several different formulae cannot be used to calculate the QTc for 
an individual subject and then the lowest QTc value used to include or 
discontinue the subject from the trial.
For purposes of data analysis, QTcB, QTcF, another QT correction formula, or a 
composite of available values of QTc will be used as specified in the Reporting 
and Analysis Plan (RAP).
CONCOMITANT MEDICATIONS
7.
Unable to refrain from prescription or non-prescription drugs, including agents active 
in the central nervous system, vitamins, herbal and dietary supplements (including St 
John’s Wort) within 7 days (or 14 days if the drug is a potential enzyme inducer) or 5 
half-lives (whichever is longer) prior to the first dose of study medication and 
throughout the study, unless in the opinion of the Investigator and/or GSK Medical 
Monitor (if needed) the medication will not interfere with the study procedures or 
compromise subject safety.
RELEVANT HABITS
8.
History of regular alcohol consumption within 6 months of the study defined as:
An average weekly intake of >21 units for males or >14 units for females. One 
unit is equivalent to 8 g of alcohol: a half-pint (~240 mL) of beer, 1 glass 
(125 mL) of wine or 1 (25 mL) measure of spirits.
9.
Urinary cotinine levels indicative of smoking or history or regular use of tobacco- or 
nicotine-containing products within 6 months prior to screening.
CONTRAINDICATIONS 
10. History of sensitivity to any of the study medications, or components thereof or a 
history of drug or other allergy that, in the opinion of the investigator or Medical 
Monitor, contraindicates their participation.
DIAGNOSTIC ASSESSMENTS AND OTHER CRITERIA
11. Presence of hepatitis B surface antigen (HBsAg), positive hepatitis C antibody test
result at screening or within 3 months prior to first dose of study treatment. For 
potent immunosuppressive agents, subjects with presence of hepatitis B core antibody
 
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(HBcAb) should also be excluded.
12. A positive pre-study drug/alcohol screen.
13. A positive test for HIV antibody.
14. Where participation in the study would result in donation of blood or blood products
in excess of 500 mL within 56 days.
15. The subject has participated in a clinical trial and has received an investigational
product within the following time period prior to the first dosing day in the current
study: 30 days, 5 half-lives or twice the duration of the biological effect of the
investigational product (whichever is longer).
16. Exposure to more than four new chemical entities within 12 months prior to the first 
dosing day.
5.3.
Screening/Baseline/Run-in Failures
Screen failures are defined as subjects who consent to participate in the clinical trial but 
are never subsequently randomised. In order to ensure transparent reporting of screen 
failure subjects, meet the Consolidated Standards of Reporting Trials (CONSORT) 
publishing requirements, and respond to queries from Regulatory authorities, a minimal 
set of screen failure information is required including Demography, Screen Failure 
details, Eligibility Criteria, and Serious Adverse Events (Section 7.2.1.4).
Subjects that are not enrolled into the study within the allotted screening window may be 
re-screened once. If re-screening is performed, subjects are assigned a different unique 
subject Identification (ID) number for the re-screening, and all screening procedures must 
be repeated.
See the Study Reference Manual (SRM) for specific details.
5.4.
Withdrawal/Stopping Criteria
Subjects may be withdrawn from the study for any of the following reasons:

A subject may withdraw from study treatment at any time at his/her own request, or 
may be withdrawn at any time at the discretion of the investigator for safety, 
behavioural or administrative reasons. If a subject withdraws from the study, he/she 
may request destruction of any samples taken, and the investigator must document 
this in the site study records. 

If a subjects oxygen saturation falls below 65% at any point during the hypoxia 
challenge. 

If the subject experiences worsening shortness of breath or other symptoms, which in 
the opinion of the investigator are consistent with altitude sickness.

The Sponsor may request a subject withdraw for reasons such as significant protocol 
deviations (after discussion with the investigator).
 
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
Study is terminated by the Sponsor.
A subject will be considered to have prematurely withdrawn from the investigational 
product if they do not complete all doses in the treatment phase having received the first 
dose of investigational product, for any reason.
Once a subject has discontinued investigational product the subject may not re-enter the 
study. Dosing of the subjects with the investigational product may be stopped at any 
time, at the request of the subject or at the discretion of the Investigator (i.e. if clinically 
significant adverse events should occur). Withdrawal due to adverse events will be 
distinguished from withdrawal for other reasons.
If a subject decides to withdraw or is withdrawn by the Investigator, the reasons for 
withdrawal and the results of any relevant tests will be recorded in the Case Report Form 
(CRF) and the planned follow-up procedures will be performed, where possible.
The following actions must be taken in relation to a subject who fails to attend the clinic 
for a required study visit:

The site must attempt to contact the subject and re-schedule the missed visit as soon 
as possible. 

The site must counsel the subject on the importance of maintaining the assigned visit 
schedule and ascertain whether or not the subject wishes to and/or should continue in 
the study. 

In cases where the subject is deemed ‘lost to follow up’, the investigator or designee 
must make every effort to regain contact with the subject (where possible, 3 
telephone calls and if necessary a certified letter to the subject’s last known mailing 
address or local equivalent methods). These contact attempts should be documented 
in the subject’s medical record. 

Should the subject continue to be unreachable, only then will he/she be considered to 
have withdrawn from the study with a primary reason of “Lost to Follow-up”.
5.4.1.
Study Stopping Criteria
An interim analysis is planned after approximately 10 subjects have completed treatment 
periods 1 and 2 and the study may be stopped if a reasonable change in PASP is not 
observed after dosing with GSK 2586881 or if review of the safety data suggests a 
change in the benefit-risk profile. The decision to stop the study will be made by the core 
members of the GSK study team.
Safety data that is collected on a continuous basis (oxygen saturation and telemetry) will 
be monitored live on site to determine whether a subject tolerates the hypoxia/exercise 
challenge; study procedures may be aborted on safety grounds if, in the Investigator's 
opinion, any of these measurements reach unsafe levels. The simulated altitude within 
the chamber may be reduced if too many participants fail to tolerate the challenge, and 
the study may be stopped if participants fail to tolerate the challenge at the minimum 
altitude. The full criteria for this procedure (which may lead to the study being stopped) 
are described in Section 7.3.
 
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In addition, the study may be stopped at the interim analysis for a safety signal in oxygen 
saturation under hypoxia and exercise, combined with a lack of evidence of mechanistic 
effect on Angiotensin biomarkers (Ang II, Ang 1-7 and Ang 1-5). Full details on 
stopping criteria are described together with the full procedure for the interim analysis in 
Section 9.3.2.
5.4.2.
QTc Stopping Criteria
The same QT correction formula must be used for each individual subject to determine 
discontinuation from the study.  For example, if a subject is eligible for the protocol 
based on QTcB, then QTcB must be used for discontinuation of this individual subject as 
well.
A subject that meets either bulleted criterion below will be withdrawn from the study.

QTcB or QTcF > 500 msec,

Change from baseline: QTc >60 msec
The QTc should be based on single or averaged QTc values of triplicate ECGs obtained 
over a brief (e.g. 5-10 minute) recording period.
5.4.3.
Liver Chemistry Stopping Criteria
Liver chemistry stopping and increased monitoring criteria have been designed to 
assure subject safety and evaluate liver event etiology (in alignment with the Food and 
Drug Administration (FDA) premarketing clinical liver safety guidance). 
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guid
ances/UCM174090.pdf
Study treatment will be discontinued for a subject if liver chemistry stopping criteria are
met.
Phase I Liver Chemistry Stopping Criteria – Liver Stopping Event Algorithm
Continue Study Treatment 
Discontinue Study Treatment 
*INR value not applicable to subjects on anticoagulants 
ALT ≥3xULN 
No
Yes
Must refer to Liver Safety Required Actions and Follow up Assessments  section in the Appendix
Report as an SAE if possible Hy’s Law case: ALT≥3xULN and  Bilirubin≥2xULN (>35% direct)  or 
INR>1.5, if measured*
 
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Liver Safety Required Actions and Follow up Assessments Section can be found in
Appendix 2.
5.4.3.1.
Study Treatment Restart or Rechallenge
Study treatment restart or rechallenge after liver chemistry stopping criteria are met by 
any subject participating in this study is not allowed.
5.5.
Subject and Study Completion
A completed subject is one who has completed all phases of the study including the 
follow-up visit.
The end of the study is defined as the last subject’s last visit.
6.
STUDY TREATMENT
6.1.
Investigational Product and Other Study Treatment
The term ‘study treatment’ is used throughout the protocol to describe any combination 
of products received by the subject as per the protocol design. Study treatment may 
therefore refer to the individual study treatments or the combination of those study 
treatments.
Study Treatment
Product name:
(Generic name and trade)
GSK2586881
Placebo
Formulation description:
rhACE2
Normal Saline (0.9%)
Dosage form:
IV
IV
Unit dose strength(s)/Dosage 
level(s):
0.8 mg/kg
Saline Placebo
Route of Administration
Intravenous
Intravenous
Dosing instructions:
Infuse over 3-5 minutes
Infuse over 3-5 minutes
Physical description:
Clear colourless liquid 
Clear colourless liquid
At Screening a unique Subject Number (CRF number) will be assigned to any subject 
who has at least one Screening procedure performed, other than informed consent. The 
unique Subject Number will be used to identify individual subjects during the course of 
the study.
Subjects who meet screening eligibility criteria will be assigned to one of the sequences 
listed in Table 1 below, in accordance with the randomisation schedule generated by 
Clinical Statistics, prior to the start of the study, using validated internal software. Once 
assigned, this number must not be reassigned to any other subject in the study.
 
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Table 1
Description of sequences
Sequence
Period 1 
Period 2
AB
Saline Placebo
GSK2586881
BA
GSK2586881
Saline Placebo
The subjects will be randomised using a central randomisation procedure created by 
GSK. 
Further details on how and when a subject is allocated a randomisation number and the 
subject numbering convention is in the SRM.
6.2.
Planned Dose Adjustments
No dose adjustments are allowed.
 
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6.3.
Blinding
This will be double blind (sponsor open) study. All study staff involved in clinical 
assessments (which includes the investigator, sub-investigators, other site staff), and the 
subject will be blinded to the treatment allocated to individual subjects. An unblinded 
qualified staff member will be required at site to prepare the study treatment for dosing. 
The unblinded staff member is not permitted to communicate the subject’s treatment 
allocation to blinded site staff. Selected study team members working for the sponsor 
(and delegates if programming activities are outsourced) will be unblinded to perform the 
interim analysis. This will include the medical monitor, study statistician, study 
programmer (and delegates) and study pharmacokineticist. Access to unblinded data will 
be kept to the minimum set of individuals required to implement any interim analyses but 
may include GSK management/review committees if alterations to the study conduct are 
required. Details of who were unblinded to what data and when will be included in the 
clinical study report.
The following will apply: 

The investigator or treating physician may unblind a subject’s treatment 
assignment only in the case of an emergency OR in the event of a serious 
medical condition when knowledge of the study treatment is essential for the 
appropriate clinical management or welfare of the subject as judged by the 
investigator. 

Investigators have direct access to the subject’s individual study treatment. 

It is preferred (but not required) that the investigator first contacts the Medical 
Monitor or appropriate GSK study personnel to discuss options before unblinding 
the subject’s treatment assignment. 

If GSK personnel are not contacted before the unblinding, the investigator must 
notify GSK as soon as possible after unblinding, but without revealing the 
treatment assignment of the unblinded subject, unless that information is 
important for the safety of subjects currently in the study. 

The date and reason for the unblinding must be fully documented in the  CRF 
A subject whose treatment sequence assignment is unblinded for emergency reasons (as 
described above) will not be permitted to continue in the study (due to the emergency 
requiring unblinding rather than the unblinding itself). The event or condition that led to 
the unblinding will be recorded in the CRF as the primary reason for discontinuation.
A subject whose treatment sequence assignment is inadvertently unblinded (either to 
investigative staff or the subject themselves) will be permitted to remain in the study, 
although the accidental unblinding will be recorded as a protocol deviation and hence the 
subject will be subject to review as to their inclusion in analyses as per the procedures set 
out in Section 9.3.1.
 
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6.4.
Packaging and Labeling
The contents of the label will be in accordance with all applicable regulatory 
requirements.
6.5.
Preparation/Handling/Storage/Accountability
A description of the methods and materials required for GSK2586881 will be detailed in 
a Study Specific Technical Agreement/Memo (TTS) or Pharmacy Section of the SRM, 
which will be accompanied by a Quality Agreement.

The investigator or designee must confirm appropriate temperature conditions 
have been maintained during transit for all study treatment received and any 
discrepancies are reported and resolved before use of the study treatment.

Only subjects enrolled in the study may receive study treatment and only 
authorized site staff may supply or administer study treatment.  All study 
treatments must be stored in a secure environmentally controlled and monitored 
(manual or automated) area in accordance with the labelled storage conditions 
with access limited to the investigator and authorized site staff. 

The investigator, institution, or the head of the medical institution (where 
applicable) is responsible for study treatment accountability, reconciliation, and 
record maintenance (i.e. receipt, reconciliation and final disposition records).  

Further guidance and information for final disposition of unused study treatment 
are provided in the SRM. 

Under normal conditions of handling and administration, study treatment is not 
expected to pose significant safety risks to site staff.  Take adequate precautions to 
avoid direct eye or skin contact and the generation of aerosols or mists. In the 
case of unintentional occupational exposure notify the monitor, Medical Monitor 
and/or GSK study contact.

A Material Safety Data Sheet (MSDS)/equivalent document describing 
occupational hazards and recommended handling precautions either will be 
provided to the investigator, where this is required by local laws, or is available 
upon request from GSK.
6.6.
Compliance with Study Treatment Administration
When the individual dose for a subject is prepared from a bulk supply, the preparation of 
the dose will be confirmed by a second member of the study site staff. 
Subjects will be dosed at the site, and they will receive study treatment directly from the 
investigator or designee, under medical supervision.  The date and time of each dose 
administered in the clinic will be recorded in the source documents.  The dose of study 
treatment and study subject identification will be confirmed at the time of dosing by a 
member of the study site staff other than the person administering the study treatment.  
 
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GSK2586881 and the saline placebo will be intravenously administered to subjects at the 
site.  Administration will be documented in the source documents and reported in the 
CRF.
6.7.
Treatment of Study Treatment Overdose
For this study, any dose of GSK2586881 > 1.5 mg/kg within a 24 hour time period will 
be considered an overdose.
GSK does not recommend specific treatment for an overdose. The investigator will use 
clinical judgment to treat any overdose.
In the event of an overdose the investigator or treating physician should:
1.
contact the Medical Monitor immediately
2.
closely monitor the subject for adverse events (AEs)/serious adverse events (SAEs) 
and laboratory abnormalities until GSK2586881can no longer be detected 
systemically (at least 3 days for GSK2586881).
3.
obtain a plasma sample for pharmacokinetic (PK) analysis within 1 day from the date 
of the last dose of study treatment if requested by the Medical Monitor (determined 
on a case-by-case basis).
4.
document the quantity of the excess dose as well as the duration of the overdosing in 
the CRF.
Decisions regarding dose interruptions or modifications will be made by the investigator 
in consultation with the Medical Monitor based on the clinical evaluation of the subject.
6.8.
Treatment after the End of the Study
Subjects will not receive any additional treatment from GSK after completion of the 
study because only healthy volunteers are eligible for study participation.
6.8.1.
Meals and Dietary Restrictions

No dietary restrictions prior to the first treatment period.
6.8.2.
Caffeine, Alcohol, and Tobacco

During each dosing session, subjects will abstain from caffeine for 12 hours prior to 
the start of dosing until collection of the final pharmacokinetic and or 
pharmacodynamic sample during each session. 

During each dosing session, subjects will abstain from alcohol for 12 hours prior to 
the start of dosing until collection of the final pharmacokinetic and or 
pharmacodynamic sample during each session. 

Use of tobacco products is not allowed as outlined in the exclusion criteria. 
 
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6.8.3.
Activity
Subjects will abstain from strenuous exercise for 24 hours prior to screening and each 
treatment period  Subjects may participate in light recreational activities between the 
planned study procedures (e.g., watch television, read).
6.9.
Concomitant Medications and Non-Drug Therapies
6.9.1.
Permitted Medications and Non-Drug Therapies
Paracetamol, at doses of 2 grams/day is permitted for use any time during the study. 
Other concomitant medication may be considered on a case by case basis by the 
investigator in consultation with the Medical Monitor if required.
6.9.2.
Prohibited Medications and Non-Drug Therapies
Subjects must abstain from taking prescription or non-prescription drugs (including 
vitamins and dietary or herbal supplements), within 7 days (or 14 days if the drug is a 
potential enzyme inducer) or 5 half-lives (whichever is longer) prior to the first dose of
study medication until completion of the follow-up visit, unless in the opinion of the 
Investigator and sponsor the medication will not interfere with the study.
 
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7.
STUDY ASSESSMENTS AND PROCEDURES
Protocol waivers or exemptions are not allowed with the exception of immediate safety 
concerns. Therefore, adherence to the study design requirements, including those 
specified in the Time and Events Table, are essential and required for study conduct.
This section lists the procedures and parameters of each planned study assessment.  The 
exact timing of each assessment is listed in the Time and Events Table Section 7.1
The following points must be noted: 

If assessments are scheduled for the same nominal time, THEN the assessments 
should occur in the following order:
1.
Ventilatory parameters
2.
Echocardiograms
3.
12-lead ECG
4.
vital signs
5.
blood draws  
Note: The timing of the assessments should allow the echocardiogram to be 
performed as close as possible to the nominal time.

The timing and number of planned study assessments, including: safety,
echocardiogram, pharmacokinetic, pharmacodynamic/biomarker or other 
assessments may be altered during the course of the study based on newly available 
data (e.g. to obtain data closer to the time of peak plasma concentrations) to ensure 
appropriate monitoring. 

The change in timing or addition of time points for any planned study assessments 
must be documented in a Note to File which is approved by the relevant GSK study 
team member and then archived in the study sponsor and site study files, but this will 
not constitute a protocol amendment. 

The Institutional Review Board (IRB)/IEC will be informed of any safety issues that 
require alteration of the safety monitoring scheme or amendment of the Informed 
Consent Form. 

No more than 500 mL of blood will be collected over the duration of the study, 
including any extra assessments that may be required.
 
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7.1.
Time and Events Table
7.1.1.
Screening and Follow up
Procedure 
Screening1
(up to 28 days prior to 
Treatment Period 1, Day 1)
Follow up
(7-10 days post 
last dose)
Notes
Informed consent
X
Inclusion and exclusion criteria
X
Demography
X
Full physical exam, including height and weight
X
X
Height and weight to be measured at screening only.  Weight at screening will 
be used for dosing calculation.
Alcohol, Drugs of Abuse, Smoking test
X
Medical history (includes substance usage  
[and family history of premature CV disease])
X
Substances: Drugs, Alcohol, tobacco
Past and current medical conditions [including 
cardiovascular medical history]
X
Serum OR urine pregnancy test (WCBP)
X
HIV, Hep B and Hep C screen
X
Laboratory assessments (include liver 
chemistries)
X
X
Non Fasting 
Immunogenicity
X
12-lead ECG
X
X
Triplicate ECG required at screening.
Vital signs
X
X
Triplicate vital signs required at screening. 
Spirometry
X
Echocardiogram
X
Concomitant Medication review 
X
X
Hypoxia chamber plus exercise 
X
Tolerance to 4000m for 10 mins followed by incremental exercise testing to 
determine maximum oxygen uptake (VO2max) and calculate 70% of VO2max 
(to be used for the exercise challenge during the Treatment Periods).  
Pharmacogenetic sample (PGx)
X
Can be taken any time after consent has been signed. Only required once and 
is optional. 
AE/SAE review
X
X
As per timings detailed in Section 7.2.1.1
1.
Screening assessments are allowed to be conducted on more than one day
 
 
 
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7.1.2.
Treatment Period 1 and 2
Procedure
Treatment Period 1 and 2 (Washout 3-14 days)
Notes
Times relative to start 
of dosing
Hypoxic Challenge ~80 min 
(Times relative to entry to 
Chamber)
Pre-dose
0h
15 min
15-45 min
0-60 min
60 min
60-70 min
Immediately after 
exercise
On exit from 
chamber
After 30 min rest
60 min after exit 
from Chamber 
Randomisation
X
Randomisation can occur up to the day before 
the first treatment period
Brief physical exam 
X
Vital signs
X
X
X5
X
Immunogenicity
X
12-lead ECG
X
X
X
Echocardiogram
X
X
X
X
X
Echocardiogram duration approx 5 min
Subject enters chamber
X
Subject enters chamber approximately 30 min
after study treatment
Study Treatment (Dosing) 
X
Subject leaves chamber
X
Subject leaves chamber after the fourth 
echocardiogram, blood samples and vital signs 
have been taken.
Exercise challenge
X
For approx 5-10 min
Ventilatory parameters
X
X
X
X
Measurements to be taken 2 min before 
echocardiograms.
Pulse Oximetry
(O2 saturation)
================================================================
Will be continuously monitored for safety. A 
measurement should be recorded at time of each 
echocardiogram and databased.
Telemetry
================================================================
Will be continuously monitored for safety.
RAS Biomarkers
X
X1
X2
X3
X2
X2
X4
X2
SP-D
X
X1
X2
X3
X2
X2
X4
X2
 
 
 
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Procedure
Treatment Period 1 and 2 (Washout 3-14 days)
Notes
Times relative to start 
of dosing
Hypoxic Challenge ~80 min 
(Times relative to entry to 
Chamber)
Pre-dose
0h
15 min
15-45 min
0-60 min
60 min
60-70 min
Immediately after 
exercise
On exit from 
chamber
After 30 min rest
60 min after exit 
from Chamber 
PK sampling
X
X1
X2
X3
X2
X2
X4
X2
AE/SAE review
============================================================
Concomitant medication review
X
1.
Take at the end of the infusion
2.
Taken immediately after echocardiogram 
3.
Immediately before entering the chamber
4.
To be taken as soon as possible after leaving chamber
5.
On this occasion ONLY, vital signs to be taken after the blood draw.
 
 
 
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After written informed consent, screening assessments will be performed as outlined in 
the Time and Events Table (Section 7.1).
The following demographic parameters will be captured: year of birth, sex, race and 
ethnicity.
Medical/medication/family history will be assessed as related to the inclusion/exclusion 
criteria listed in Section 5.
Cardiovascular medical history/risk factors (as detailed in the CRF) will be assessed at 
screening.
Cardiorespiratory fitness during bicycle exercise and hypoxia tolerance will be assessed.
Procedures conducted as part of the subject’s routine clinical management (e.g. blood 
count) and obtained prior to signing of informed consent may be utilized for Screening or 
baseline purposes provided the procedure meets the protocol-defined criteria and has 
been performed in the timeframe of the study.
7.2.
Safety
Planned time points for all safety assessments are listed in the Time and Events Table 
(Section 7.1).  Additional time points for safety tests such as vital signs, physical exams 
and laboratory safety tests may be added during the course of the study based on newly 
available data to ensure appropriate safety monitoring.
7.2.1.
Adverse Events (AE) and Serious Adverse Events (SAEs)
The definitions of an AE or SAE can be found in Appendix 4.
The investigator and their designees are responsible for detecting, documenting and 
reporting events that meet the definition of an AE or SAE. 
7.2.1.1.
Time period and Frequency for collecting AE and SAE information

Any SAEs assessed as related to study participation (e.g., protocol-mandated 
procedures, invasive tests, or change in existing therapy) or related to a GSK product 
will be recorded from the time a subject consents to participate in the study up to and 
including any follow-up contact. 

AEs will be collected from the start of Study Treatment until the follow-up contact 
(see Section 7.2.1.3), at the time-points specified in the Time and Events Table 
(Section 7.1).

Medical occurrences that begin prior to the start of study treatment but after 
obtaining informed consent may be recorded on the Medical History/Current 
Medical Conditions section of the CRF.

All SAEs will be recorded and reported to GSK within 24 hours, as indicated in 
Appendix 4.
 
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
Investigators are not obligated to actively seek AEs or SAEs in former study 
subjects. However, if the investigator learns of any SAE, including a death, at any 
time after a subject has been discharged from the study, and he/she considers the 
event reasonably related to the study treatment or study participation, the investigator 
must promptly notify GSK.
NOTE: The method of recording, evaluating and assessing causality of AEs and SAEs 
plus procedures for completing and transmitting SAE reports to GSK are provided in 
Appendix 4.
7.2.1.2.
Method of Detecting AEs and SAEs
Care will be taken not to introduce bias when detecting AEs and/or SAEs. Open-ended 
and non-leading verbal questioning of the subject is the preferred method to inquire about 
AE occurrence.  Appropriate questions include:

“How are you feeling?” 

“Have you had any (other) medical problems since your last visit/contact?” 

“Have you taken any new medicines, other than those provided in this study, since 
your last visit/contact?” 
7.2.1.3.
Follow-up of AEs and SAEs
After the initial AE/SAE report, the investigator is required to proactively follow each 
subject at subsequent visits/contacts.  All SAEs will be followed until resolution, until the 
condition stabilizes, until the event is otherwise explained, or until the subject is lost to 
follow-up (as defined in Section 5.4). Further information on follow-up procedures is 
given in Appendix 4.
7.2.1.4.
Regulatory Reporting Requirements for SAEs
Prompt notification by the investigator to GSK of SAEs related to study treatment (even 
for non- interventional post-marketing studies) is essential so that legal obligations and 
ethical responsibilities towards the safety of subjects and the safety of a product under 
clinical investigation are met. 
GSK has a legal responsibility to notify both the local regulatory authority and other 
regulatory agencies about the safety of a product under clinical investigation.  GSK will 
comply with country specific regulatory requirements relating to safety reporting to the 
regulatory authority, Institutional Review Board (IRB)/Independent Ethics Committee 
(IEC) and investigators.
Investigator safety reports are prepared for suspected unexpected serious adverse 
reactions according to local regulatory requirements and GSK policy and are forwarded 
to investigators as necessary.
An investigator who receives an investigator safety report describing a SAE(s) or other 
specific safety information (e.g., summary or listing of SAEs) from GSK will file it with 
the IB and will notify the IRB/IEC, if appropriate according to local requirements.
 
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7.2.2.
Physical Exams

A complete physical examination will include, at a minimum, assessment of the 
Cardiovascular, Respiratory, Gastrointestinal and Neurological systems. Height and 
weight will also be measured and recorded, at screening only. 

A brief physical examination will include, at a minimum assessments of the skin,
lungs, cardiovascular system, and abdomen (liver and spleen). To be carried out at 
the start of each period. 

Investigators should pay special attention to clinical signs related to previous serious 
illnesses.
7.2.3.
Vital Signs

Vital signs will be measured in semi-supine position after 5 minutes rest and will 
include temperature, systolic and diastolic blood pressure and pulse rate. 

Triplicate measurements will be taken at screening, and single measurements at other 
time-points.  The first reading should be rejected.  Second and third readings should 
be averaged to give the measurement to be recorded in the CRF.
7.2.4.
Electrocardiogram (ECG)

Triplicate 12-lead ECGs will be obtained at screening. At all other time-points, a 
single 12-lead ECGs will be obtained using an ECG machine that automatically 
calculates the heart rate and measures PR, QRS, QT, and QTc intervals.  Refer to 
Section 5.4.2 for QTc withdrawal criteria and additional QTc readings that may be 
necessary.

ECG to be measured in a semi-supine position after 5 minutes rest.

The same QT correction formula must be used for each individual subject for all QTc 
data being collected for data analysis.  Safety ECGs and other non-protocol specified 
ECGs are an exception.
7.2.5.
Clinical Safety Laboratory Assessments
All protocol required laboratory assessments, as defined in Table 2, must be conducted in 
accordance with the Protocol Time and Events Schedule. Laboratory requisition forms 
must be completed and samples must be clearly labelled. Details for the preparation and 
shipment of samples will be provided by the laboratory. Reference ranges for all safety 
parameters will be provided to the site by the laboratory responsible for the assessments.
If additional non-protocol specified laboratory assessments are performed at the 
institution’s local laboratory and result in a change in subject management or are 
considered clinically significant by the investigator (e.g., SAE or AE or dose 
modification) the results must be recorded in the CRF.
Haematology, clinical chemistry, urinalysis and additional parameters to be tested are 
listed in Table 2. 
 
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Table 2
Protocol Required Safety Laboratory Assessments
Laboratory 
Assessments
Parameters
Haematology
Platelet Count
RBC Indices:
WBC count with Differential:
RBC Count
MCV
Neutrophils
Hemoglobin
MCH
Lymphocytes
Hematocrit
Monocytes
Eosinophils
Basophils
Clinical 
Chemistry 1
BUN
Potassium
AST (SGOT)
Total and direct bilirubin
Urea
Sodium
ALT (SGPT)
Total Protein
Creatinine
Calcium
Alkaline phosphatise
Albumin
Glucose 
Routine 
Urinalysis

Specific gravity

pH, glucose, protein, blood and ketones by dipstick

Microscopic examination (if blood or protein is abnormal)
Other 
Screening 
Tests

HIV

Hepatitis B (HBsAg)

Hepatitis C (Hep C antibody)

Alcohol, smoking and drug screen (to include at minimum: 
amphetamines, barbiturates, cocaine, opiates, cannabinoids, 
benzodiazepines and cotinine) performed at site

Urine hCG Pregnancy test (as needed) 2
NOTES :
1.
Details of Liver Chemistry Stopping Criteria and Required Actions and Follow-Up 
Assessments after liver stopping or monitoring event are given in Section 5.4.2 and 
Appendix 2.
2.
Local urine testing will be standard for the protocol unless serum testing is required 
by local regulation or ethics committee.
All laboratory tests with values that are considered clinically significantly abnormal 
during participation in the study or within 3 days after the last dose of study treatment 
should be repeated until the values return to normal or baseline.  If such values do not 
return to normal within a period judged reasonable by the investigator, the etiology
should be identified and the sponsor notified.
7.3.
Hypoxia Challenge
Each subject will be inside the hypoxia chamber for approximately 80 minutes per 
period, during which time they will be under the full 4000 m ± 10% hypoxic conditions. 
 
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If three or more subjects do not tolerate the hypoxic challenge, either due to symptoms or 
O2 saturation of <65%, then the simulated altitude will be adjusted in decrements of 
500 m (i.e. from 4000 m to 3500 m) for all remaining subjects to a minimum of 3000 m.
Further details about the hypoxia challenge is detailed in the SRM. 
7.3.1.
Exercise Challenge
Subjects will perform an exercise challenge at 70% of maximum VO2 uptake on a cycle
ergometer within the hypoxia chamber for 10 minutes.
Subjects must complete a minimum of 5 minutes exercise at 70% of maximumVO2 
uptake (calculated from the incremental exhaustive exercise test at the screening visit).
Further detail about the exercise challenge is detailed in the SRM. 
7.4.
Echocardiogram
Echocardiograms will be taken as detailed in the Time and Events table (Section 7.1). 
Echocardiograms will be obtained with the subject resting supine or lying on their left 
side. 
PASP will be measured and recorded.
PASP will be determined by measuring maximal tricuspid regurgitation velocity and 
applying the modified Bernoulli equation to convert this value into pressure values. 
Estimated right atrial pressure (RAP) must be added to this obtained value.
Further details about the PASP measurement is detailed in the SRM. 
Additional echocardiograms may be obtained for each subject as needed (in the 
judgement of the Investigator and GSK Medical Monitor, if required).
7.5.
Ventilatory parameters
Ventilatory parameters will be measured as detailed in the Time and Events table 
(Section 7.1). 
Ventilatory parameters will be recorded for 2 minutes before echocardiograms.  The 
second minute of the recording will be averaged and used for data analysis.
Measurements may include change from baseline of oxygen consumption (VO2), carbon 
dioxide production (CO2), total tidal volume, inspiratory tidal volume, expiratory tidal 
volume, total respiratory time, inspiratory time, expiratory time, duty cycle, mean 
respiratory flow and respiratory rate, as data permit.
 
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7.6.
Pulse Oximetry
Oxygen saturation will be monitored continuously via pulse oximetry as detailed in the 
SRM. Measurements will be taken at the same time as the echocardiograms and recorded 
in the eCRF. 
7.7.
Telemetry
Continuous ECG monitoring will occur via telemetry during both treatment periods.
7.8.
Pharmacokinetics
7.8.1.
Blood Sample Collection
Blood samples for pharmacokinetic (PK) analysis of GSK2586881 will be collected at 
the time points indicated in the Time and Events Table (Section 7.1).  The actual date and 
time of each blood sample collection will be recorded.  
The timing of PK samples may be altered and/or PK samples may be obtained at 
additional time points to ensure thorough PK monitoring.  
Details of PK blood sample collection (including volume to be collected), processing, 
storage and shipping procedures are provided in the SRM.
7.8.2.
Sample Analysis
Plasma analysis will be performed under the control of PTS, In Vitro/In Vivo 
Translations (IVIVT) Department and Third Party Resourcing (TPR), GlaxoSmithKline. 
The details of the Bioanalytical Laboratory will be included in the SRM. Concentrations 
of GSK2586881 will be determined in plasma samples using the currently approved 
bioanalytical methodology. Raw data will be archived at the Bioanalytical Site 
(Bioanalytical Site to be detailed in the SRM).
7.9.
Biomarker(s)/Pharmacodynamic Markers
Blood samples for biomarker/PD analysis will be collected at the time points indicated in 
the Time and Events Table (Section 7.1).  The actual date and time of each blood sample 
collection will be recorded.  The timing of biomarker/PD samples may be altered and/or 
samples may be obtained at additional time points to ensure thorough monitoring.  
Details of biomarker/PD blood sample collection (including volume to be collected), 
processing, storage and shipping procedures are provided in the SRM.
7.9.1.
Renin-angiotensin system biomarkers
RAS peptides including, but not limited to, AngII, Ang(1-7) and Ang(1-5) may be 
analysed as data permit.  Raw data will be archived at the Bioanalytical Site 
(Bioanalytical Site detailed in the SRM).
 
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7.9.2.
Surfactant Protein-D and other biomarkers
SP-D will be analysed. Raw data will be archived at the Bioanalytical Site (Bioanalytical 
Site to be detailed in the SRM).  Additional analytes may be analysed, as data permit.  
7.10.
Genetics
Information regarding genetic research is included in Appendix 3.
Genetic sampling is optional. Subjects can refuse genetic sampling, but will still be 
allowed to participate in the study. 
7.10.1.
Blood sample collection
A blood sample to investigate the association between the loss of function polymorphism 
rs1799752, representing the I/D polymorphism, in intron 16 of the Angiotensin 
Converting Enzyme (ACE) gene and Ang II (and possibly other RAS peptides) and 
hypoxic pulmonary vasoconstriction will be collected as specified in the Time and Events 
Table (Section 7.1). 
Further information for blood sample collection, processing, storage and shipping 
procedures are provided in the SRM. 
Information regarding genetic research is included in Appendix 3.
7.11.
Immunogenicity
7.11.1.
Sample collection
Blood samples for immunogenicity analysis will be collected at the time points indicated 
in Section 7.1, Time and Events Table. Additional visits to obtain immunogenicity 
samples may be required in the unlikely event that subjects develop a clinically relevant 
immunoglobulin response to the drug as described in the SRM.
Details of immunogenicity blood sample collection (including volume to be collected), 
processing, storage and shipping procedures are provided in the SRM.
7.11.2.
Sample analysis
Immunogenicity analysis will be performed under the management of Clinical 
Immunology, Biopharm R&D, GlaxoSmithKline. All pre-dose and post-dose samples
will be first tested for Anti-ACE2 binding antibodies by screening and confirmation assay 
steps. The post-dose samples tested positive for anti-ACE2 binding antibodies will be 
further characterized for anti-ACE2 neutralizing antibodies. Both positive incidences for 
anti-ACE2 binding and neutralizing antibodies will be reported.
 
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8.
DATA MANAGEMENT

For this study subject data will be entered into GSK defined CRFs, transmitted 
electronically to GSK or designee and combined with data provided from other 
sources in a validated data system.  

Management of clinical data will be performed in accordance with applicable GSK 
standards and data cleaning procedures to ensure the integrity of the data, e.g. 
removing errors and inconsistencies in the data.

Adverse events and concomitant medications terms will be coded using MedDRA 
(Medical Dictionary for Regulatory Activities) and an internal validated medication 
dictionary, GSKDrug.  

CRFs (including queries and audit trails) will be retained by GSK, and copies will be 
sent to the investigator to maintain as the investigator copy.  Subject initials and 
day/month of birth will not be collected or transmitted to GSK according to GSK 
policy.
9.
STATISTICAL CONSIDERATIONS AND DATA 
ANALYSES
9.1.
Hypotheses
The focus of this study is on the exploration of the effect of GSK2586881 on a range of 
echocardiography, pulse oximetry, biomarker, safety and PK endpoints, when subjecting 
healthy volunteers to an exercise challenge under hypoxic conditions. No formal 
statistical hypotheses are being tested. A Bayesian statistical analysis framework with 
non-informative priors for model parameters (unless otherwise specified) will be used to 
obtain posterior distributions for effects of interest. These posterior distributions will be 
used to obtain a number of probability statements about the magnitude of treatment 
effects (e.g. Probability of any treatment related reduction in PASP, or Probability that 
the treatment related reduction in PASP 5 mmHg).
A rule of thumb for end of “study success” is if the probability of any treatment related 
reduction in PASP (T3-T0) exceeds 0.95 (success is also conditional on the probability of 
(absolute) treatment related reductions in oxygen saturation exceeding 5%, being small).
9.2.
Sample Size Considerations
The sample size of 20 patients is based on logistical considerations and is not based on 
formal sample size calculations. However, estimates of precision for the treatment 
difference in the primary endpoint are presented for context (Note: precision in this 
context is defined as one half of the width of the 95% confidence interval). A sample 
size re-estimation is planned after 10 subjects. 
9.2.1.
Sample Size Assumptions
The precision of the primary treatment comparison (change from baseline PASP to 
hypoxic/exercise PASP) was estimated using simulation. PASP data points were 
 
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simulated for each subject: normoxic at rest, and hypoxic after exercise, each for two 
study periods, giving a total of four PASP measurements for each subject. The four PASP 
measurements were drawn from a multivariate normal distribution to allow for different 
levels of within-subject correlation. One simulated study with a given sample size (N) 
was created by repeating this process of generating individual subject data N times, 
randomly allocating each subject to a treatment sequence in a 1:1 ratio, and calculating 
the half-width of the confidence interval of the treatment difference in change from 
baseline in PASP from that simulated dataset (using a linear mixed effects model 
including period baseline, subject baseline, treatment and period as fixed effects, and 
subject as a random effect). A full simulation run consisted of 1000 iterations of 
simulated studies, and a final estimate for precision was calculated as the mean precision 
across the 1000 iterations.
The following assumptions were made regarding the mean and Standard Deviation (SD) 
of PASP based on data from Antoni Ricart, 2005:

Mean PASP was 30 mmHg at baseline (i.e. normoxic and at rest) and 45 mmHg 
under hypoxia and exercise

SD of PASP was 2.81 mmHg at baseline and 4.30 mmHg under hypoxia and exercise

As the purpose of this simulation was to estimate precision by evaluating the SD of 
the treatment difference rather than the mean, there was no treatment effect assumed 
in the simulations

The within-subject correlation of PASP was unknown, therefore four different 
scenarios of within-subject correlation were evaluated: zero correlation, low 
correlation (0.3), high correlation (0.6) and very high correlation (0.9).

A range of sample sizes was considered: from 5 to 10 in increments of 1, and then up 
to 40 in increments of 5. The table below shows a subset of these; the figure includes 
them all.
Based on these assumptions, the estimated precisions for these sample sizes and under 
these scenarios of within-subject correlation were as follows (smaller number for 
precision denotes more precise estimates):
 
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Table 3
Estimated precision of treatment comparisons of change from 
baseline in PASP (mmHg) for a range of sample sizes and within-
subject correlation scenarios
Within-subject correlation
Sample size (N)
0
0.3
0.6
0.9
10
4.35
3.83
2.92
1.48
20
2.76
2.40
1.83
0.91
30
2.22
1.91
1.46
0.72
40
1.91
1.63
1.23
0.62
Figure 4 illustrates precision estimates under the full range of sample sizes considered 
(from 5 to 40), and for all within-subject correlation scenarios. The red line at 5 mmHg is 
superimposed to indicate a rough guide to the magnitude of a clinically meaningful 
difference.
Figure 4
Sensitivity of study precision to sample size and within subject 
correlation of PASP
9.2.2.
Sample Size Re-estimation
A sample size re-estimation will be conducted at the interim analysis (see Section 9.3.2). 
The purpose of the sample size re-estimation is to determine whether the total number of 
subjects can be reduced below the anticipated 20, based on treatment comparison 
between GSK2586881 and Placebo in change from pre-dose PASP to hypoxic/exercised 
 
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PASP (i.e. T3-T0). The sample size re-estimation is to be considered advisory, and taken 
into account together with other considerations. These will include:

ensuring sufficient data is collected on secondary endpoints,

non-conclusive safety data at the time of interim analysis (e.g. a weak signal of a 
reduction in oxygen saturation data that would require the full set of remaining 
subjects to be able to reach a conclusion),

speed of recruitment.
9.3.
Data Analysis Considerations
Data will be listed and summarised according to GSK integrated data standards library 
(IDSL) reporting standards where applicable.  Complete details will be provided in the 
Reporting and Analysis Plan (RAP).
The key endpoints referred to in the text below comprise PASP measured by 
echocardiography, oxygen saturation measured by continuous pulse oximetry, RAS 
peptides and safety data.
9.3.1.
Analysis Populations
All Subjects Screened Population: This population contains all subjects that complete at 
least one Visit 1 (Screening) procedure. This population will be used for the summary of 
subject disposition (including reasons for screening failures, run-in failures, and 
stabilization failures) and for the listing of AEs and SAEs for non-randomised subjects.
Intent-to-Treat (ITT) Population: This population will comprise all randomised subjects, 
excluding those who were randomised in error. A subject who is recorded as a screen 
failure, run-in failure, or stabilisation failure, but is randomised and does not receive a 
dose of study treatment, is considered to be randomised in error. Any other subject who 
receives a randomisation number will be considered to have been randomised. This will 
constitute the primary population for all safety and pharmacodynamic analyses.
Pharmacokinetic (PK) population: This population will comprise all subjects in the ITT 
Population for whom a PK sample was obtained and analysed and on active treatment.
In addition to the above populations, the effect of important protocol violations, including 
any subjects who failed the inclusion/exclusion criteria, may be assessed by means of 
sensitivity analyses. A blind review of all protocol violations will be performed prior to 
DBF in order to identify any important deviations and consequently identify any subjects 
who will be excluded from such sensitivity analyses.
9.3.2.
Interim Analysis
An interim analysis is planned after 10 subjects have completed the following critical 
assessments:

PASP at T0 and T3 for both study periods
 
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
Oxygen saturation at T0 and T3 for both study periods

Adverse events 
The interim analysis will use the following study data:

PASP at time T0 and T3 for both periods, for the first 10 subjects

Oxygen saturation at T0 and T3 for both periods, for the first 10 subjects

Adverse events for the first 10 subjects

RAS peptide concentrations for the first 5 subjects (to allow time for the samples 
to be analysed by the external lab).
The interim analysis will use a data snapshot that has been cleaned to the best extent 
allowed by the timeframes (i.e. the interim data will not be fully cleaned or fully QC’d 
data and there will not be a locked database).
The aims of the interim analysis, and the endpoints to be used to address them, are as 
follows:

Using the primary endpoint (treatment differences between GSK2586881 and 
Placebo in change from pre-dose PASP to hypoxic/exercised PASP [T3-T0]):
o
To decide whether to continue the study or stop based on futility, and
o
to conduct an advisory sample-size re-estimation with the view to 
potentially reduce the number of subjects participating in the study below 
20.

Using secondary endpoints:
o
to estimate treatment differences between GSK2586881 and Placebo in 
change from pre-dose oxygen saturation to hypoxic/exercised oxygen 
saturation [T3-T0], with a view to stopping the study if there is evidence 
that GSK2586881 causes a reduction in oxygen saturation in healthy 
volunteers. As a non-binding guide high posterior probability of observing 
5% absolute differences in mean oxygenation saturation values between 
placebo and active arms would be of concern; but clinical judgement 
would override any statistical methods if, for example, the majority of 
subjects displayed consistent patterns of reductions e.g. between 2-3%).
o
to compare adverse events within the two treatment groups and explore 
any potential safety signals that may emerge
To assess the operating characteristics of the interim analysis decisions to be made based 
on the primary endpoint, a simulation was carried out to estimate the relative proportion 
of studies reaching conclusions to stop for futility, continue with no change to the sample 
 
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size, and to continue with a reduced sample size, under various different scenarios of the 
true treatment effect. Broadly speaking, the aim of the simulation was to confirm that (in 
an overwhelming majority of cases) a decision to stop for futility would be reached in the 
case of no true treatment effect and a decision to continue (perhaps with reduced sample 
size) would be reached in the case of a true treatment effect.
Simulated datasets of PASP at baseline (i.e. normoxic and at rest) and under hypoxia and 
exercise for 10 subjects, each receiving both treatments in sequence, were generated 
using the following assumptions:

10 simulated subjects were randomised to one of the two available treatment 
sequences (see Section 6.2) using block randomisation with block size of 4 records

PASP at baseline and under hypoxia and exercise for both treatment groups (a total of 
four PASP measurements per subject) were sampled from a multivariate normal 
distribution, using values for mean PASP, standard deviation of PASP and within-
subject correlation of PASP as described below.

Mean PASP was 30 mmHg at baseline (i.e. normoxic and at rest) for both treatments, 
and 45 mmHg under hypoxia and exercise for Placebo (as in Section 9.2.1). For 
GSK2586881, mean PASP under hypoxia and exercise was (45 - Δ) mmHg, where Δ 
(the mean treatment difference) was varied according to four different scenarios:
o
no treatment difference (Δ = 0 mmHg)
o
weak treatment difference of a magnitude of half the clinically meaningful 
difference (Δ = 2.5 mmHg)
o
minimum clinically meaningful difference (Δ = 5 mmHg)
o
overwhelming treatment difference one-and-a-half times the clinically 
meaningful difference (Δ = 7.5 mmHg)

SD of PASP was 2.81 mmHg at baseline and 4.30 mmHg under hypoxia and 
exercise, for both treatment groups (as in Section 9.2.1) 

The within-subject correlation of PASP was unknown, therefore four different 
scenarios of within-subject correlation were evaluated: zero correlation, low 
correlation (0.3), high correlation (0.6) and very high correlation (0.9) (as in Section 
9.2.1). Within-subject correlation of PASP was assumed to be compound symmetric 
(i.e. the same correlation was used for each of the six possible pairs of the four PASP 
measurements within each subject).

It was assumed that there would be no effect of period in the simulation, i.e. it was 
assumed that it would make no difference if the measurement was taken from the first 
or second chronological period in the treatment sequence.
Modelling took on a three-step process, with decisions after each. Firstly, the treatment 
difference and its associated standard error was then estimated for the dataset of 10
 
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simulated subjects using a mixed effects linear regression model, including covariates for 
period, treatment, period baseline and subject baseline (the mean of the two period 
baselines) as fixed effects and subject as a random effect. If the sign of treatment 
difference arising from the simulated data was in the wrong direction (i.e. the simulated 
outcome for GSK2586881 was worse than for Placebo), then the simulated study was 
stopped for futility.
Secondly, in the alternative case that the simulated treatment difference was in favour of 
GSK2586881 over Placebo, a posterior probability of success (where success was defined 
as a 97.5% posterior probability of the treatment difference being in favour of 
GSK2586881 over Placebo) was evaluated for 20 subjects. This was evaluated using a t-
distribution, with the mean and standard deviation taken as the treatment difference and 
standard error (multiplied by a factor of the square root of 10 to estimate the standard 
deviation) from step one, respectively. If this posterior probability was less than 0.2, then 
the study was stopped for futility as being unlikely to show any benefit of GSK2586881 
over Placebo.
Thirdly, provided that the simulated study hadn't been stopped for futility in either of the 
first two steps, posterior probabilities of success were calculated for N ranging from 10 to 
19 subjects. If any of these posterior probabilities of success were greater than or equal to 
0.9, then the study was continued with a reduced sample size equal to the lowest N at 
which that threshold was reached. Otherwise, the conclusion from the simulated interim 
analysis would be to continue the study with unchanged sample size.
This whole process (simulating data for 10 subjects, modelling the treatment difference, 
evaluating posterior probabilities of success and simulating the decision-making process) 
was replicated 10000 times for each scenario, with the decision ("futile", "no change to 
N" or "reduce N") recorded for each iteration. Each combination of the four treatment 
difference scenarios and the four correlation scenarios was evaluated for a total of 16 
scenarios in all.
The estimated proportions of each decision being reached under each of the 16 scenarios 
are presented in Table 4.
Table 4
Operating characteristics of interim analysis at N=10 under four 
scenarios of treatment effect and four scenarios of within-subject 
correlation
Frequency of decisions (%)
Treatment 
effect 
Scenario
Within-subject 
correlation of PASP
Futile
Continue with 20 
subjects
Continue with 
reduced sample 
size
Δ=0 mmHg (no treatment difference)
0.0
85%
15%
1%
0.3
85%
15%
1%
0.6
85%
15%
1%
0.9
85%
14%
1%
 
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Frequency of decisions (%)
Treatment 
effect 
Scenario
Within-subject 
correlation of PASP
Futile
Continue with 20 
subjects
Continue with 
reduced sample 
size
Δ=2.5 mmHg (weak treatment effect, less than clinically meaningful difference)
0.0
44%
50%
6%
0.3
36%
56%
9%
0.6
21%
63%
16%
0.9
1%
31%
68%
Δ=5 mmHg (good treatment effect, at threshold of clinical meaningful difference)
0.0
9%
60%
31%
0.3
4%
54%
42%
0.6
1%
31%
68%
0.9
0%
0%
100%
Δ=7.5 mmHg (very strong treatment effect)
0.0
1%
32%
67%
0.3
0%
18%
82%
0.6
0%
3%
96%
0.9
0%
0%
100%
These results suggest primarily that if there is no true treatment difference between 
GSK2586881 and Placebo, the study would be stopped for futility 85% of the time 
(irrespective of within-subject correlation of PASP). A drug with a weak treatment effect 
would most likely result in the study being continued without change or stopped for 
futility (except in the case where within-subject correlation is 0.9, which is presented here 
as an extreme case, unlikely to occur in practice). If the true treatment effect is at the 
clinically relevant threshold of 5 mmHg, then the study is unlikely to be stopped for 
futility and may indicate being reduced in sample size.
Secondarily, it should be noted that the higher the within-subject correlation, then the 
higher the probability of success. This is because the more correlation there is in 
measurements within the same individual, the less variability there will be in change from 
baseline. Results for correlations of 0.0 and 0.9 are presented as extreme cases unlikely to 
occur in practice, though the exact strength of within-subject correlation of PASP 
(particularly under different stressed conditions) is not known.
Full details of the interim analysis will be supplied in the RAP.
9.3.3.
Multiple Comparisons and Multiplicity
As this is an early-phase exploratory study, no adjustment for multiple comparisons will 
be made. Treatment comparisons will be presented as effect sizes with 95% confidence 
intervals.
 
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9.4.
Key Elements of Analysis Plan
Each subject will undergo two treatment periods in this crossover study, each one of 
which being subdivided into five key sub-epochs (labelled T0-T4) as follows:

T0: Pre-dose (period baseline)

T1: Post-dose, normoxic, at rest, pre-challenge

T2: Hypoxic, at rest

T3: Hypoxic, immediately after exercise

T4: Post-challenge, normoxic, at rest
This follows the principle illustrated in the diagram of echocardiograph measurements 
(Figure 2).
PASP and Oxygen Saturation will be assigned to T0 thru T4 timepoints based on when 
they happened relative to the sequence of events that the subject undertakes during the 
course of the study day.  Biomarkers will be collected at times T0 thru T4, plus additional 
timepoints.
Pharmacokinetic endpoints will be timed based on elapsed time since dose 
administration.
In addition to T0 being defined as the period baseline, an overall subject baseline will be 
defined as the mean of the two T0 measurements (one from each period).
Change from baseline at time points T1 - T4 will be calculated as the difference between 
the measurement at the time point in question and the period baseline.  In general, 
statistical modelling of changes from baseline will be done using a Bayesian mixed 
effects regression model, including covariates for period, treatment, period baseline and 
subject baseline (the mean of the two period baselines).  Subject will be fitted as a 
random effect and non-informative priors will be used for model parameters. A 
compound symmetric covariance structure within each subject-period-treatment cell will 
be assumed to account for repeated measurements a) inherent in the two-period crossover 
design and b) due to the four post-baseline timepoints within each treatment period.
PASP data will be summarized by treatment and time-point in tabular and graphical 
format. A Bayesian mixed effects regression model (as described above) will be fitted 
(using non-informative priors for the model parameters), and an estimate of the mean 
change from baseline in PASP for each treatment group and post-baseline timepoint, 
together with its 95% credible interval, will be obtained.  Estimates for treatment 
differences will also be presented. Data may be log-transformed if necessary.
Details of the analysis of other endpoints will be described in the RAP.
 
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9.4.1.
Pharmacokinetic Analyses
Pharmacokinetic analysis will be performed by, or under the auspices, of Clinical 
Pharmacology Modelling and Simulation Department within GlaxoSmithKline.  Plasma 
GSK2586881 concentration-time data will be analysed by non-compartmental methods 
with WinNonLin V6.3 or greater.  Calculations will be based on the actual sampling 
times recorded during the study.
From the plasma concentration-time data, the following pharmacokinetic parameters will 
be determined, as data permit: maximum observed plasma concentration (Cmax), time to 
Cmax (tmax), area under the plasma concentration-time curve over the study period 
[nominally AUC(0-2.5h) post-dose], AUC over the hypoxia challenge (nominally 
AUC(0.5-2.0h post-dose), plasma clearance (CL), volume of distribution (V) and 
apparent terminal phase half-life (t1/2), if data permit.  Other PK parameters may also be 
determined.
Pharmacokinetic data will be presented in graphical and/or tabular form and will be
summarized descriptively. All pharmacokinetic data will be stored in the Archives, 
GlaxoSmithKline Pharmaceuticals, R&D. 
The relationship between the RAS biomarkers and other pharmacodynamic endpoints 
(echocardiography and pulse oximetry) and GSK2586881 concentrations and/or PK 
parameters may also be explored, if appropriate.
If appropriate, a population PK analysis may also be conducted, in addition the plasma 
concentration-time data may be merged with historical data and analysed as part of a 
population PK meta-analysis.
10.
STUDY GOVERNANCE CONSIDERATIONS
10.1.
Posting of Information on Publicly Available Clinical Trial 
Registers
Study information from this protocol will be posted on publicly available clinical trial 
registers before enrollment of subjects begins.
10.2.
Regulatory and Ethical Considerations, Including the 
Informed Consent Process
Prior to initiation of a site, GSK will obtain favourable opinion/approval from the 
appropriate regulatory agency to conduct the study in accordance with ICH Good Clinical 
Practice (GCP) and applicable country-specific regulatory requirements.
The study will be conducted in accordance with all applicable regulatory requirements, 
and with GSK policy.
The study will also be conducted in accordance with ICH Good Clinical Practice (GCP), 
all applicable subject privacy requirements, and the guiding principles of the current 
version of the Declaration of Helsinki.  This includes, but is not limited to, the following:
 
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
IRB/IEC review and favorable opinion/approval of the study protocol and 
amendments as applicable

Obtaining signed informed consent

Investigator reporting requirements (e.g. reporting of AEs/SAEs/protocol 
deviations to IRB/IEC)

GSK will provide full details of the above procedures, either verbally, in writing, 
or both.

Signed informed consent must be obtained for each subject prior to participation 
in the study

The IEC/IRB, and where applicable the regulatory authority, approve the clinical 
protocol and all optional assessments, including genetic research.  

Optional assessments (including those in a separate protocol and/or under separate 
informed consent) and the clinical protocol should be concurrently submitted for 
approval unless regulation requires separate submission.  

Approval of the optional assessments may occur after approval is granted for the 
clinical protocol where required by regulatory authorities.  In this situation, 
written approval of the clinical protocol should state that approval of optional 
assessments is being deferred and the study, with the exception of the optional 
assessments, can be initiated.
10.3.
Quality Control (Study Monitoring)

In accordance with applicable regulations including GCP, and GSK procedures, 
GSK monitors will contact the site prior to the start of the study to review with the 
site staff the protocol, study requirements, and their responsibilities to satisfy 
regulatory, ethical, and GSK requirements.  

When reviewing data collection procedures, the discussion will also include 
identification, agreement and documentation of data items for which the CRF will 
serve as the source document.

Source documents provide evidence for the existence of the participant and 
substantiate the integrity of the data collected. Source documents are filed at the 
investigator’s site.

Data entered in the eCRFs that are transcribed from source documents must be 
consistent with the source documents or the discrepancies must be explained. The 
investigator may need to request previous medical records or transfer records, 
depending on the study; also current medical records must be available.
GSK will monitor the study and site activity to verify that the:

Data are authentic, accurate, and complete.

Safety and rights of subjects are being protected.

Study is conducted in accordance with the currently approved protocol and any 
other study agreements, GCP, and all applicable regulatory requirements.
 
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The investigator and the head of the medical institution (where applicable) agrees to 
allow the monitor direct access to all relevant documents
10.4.
Quality Assurance

To ensure compliance with GCP and all applicable regulatory requirements, GSK 
may conduct a quality assurance assessment and/or audit of the site records, and 
the regulatory agencies may conduct a regulatory inspection at any time during or 
after completion of the study. 

In the event of an assessment, audit or inspection, the investigator (and institution) 
must agree to grant the advisor(s), auditor(s) and inspector(s) direct access to all 
relevant documents and to allocate their time and the time of their staff to discuss 
the conduct of the study, any findings/relevant issues and to implement any 
corrective and/or preventative actions to address any findings/issues identified.
10.5.
Study and Site Closure

Upon completion or premature discontinuation of the study, the GSK monitor will 
conduct site closure activities with the investigator or site staff, as appropriate, in 
accordance with applicable regulations including GCP, and GSK Standard 
Operating Procedures.

GSK reserves the right to temporarily suspend or prematurely discontinue this 
study at any time for reasons including, but not limited to, safety or ethical issues 
or severe non-compliance. For multicenter studies, this can occur at one or more 
or at all sites.  

If GSK determines such action is needed, GSK will discuss the reasons for taking 
such action with the investigator or the head of the medical institution (where 
applicable).  When feasible, GSK will provide advance notification to the 
investigator or the head of the medical institution, where applicable, of the 
impending action.

If the study is suspended or prematurely discontinued for safety reasons, GSK will 
promptly inform all investigators, heads of the medical institutions (where 
applicable) and/or institution(s) conducting the study. GSK will also promptly 
inform the relevant regulatory authorities of the suspension or premature 
discontinuation of the study and the reason(s) for the action.  

If required by applicable regulations, the investigator or the head of the medical 
institution (where applicable) must inform the IRB/IEC promptly and provide the 
reason for the suspension or premature discontinuation.
10.6.
Records Retention

Following closure of the study, the investigator or the head of the medical 
institution (where applicable) must maintain all site study records (except for 
those required by local regulations to be maintained elsewhere), in a safe and 
secure location.  
 
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
The records must be maintained to allow easy and timely retrieval, when needed 
(e.g., for a GSK audit or regulatory inspection) and must be available for review 
in conjunction with assessment of the facility, supporting systems, and relevant 
site staff.  

Where permitted by local laws/regulations or institutional policy, some or all of 
these records can be maintained in a format other than hard copy (e.g., microfiche, 
scanned, electronic); however, caution needs to be exercised before such action is 
taken.  

The investigator must ensure that all reproductions are legible and are a true and 
accurate copy of the original and meet accessibility and retrieval standards, 
including re-generating a hard copy, if required.  Furthermore, the investigator 
must ensure there is an acceptable back-up of these reproductions and that an 
acceptable quality control process exists for making these reproductions.

GSK will inform the investigator of the time period for retaining these records to 
comply with all applicable regulatory requirements.  The minimum retention time 
will meet the strictest standard applicable to that site for the study, as dictated by 
any institutional requirements or local laws or regulations, GSK 
standards/procedures, and/or institutional requirements.  

The investigator must notify GSK of any changes in the archival arrangements, 
including, but not limited to, archival at an off-site facility or transfer of 
ownership of the records in the event the investigator is no longer associated with 
the site.
10.7.
Provision of Study Results to Investigators, Posting of 
Information on Publically Available Clinical Trials Registers 
and Publication
Where required by applicable regulatory requirements, an investigator signatory will be 
identified for the approval of the clinical study report.  The investigator will be provided 
reasonable access to statistical tables, figures, and relevant reports and will have the 
opportunity to review the complete study results at a GSK site or other mutually-
agreeable location.
GSK will also provide the investigator with the full summary of the study results.  The 
investigator is encouraged to share the summary results with the study subjects, as 
appropriate.
GSK will provide the investigator with the randomisation codes for their site only after 
completion of the full statistical analysis.
The procedures and timing for public disclosure of the results summary and for 
development of a manuscript for publication will be in accordance with GSK Policy.
A manuscript will be progressed for publication in the scientific literature if the results 
provide important scientific or medical knowledge.
 
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11.
REFERENCES
Abraham WT, Raynolds MV, Badesch DB, Wynne KM, Groves BM, Roden RL,et al..
Angiotensin-converting enzyme DD genotype in patients with primary pulmonary 
hypertension: increased frequency and association with preserved haemodynamics.  J 
Renin Angiotensin Aldosterone Syst. 2003 Mar;4(1):27-30.
Antoni Ricart, Jaume Maristany, Núria Fort, Conxita Leal, Teresa Pagés, and Ginés 
Viscor. High Altitude Medicine & Biology. March 2005, 6(1): 43-49. 
doi:10.1089/ham.2005.6.43
Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, et al. The American-
European consensus conference on ARDS: definitions, mechanisms, relevant outcomes, 
and clinical trial coordination. Am J Respir Crit Care Med. 1994;49:818-822. 
Cargil RI, Lipworth BJ. Lisinopril attenuates acute hypoxic pulmonary vasoconstriction 
in humans. Chest. 1996 Feb;109(2):424-9/
GlaxoSmithKline Document Number 2010N108777_00 Study ID GSK2586881. 
Investigator's Brochure for GSK2586881 (formerly known as APN01)– A Soluble 
Recombinant Human Angiotensin Converting Enzyme 2 (rhACE2). Report Date 16-
FEB-2011. 
Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F, Kowal D, editors. 
Contraceptive Technology. 19th edition. New York: Ardent Media, 2007(a): 24. Table 3-
2.
Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F, Kowal D, editors. 
Contraceptive Technology. 19th edition. New York: Ardent Media, 2007(b): 28.
ICH Topic M3 (R2)  Non-clinical safety studies for the conduct of human clinical trials 
and marketing authorisation for pharmaceuticals, 2009
Idell S, Kueppers, F, Lippmann, M, Rosen, H, Niederman, M, Fein, A. ACE elevated in 
ARDS BAL. Angiotensin converting enzyme in bronchoalveolar lavage in ARDS. Chest. 
1987;91:52-56.
Kiely DG, Cargill RI, Lipworth BJ (1996) Effects of hypercapnia on hemodynamic, 
inotropic, lusitropic, and electrophysiologic indices in humans. Chest 109:1215–1221
Kiely DG1, Cargill RI, Wheeldon NM, Coutie WJ, Lipworth BJ. Haemodynamic and 
endocrine effects of type 1 angiotensin II receptor blockade in patients with hypoxaemic 
cor pulmonale. Cardiovasc Res. 1997 Jan;33(1):201-8.
Kleinsasser A1, Pircher I, Treml B, Schwienbacher M, Schuster M, Janzek E, Loibner H, 
Penninger JM, Loeckinger A. Recombinant angiotensin-converting enzyme 2 suppresses 
pulmonary vasoconstriction in acute hypoxia. Wilderness Environ Med. 2012 
Mar;23(1):24-30
 
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Maron BA, Leopold JA. The role of the renin-angiotensin-aldosterone system in the 
pathobiology of pulmonary arterial hypertension (2013 Grover Conference series. Pulm 
Circ. 2014 Jun;4(2):200-10. doi: 10.1086/675984  
Marshall RP, Webb S, Bellingan GJ, Montgomery HE, Chaudhari B, Chambers RJ, , GJ
et al. Angiotensin converting enzyme insertion/deletion polymorphism is associated with 
susceptibility and outcome in acute respiratory distress syndrome. Am. J. Resp. Crit. Care 
Med. 2002;166:646-650. 
Paul M, Bachmann J, Ganten D. Angiotensin II-induced vasoconstriction and sodium 
resorption. The Tissue Renin-Angiotensin System in Cardiovascular Disease. Trends 
Cardiovasc. Med. 1992;2:94-99. 
Ricart A1, Maristany J, Fort N, Leal C, Pagés T, Viscor G. Effects of sildenafil on the 
human response to acute hypoxia and exercise. High Alt Med Biol. 2005 Spring;6(1):43-
9.
Rubenfeld GD, Caldwell E, Peabody E. Incidence and Outcomes of Acute Lung Injury. N 
Engl J Med. 2005;353:1685-1693. 
Santos RAS, Ferreira AJ, Pinheiro SVB, Sampaio WO, Touyz R, Campangole-Santos 
MJ. Counter-regulatory effects of ANG (1-7) in ANG II. Angiotensin(1-7) and its 
receptor as potential targets for cardiovascular drugs’ Expert Op. Investig. Drugs. 
2005;1019:1031. 
Santos RAS, Simoes e Silva, AC, Maric C, Silva DMR, Machado RP, de Buhr I, et al. 
ANG (1-7) as the agonist of mas. ‘Angiotensin (1-7) is an endogenous ligand for the G-
protein coupled receptor Mas’ Proc. Natl. Acad. Sci. USA. 2003;100:8258-8263. 
Suzuki Y, Ruiz-Ortega, M., Lorenzo, O., Ruperez, M., Esteban, V., Egido, J. 
Inflammatory and pro-fibrotic activity of ANG II. ) Inflammation and Angiotensin II. Int. 
J. Biochem. Cell Biol. 2003;35:881-900. 
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes 
as compared with traditional tidal volumes for acute lung injury and the acute respiratory 
distress syndrome. N Engl J Med. 2000;342:1301-1308. 
The ARDS Network Authors for the ARDS network. Ketoconzaole for Early Treatment 
of Acute Lung Injury and Acute Respiratory Distress Syndrome. JAMA. 2000;283:1995-
2002. 
Tom B, deVries R, Saxena PR, Danser J. ANG (1-7) inhibiting ACE and modifying 
Bradykinin responses. Bradykinin potentiation by angiotensin (1-7) and ACE inhibitors 
correlates with C- and N-terminal blockade’ Hypertension. 2001;38:95-99.
Torre-Bueno JR, Wagner PD, Saltzman HA, Gale GE, Moon RE. Diffusion limitation in 
normal humans during exercise at sea level and simulated altitude. J Appl Physiol (1985). 
1985 Mar;58(3):989-95
 
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Wenz M, Hoffmann B, Bohlender J, Kaczmarczyk G. ANG II elevated in ARDS. 
Anfgiotensin II formation and endothelin clearance in ARDS patients in supine and prone 
positions. Intensive Care Med. 2000;26:292-298. 
Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP, deBoisblanc 
B,et al.. Pulmonary-Artery versus Central Venous Catheter to Guide Treatment of Acute 
Lung Injury. N Engl J Med. 2006;25:354(21):2213-24. Epub 2006 May 21.
Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B,et 
al. Comparison of Two Fluid-Management Strategies in Acute Lung Injury. N Engl J 
Med. 2006;354(24):2564-75. Epub 2006 May 21.
 
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12.
APPENDICES
12.1.
Appendix 1: Abbreviations and Trademarks
Abbreviations
ACE2
Angiotensin converting enzyme type 2
AE
Adverse Event
ALI
Acute Lung Injury
ALT
Alanine aminotransferase (SGPT)
Ang II
Angiotensin II
ARDS
Acute respiratory distress syndrome
AST
Aspartate aminotransferase (SGOT)
AUC
Area under concentration-time curve
BID
Bi-Daily
BUN
Blood urea nitrogen
CBP
Child Bearing Potential
CL
Clearance
CO2
Carbon dioxide
CONSORT
Consolidated Standards of Reporting Trials
CRF
Case Report Form
CV
Cardiovascular
DNA
Deoxyribonucleic acid
ECG
Electrocardiogram
eCRF
Electronic case report form
FDA
Food and Drug Administration
FRP
Females of Reproductive Potential
GCP
Good Clinical Practice
GLP
Good Laboratory Practice
GSK
GlaxoSmithKline
HBcAb
Hepatitis B core antibody
HBsAg
Hepatitis B surface antigen
hCG
Human chorionic gonadotropin
HIV
Human Immunodeficiency Virus
HPLC
High performance liquid chromatography
HPV
Hypoxic pulmonary vasoconstriction
IB
Investigator’s Brochure
ICH
International Conference on Harmonization of Technical 
Requirements for Registration of Pharmaceuticals for 
Human Use
ID
Identification
IEC
Independent Ethics Committee
IgG
Immunoglobulin G
IND
Investigational New Drug
IP
Investigational Product
IRB
Institutional Review Board
 
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ITT
Intent-to-Treat
IV
Intravenous
IVIVT
In Vitro/In Vivo Translations
Kg
Kilogram
LDH
Lactate dehydrogenase
LFTs
Liver function tests
m
Meters
MCH
Mean corpuscular hemogloin
MCV
Mean corpuscular volume
MedDRA
Medical Dictionary for Regulatory Activities
mg
Milligrams
mL
Milliliter
MSDS
Material Safety Data Sheet
msec
Milliseconds
NOAEL
No observed adverse effect level
O2
Oxygen
PaO2
Partial Pressure of Oxygen in arterial blood
PAH
Pulmonary Arterial Hypertension
PASP
Pulmonary Artery Systolic Pressure
PD
Pharmacodynamic
PGx
Pharmacogenetics
PK
Pharmacokinetic
Q
Perfusion
QC
Quality control
QTcB
QT duration corrected for heart rate by Bazett’s formula
QTcF
QT duration corrected for heart rate by Fridericia’s formula
RAP
Reporting and Analysis Plan
RAS
Renin-Angiotensin System
RBC
Red blood cells
rhACE2
Recombinant human angiotensin converting enzyme type 2
RNA
Ribonucleic acid
SAE
Serious adverse event(s)
SD
Standard deviation
SP-D
Surfactant Protein-D
SRM
Study Reference Manual
TPR
Third Party Resourcing
TTS
Technical Terms of Supply
t½
Terminal phase half-life
tmax
Time of occurrence of Cmax
V
Volume of Distribution
VA
Ventilation
VO2
Oxygen Consumption
 
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Trademark Information
Trademarks of the GlaxoSmithKline 
group of companies
Trademarks not owned by the 
GlaxoSmithKline group of companies
NONE
MedDRA
WinNonlin
 
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12.2.
Appendix 2: Liver Safety Required Actions and Follow up 
Assessments
Phase I Liver chemistry stopping criteria have been designed to assure subject safety and 
to evaluate liver event etiology (in alignment with the FDA premarketing clinical liver 
safety guidance).
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guid
ances/UCM174090.pdf.
Phase I liver chemistry stopping criteria and required follow up assessments
Liver Chemistry Stopping Criteria – Liver Stopping Event
ALT-absolute
ALT≥3xULN
If  ALT≥3xULN AND bilirubin1,2 2xULN (>35% direct bilirubin) or  INR >1.5, 
Report as an SAE.
See additional Actions and Follow Up Assessments listed below
Required Actions and Follow up Assessments following Liver Stopping Event
Actions
Follow Up Assessments

Immediately discontinue study treatment

Report the event to GSK within 24 hours

Complete the liver event CRF, and complete 
an SAE data collection tool if the event also 
meets the criteria for an SAE2

Perform liver event follow up assessments 

Monitor the subject until liver chemistries 
resolve, stabilise, or return to within baseline
(see MONITORING below)
MONITORING:
If ALT≥3xULN AND bilirubin 2xULN  or INR 
>1.5

Repeat liver chemistries (include ALT, AST, 
alkaline phosphatase, bilirubin) and perform 
liver event follow up assessments within  24 
hrs

Monitor subjects twice weekly until liver 
chemistries resolve, stabilise or return to 
within baseline

A specialist or hepatology consultation is 

Viral hepatitis serology3

Obtain INR and recheck with each liver 
chemistry assessment until the 
transaminases values show downward 
trend.

Blood sample for PK analysis, obtained 24 
hours after last dose 4

Serum creatine phosphokinase (CPK) and 
lactate dehydrogenase (LDH).

Fractionate bilirubin, if total 
bilirubin2xULN

Obtain complete blood count with 
differential to assess eosinophilia

Record the appearance or worsening of 
clinical symptoms of liver injury, or 
hypersensitivity, on the AE report form

Record use of concomitant medications on 
the concomitant medications report form
including acetaminophen, herbal remedies, 
other over the counter medications.
 
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Liver Chemistry Stopping Criteria – Liver Stopping Event
recommended
If ALT≥3xULN AND bilirubin < 2xULN  and 
INR ≤1.5:

Repeat liver chemistries (include ALT, AST, 
alkaline phosphatase, bilirubin) and perform
liver event follow up assessments within 24-
72 hrs

Monitor subjects weekly until liver 
chemistries resolve, stabilize or return to 
within baseline

Record alcohol use on the liver event 
alcohol intake case report form
If ALT≥3xULN AND bilirubin 2xULN  or 
INR >1.5:

Anti-nuclear antibody, anti-smooth muscle 
antibody, Type 1 anti-liver kidney 
microsomal antibodies, and quantitative 
total immunoglobulin G (IgG or gamma 
globulins).

Serum acetaminophen adduct HPLC assay 
(quantifies potential acetaminophen 
contribution to liver injury in subjects with 
definite or likely acetaminophen use in the 
preceding week [James, 2009]. 

Liver imaging (ultrasound, magnetic 
resonance, or computerised tomography) 
and /or liver biopsy to evaluate liver 
disease; complete Liver Imaging and/or 
Liver Biopsy CRF forms.
1.
Serum bilirubin fractionation should be performed if testing is available. If serum bilirubin fractionation is not 
immediately available, discontinue study treatment for that subject if ALT 3xULN and bilirubin 2xULN. 
Additionally, if serum bilirubin fractionation testing is unavailable, record presence of detectable urinary bilirubin on 
dipstick, indicating direct bilirubin elevations and suggesting liver injury. 
2.
All events of ALT 3xULN and bilirubin 2xULN (>35% direct bilirubin) or ALT 3xULN and INR>1.5, if INR 
measured, which may indicate severe liver injury (possible ‘Hy’s Law’), must be reported as an SAE (excluding 
studies of hepatic impairment or cirrhosis); INR measurement is not required and the threshold value stated will 
not apply to subjects receiving anticoagulants
3.
Includes: Hepatitis A IgM antibody; Hepatitis B surface antigen and Hepatitis B Core Antibody (IgM); Hepatitis C
RNA; Cytomegalovirus IgM antibody;  Epstein-Barr viral capsid antigen IgM antibody (or if unavailable, obtain 
heterophile antibody or monospot testing);  Hepatitis E IgM antibody 
4.
Record the date/time of the PK blood sample draw and the date/time of the last dose of study treatment prior to 
blood sample draw on the CRF. If the date or time of the last dose is unclear, provide the subject’s best 
approximation. If the date/time of the last dose cannot be approximated OR a PK sample cannot be collected in 
the time period indicated above, do not obtain a PK sample. Instructions for sample handling and shipping are in 
the SRM.
References
James LP, Letzig L, Simpson PM, Capparelli E, Roberts DW, Hinson JA,et al.. 
Pharmacokinetics of Acetaminophen-Adduct in Adults with Acetaminophen Overdose 
and Acute Liver Failure. Drug Metab Dispos 2009; 37:1779-1784.
 
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12.3.
Appendix 3: Genetic Research
Genetics – Background
Naturally occurring genetic variation may contribute to inter-individual variability in 
response to medicines, as well as an individual's risk of developing specific diseases. 
Genetic factors associated with disease characteristics may also be associated with 
response to therapy, and could help to explain some clinical study outcomes. For 
example, genetic variants associated with age-related macular degeneration (AMD) are 
reported to account for much of the risk for the condition [Gorin, 2012] with certain 
variants reported to influence treatment response [Chen, 2012]. Thus, knowledge of the 
genetic etiology of disease may better inform understanding of disease and the 
development of medicines. Additionally, genetic variability may impact the 
pharmacokinetics (absorption, distribution, metabolism, and elimination), or 
pharmacodynamics (relationship between concentration and pharmacologic effects or the 
time course of pharmacologic effects) of a specific medicine and/or clinical outcomes 
(efficacy and/or safety) observed in a clinical study.
Genetic Research Objectives and Analyses
The objectives of the genetic research are to investigate the relationship between genetic 
variants and: 

Response to medicine, including [any treatment regimens under investigation in 
this study] or any concomitant medicines;
Genetic data may be generated while the study is underway or following completion of 
the study.  Genetic evaluations may include focused candidate gene approaches and/or 
examination of a large number of genetic variants throughout the genome (whole genome 
analyses). Genetic analyses will utilize data collected in the study and will be limited to 
understanding the objectives highlighted above.  Analyses may be performed using data 
from multiple clinical studies to investigate these research objectives.
Appropriate descriptive and/or statistical analysis methods will be used. A detailed 
description of any planned analyses will be documented in a Reporting and Analysis Plan 
(RAP) prior to initiation of the analysis. Planned analyses and results of genetic 
investigations will be reported either as part of the clinical RAP and study report, or in a 
separate genetics RAP and report, as appropriate.
Study Population
Any subject who is enrolled in the study can participate in genetic research.  Any subject 
who has received an allogeneic bone marrow transplant must be excluded from the 
genetic research.
Study Assessments and Procedures
A key component of successful genetic research is the collection of samples during 
clinical studies. Collection of samples, even when no a priori hypothesis has been 
 
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identified, may enable future genetic analyses to be conducted to help understand 
variability in disease and medicine response.  

A 6 ml blood sample will be taken for Deoxyribonucleic acid (DNA) extraction. 
A blood sample is collected at the baseline visit, after the subject has been 
randomised and provided informed consent for genetic research. Instructions for 
collection and shipping of the genetic sample are described in the laboratory 
manual. The DNA from the blood sample may undergo quality control analyses to
confirm the integrity of the sample. If there are concerns regarding the quality of 
the sample, then the sample may be destroyed. The blood sample is taken on a 
single occasion unless a duplicate sample is required due to an inability to utilize 
the original sample.  
The genetic sample is labelled (or “coded”) with the same study specific number used to 
label other samples and data in the study.   This number can be traced or linked back to 
the subject by the investigator or site staff. Coded samples do not carry personal 
identifiers (such as name or social security number). 
Samples will be stored securely and may be kept for up to 15 years after the last subject 
completes the study, or GSK may destroy the samples sooner.  GSK or those working 
with GSK (for example, other researchers) will only use samples collected from the study 
for the purpose stated in this protocol and in the informed consent form.  Samples may be 
used as part of the development of a companion diagnostic to support the GSK medicinal 
product.
Subjects can request their sample to be destroyed at any time.
Informed Consent
Subjects who do not wish to participate in the genetic research may still participate in the 
study.  Genetic informed consent must be obtained prior to any blood being taken.
Subject Withdrawal from Study
If a subject who has consented to participate in genetic research withdraws from the 
clinical study for any reason other than being lost to follow-up, the subject will be given a 
choice of one of the following options concerning the genetic sample, if already 
collected:

Continue to participate in the genetic research in which case the genetic DNA 
sample is retained

Discontinue participation in the genetic research and destroy the genetic DNA 
sample 
If a subject withdraws consent for genetic research or requests sample destruction for any 
reason, the investigator must complete the appropriate documentation to request sample 
destruction within the timeframe specified by GSK and maintain the documentation in 
the site study records. 
 
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Genotype data may be generated during the study or after completion of the study and 
may be analyzed during the study or stored for future analysis. 

If a subject withdraws consent for genetic research and genotype data has not been 
analyzed, it will not be analyzed or used for future research.  

Genetic data that has been analyzed at the time of withdrawn consent will 
continue to be stored and used, as appropriate. 
Screen and Baseline Failures
If a sample for genetic research has been collected and it is determined that the subject 
does not meet the entry criteria for participation in the study, then the investigator should 
instruct the subject that their genetic sample will be destroyed. No forms are required to 
complete this process as it will be completed as part of the consent and sample 
reconciliation process.  In this instance a sample destruction form will not be available to 
include in the site files.
Provision of Study Results and Confidentiality of Subject’s Genetic Data
GSK may summarize the genetic research results in the clinical study report, or 
separately and may publish the results in scientific journals. 
GSK may share genetic research data with other scientists to further scientific 
understanding in alignment with the informed consent. GSK does not inform the subject, 
family members, insurers, or employers of individual genotyping results that are not 
known to be relevant to the subject’s medical care at the time of the study, unless 
required by law. This is due to the fact that the information generated from genetic 
studies is generally preliminary in nature, and therefore the significance and scientific 
validity of the results are undetermined.  Further, data generated in a research laboratory 
may not meet regulatory requirements for inclusion in clinical care.
Chen H, Yu KD, Xu GZ. Association between Variant Y402H in Age-Related Macular 
Degeneration (AMD) Susceptibility Gene CFH and Treatment Response of AMD: A 
Meta-Analysis. PloS ONE 2012; 7: e42464
Gorin MB. Genetic insights into age-related macular degeneration: Controversies 
addressing risk, causality, and therapeutics. Mol. Asp. Med. 2012; 33: 467-486.
 
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12.4.
Appendix 4: Definition of and Procedures for Recording, 
Evaluating, Follow-Up and Reporting of Adverse Events
12.4.1.
Definition of Adverse Events
Adverse Event Definition:

An AE is any untoward medical occurrence in a patient or clinical investigation 
subject, temporally associated with the use of a medicinal product, whether or not 
considered related to the medicinal product.

NOTE: An AE can therefore be any unfavorable and unintended sign (including an 
abnormal laboratory finding), symptom, or disease (new or exacerbated) temporally 
associated with the use of a medicinal product.
Events meeting AE definition include:

Any abnormal laboratory test results (hematology, clinical chemistry, or urinalysis) 
or other safety assessments (e.g., ECGs, radiological scans, vital signs 
measurements), including those that worsen from baseline, and felt to be clinically 
significant in the medical and scientific judgement of the investigator.

Exacerbation of a chronic or intermittent pre-existing condition including either an 
increase in frequency and/or intensity of the condition.

New conditions detected or diagnosed after study treatment administration even 
though it may have been present prior to the start of the study.

Signs, symptoms, or the clinical sequelae of a suspected interaction.

Signs, symptoms, or the clinical sequelae of a suspected overdose of either study 
treatment or a concomitant medication (overdose per se will not be reported as an 
AE/SAE unless this is an intentional overdose taken with possible suicidal/self-
harming intent.  This should be reported regardless of sequelae).
Events NOT meeting definition of an AE include:

Any clinically significant abnormal laboratory findings or other abnormal safety 
assessments which are associated with the underlying disease, unless judged by the 
investigator to be more severe than expected for the subject’s condition.

The disease/disorder being studied or expected progression, signs, or symptoms of 
the disease/disorder being studied, unless more severe than expected for the subject’s 
condition.

Medical or surgical procedure (e.g., endoscopy, appendectomy): the condition that 
leads to the procedure is an AE.

Situations where an untoward medical occurrence did not occur (social and/or 
 
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convenience admission to a hospital).

Anticipated day-to-day fluctuations of pre-existing disease(s) or condition(s) present 
or detected at the start of the study that do not worsen.
12.4.2.
Definition of Serious Adverse Events
If an event is not an AE per definition above, then it cannot be an SAE even if serious 
conditions are met (e.g., hospitalization for signs/symptoms of the disease under study, 
death due to progression of disease, etc).
Serious Adverse Event (SAE) is defined as any untoward medical occurrence that, 
at any dose:
a.
Results in death
b.
Is life-threatening
NOTE:
The term 'life-threatening' in the definition of 'serious' refers to an event in which the 
subject was at risk of death at the time of the event.  It does not refer to an event, which 
hypothetically might have caused death, if it were more severe.
c.
Requires hospitalization or prolongation of existing hospitalization
NOTE:

In general, hospitalization signifies that the subject has been detained (usually 
involving at least an overnight stay) at the hospital or emergency ward for 
observation and/or treatment that would not have been appropriate in the physician’s 
office or out-patient setting.  Complications that occur during hospitalization are 
AEs.  If a complication prolongs hospitalization or fulfills any other serious criteria, 
the event is serious.  When in doubt as to whether “hospitalization” occurred or was 
necessary, the AE should be considered serious.

Hospitalization for elective treatment of a pre-existing condition that did not worsen 
from baseline is not considered an AE.
 
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d.
Results in disability/incapacity
NOTE:

The term disability means a substantial disruption of a person’s ability to conduct 
normal life functions.

This definition is not intended to include experiences of relatively minor medical 
significance such as uncomplicated headache, nausea, vomiting, diarrhea, influenza, 
and accidental trauma (e.g. sprained ankle) which may interfere or prevent everyday 
life functions but do not constitute a substantial disruption
e.
Is a congenital anomaly/birth defect
f.
Other situations:

Medical or scientific judgment should be exercised in deciding whether reporting is 
appropriate in other situations, such as important medical events that may not be 
immediately life-threatening or result in death or hospitalization but may jeopardize 
the subject or may require medical or surgical intervention to prevent one of the 
other outcomes listed in the above definition.  These should also be considered 
serious.

Examples of such events are invasive or malignant cancers, intensive treatment in an 
emergency room or at home for allergic bronchospasm, blood dyscrasias or 
convulsions that do not result in hospitalization, or development of drug dependency 
or drug abuse
g.
Is associated with liver injury and impaired liver function defined as:

ALT 3xULN and total bilirubin* 2xULN (>35% direct), or

ALT 3xULN and INR** > 1.5.
* Serum bilirubin fractionation should be performed if testing is available; if unavailable, 
measure urinary bilirubin via dipstick.  If fractionation is unavailable and ALT 3xULN 
and total bilirubin 2xULN, then the event is still to be reported as an SAE.
** INR testing not required per protocol and the threshold value does not apply to 
subjects receiving anticoagulants.  If INR measurement is obtained, the value is to be 
recorded on the SAE form.

Refer to Appendix 2 for the required liver chemistry follow-up instructions
 
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12.4.3.
Definition of Cardiovascular Events
Cardiovascular Events (CV) Definition:
Investigators will be required to fill out the specific CV event page of the CRF for the 
following AEs and SAEs:

Myocardial infarction/unstable angina

Congestive heart failure

Arrhythmias

Valvulopathy

Pulmonary hypertension

Cerebrovascular events/stroke and transient ischemic attack

Peripheral arterial thromboembolism

Deep venous thrombosis/pulmonary embolism

Revascularization
12.4.4.
Recording of AEs and SAEs
AEs and SAE Recording:

When an AE/SAE occurs, it is the responsibility of the investigator to review all 
documentation (e.g., hospital progress notes, laboratory, and diagnostics reports) 
relative to the event.

The investigator will then record all relevant information regarding an AE/SAE in 
the CRF

It is not acceptable for the investigator to send photocopies of the subject’s medical 
records to GSK in lieu of completion of the GSK, AE/SAE CRF page.

There may be instances when copies of medical records for certain cases are 
requested by GSK.  In this instance, all subject identifiers, with the exception of the 
subject number, will be blinded on the copies of the medical records prior to 
submission of to GSK.

The investigator will attempt to establish a diagnosis of the event based on signs, 
symptoms, and/or other clinical information.  In such cases, the diagnosis will be 
documented as the AE/SAE and not the individual signs/symptoms.

Subject-completed Value Evidence and Outcomes questionnaires and the collection 
of AE data are independent components of the study.

Responses to each question in the Value Evidence and Outcomes questionnaire will 
be treated in accordance with standard scoring and statistical procedures detailed by 
the scale’s developer.
 
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
The use of a single question from a multidimensional health survey to designate a 
cause-effect relationship to an AE is inappropriate.
12.4.5.
Evaluating AEs and SAEs
Assessment of Intensity
The investigator will make an assessment of intensity for each AE and SAE reported 
during the study and will assign it to one of the following categories:

Mild:  An event that is easily tolerated by the subject, causing minimal discomfort 
and not interfering with everyday activities.

Moderate:  An event that is sufficiently discomforting to interfere with normal 
everyday activities

Severe:  An event that prevents normal everyday activities. - an AE that is assessed 
as severe will not be confused with an SAE. Severity is a category utilized for rating 
the intensity of an event; and both AEs and SAEs can be assessed as severe.

An event is defined as ‘serious’ when it meets at least one of the pre-defined 
outcomes as described in the definition of an SAE.
Assessment of Causality

The investigator is obligated to assess the relationship between study treatment and 
the occurrence of each AE/SAE.

A "reasonable possibility" is meant to convey that there are facts/evidence or 
arguments to suggest a causal relationship, rather than a relationship cannot be ruled 
out.

The investigator will use clinical judgment to determine the relationship.

Alternative causes, such as natural history of the underlying diseases, concomitant 
therapy, other risk factors, and the temporal relationship of the event to the study 
treatment will be considered and investigated.

The investigator will also consult the Investigator Brochure (IB) and/or Product 
Information, for marketed products, in the determination of his/her assessment.

For each AE/SAE the investigator must document in the medical notes that he/she 
has reviewed the AE/SAE and has provided an assessment of causality.

There may be situations when an SAE has occurred and the investigator has minimal 
information to include in the initial report to GSK.  However, it is very important 
that the investigator always make an assessment of causality for every event 
prior to the initial transmission of the SAE data to GSK.

The investigator may change his/her opinion of causality in light of follow-up 
 
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information, amending the SAE data collection tool accordingly.

The causality assessment is one of the criteria used when determining regulatory 
reporting requirements.
Follow-up of AEs and SAEs

The investigator is obligated to perform or arrange for the conduct of supplemental 
measurements and/or evaluations as may be indicated or as requested by GSK to 
elucidate as fully as possible the nature and/or causality of the AE or SAE.

The investigator is obligated to assist.  This may include additional laboratory tests 
or investigations, histopathological examinations or consultation with other health 
care professionals.

If a subject dies during participation in the study or during a recognized follow-up 
period, the investigator will provide GSK with a copy of any post-mortem findings, 
including histopathology.

New or updated information will be recorded in the originally completed CRF.

The investigator will submit any updated SAE data to GSK within the designated 
reporting time frames.
12.4.6.
Reporting of SAEs to GSK
SAE reporting to GSK via electronic data collection tool

Primary mechanism for reporting SAEs to GSK will be the electronic data collection 
tool

If the electronic system is unavailable for greater than 24 hours, the site will use the 
paper SAE data collection tool and fax it to the Medical Monitor Site will enter the 
serious adverse event data into the electronic system as soon as it becomes available.

The investigator will be required to confirm review of the SAE causality by ticking 
the ‘reviewed’ box at the bottom of the eCRF page within 72 hours of submission of 
the SAE.

After the study is completed at a given site, the electronic data collection tool (e.g., 
InForm system) will be taken off-line to prevent the entry of new data or changes to 
existing data

If a site receives a report of a new SAE from a study subject or receives updated data 
on a previously reported SAE after the electronic data collection tool has been taken 
off-line, the site can report this information on a paper SAE form or to the Medical 
Monitor telephone.

Contacts for SAE receipt can be found at the beginning of this protocol on the 
Sponsor/Medical Monitor Contact Information page.
 
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SAE reporting to GSK via paper CRF

Facsimile transmission of the SAE paper CRF is the preferred method to transmit 
this information to the Medical Monitor

In rare circumstances and in the absence of facsimile equipment, notification by 
telephone is acceptable, with a copy of the SAE data collection tool sent by 
overnight mail

Initial notification via the telephone does not replace the need for the investigator to 
complete and sign the SAE CRF pages within the designated reporting time frames.

Contacts for SAE receipt can be found at this beginning of the protocol on the 
Sponsor/Medical Monitor Contact Information page.
 
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12.5.
Appendix 5: Modified List of Highly Effective Methods for 
Avoiding Pregnancy and Collection of Pregnancy 
Information
12.5.1.
Modified List of Highly Effective Methods for Avoiding Pregnancy
The list does not apply to FRP with same sex partners or for subjects who are and will 
continue to be abstinent from penile-vaginal intercourse on a long term and persistent 
basis, when this is their preferred and usual lifestyle. Periodic abstinence (e.g. calendar, 
ovulation, symptothermal, post-ovulation methods) and withdrawal are not acceptable 
methods of contraception.
1.
Contraceptive subdermal implant
2.
Intrauterine device or intrauterine system
3.
Combined estrogen and progestogen oral contraceptive [Hatcher RA, 2011]
4.
Injectable progestogen [Hatcher RA, 2011]
5.
Contraceptive vaginal ring [Hatcher RA, 2011]
6.
Percutaneous contraceptive patches [Hatcher RA, 2011]
7.
Male partner sterilization with documentation of azoospermia prior to the female 
subject's entry into the study, and this male is the sole partner for that subject 
[Hatcher RA, 2011]. The documentation on male sterility can come from the site 
personnel’s: review of subject’s medical records, medical examination and/or semen 
analysis, or medical history interview provided by her or her partner.
These allowed methods of contraception are only effective when used consistently, 
correctly and in accordance with the product label. The investigator is responsible for 
ensuring that subjects understand how to properly use these methods of contraception.
Contraceptive requirements for male subjects with female partners of reproductive 
potential (when applicable).
Male subjects with female partners of child bearing potential must comply with the 
following contraception requirements from the time of first dose of study medication 
until [at least five half-lives of study medication OR for a cycle of spermatogenesis 
following five terminal half-lives] after the last dose of study medication.
1.
Vasectomy with documentation of azoospermia. The documentation on male sterility 
can come from the site personnel’s: review of subject’s medical records, medical 
examination and/or semen analysis, or medical history interview.
2.
Male condom plus partner use of one of the contraceptive options below that meets 
the Standard Operating Procedure (SOP) effectiveness criteria including a <1% rate 
of failure per year, as stated in the product label:

Contraceptive subdermal implant

Intrauterine device or intrauterine system
 
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
Combined estrogen and progestogen oral contraceptive [Hatcher RA, 2011] 

Injectable progestogen [Hatcher RA, 2011]

Contraceptive vaginal ring [Hatcher RA, 2011]

Percutaneous contraceptive patches [Hatcher RA, 2011]
These allowed methods of contraception are only effective when used consistently, 
correctly and in accordance with the product label. The investigator is responsible for 
ensuring that subjects understand how to properly use these methods of contraception.
12.5.2.
Collection of Pregnancy Information

Investigator will collect pregnancy information on any female subject, who becomes 
pregnant while participating in this study

Information will be recorded on the appropriate form and submitted to GSK within 2 
weeks of learning of a subject's pregnancy.

Subject will be followed to determine the outcome of the pregnancy. The 
investigator will collect follow up information on mother and infant, which will be 
forwarded to GSK.  Generally, follow-up will not be required for longer than 6 to 8 
weeks beyond the estimated delivery date. 

Any termination of pregnancy will be reported, regardless of fetal status (presence or 
absence of anomalies) or indication for procedure.

While pregnancy itself is not considered to be an AE or SAE, any pregnancy 
complication or elective termination of a pregnancy will be reported as an AE or 
SAE.

A spontaneous abortion is always considered to be an SAE and will be reported as 
such.  

Any SAE occurring as a result of a post-study pregnancy which is considered 
reasonably related to the study treatment by the investigator, will be reported to GSK 
as described in Appendix 5. While the investigator is not obligated to actively seek 
this information in former study participants, he or she may learn of an SAE through 
spontaneous reporting.
Any female subject who becomes pregnant while participating

will discontinue study medication or be withdrawn from the study

Investigator will attempt to collect pregnancy information on any female partner of a 
male study subject who becomes pregnant while participating in this study. This 
applies only to subjects who are randomised to receive study medication. 

After obtaining the necessary signed informed consent from the female partner 
directly, the investigator will record pregnancy information on the appropriate form 
and submit it to GSK within 2 weeks of learning of the partner’s pregnancy
 
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
Partner will also be followed to determine the outcome of the pregnancy.  
Information on the status of the mother and child will be forwarded to GSK. 

Generally, follow-up will be no longer than 6 to 8 weeks following the estimated 
delivery date.  Any termination of the pregnancy will be reported regardless of fetal 
status (presence or absence of anomalies) or indication for procedure.
12.5.3.
References
Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F, Kowal D, Policar MS, 
editors. Contraceptive Technology. 20th edition. Atlanta, Georgia: Ardent Media, Inc., 
2011: 50. Table 3-2.
 
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12.6.
Appendix 6:  Protocol Changes
12.6.1.
Protocol Amendment 01 (24-Feb-2017) from Original Protocol 
(23-Sep-2016)
This is a global amendment.
12.6.1.1.
Summary of Changes and Rationale for Amendment
Additional Inclusion Criteria (Section 5.2) and Subject Stopping Criteria (Section 5.4) 
added in response to comments from BfArM.
12.6.1.2.
List of Specific Changes
Title Page, Author (s)
Rationale for change:  Addition and removal of author(s).
 
 
Sponsor Signatory
Rationale for change:  Change in sponsor signatory
Dr Richard Marshall Dr Aili Lazaar
Vice President, Fibrosis & Lung Injury Discovery Performance Unit (DPU) Head, 
Respiratory Therapy Area Unit Director, Discovery Medicine
Project Physician Leader, Respiratory Therapy Area
Section 5.2:  Exclusion Criteria
Rationale for change: Addition of exclusion criteria number 4 and 5.
CONCURRENT CONDITIONS/MEDICAL HISTORY (INCLUDES LIVER 
FUNCTION AND QTc INTERVAL) 
1. ALT >1.5x Upper limit of normal (ULN).
2. Bilirubin >1.5xULN (isolated bilirubin >1.5xULN is acceptable if bilirubin is 
fractionated and direct bilirubin <35%).
3. Current or chronic history of liver disease, or known hepatic or biliary abnormalities 
(with the exception of Gilbert's syndrome or asymptomatic gallstones).
4. Prior history of altitude sickness.
5. Recently been scuba diving (within 1 week before screening).
 
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6. QTc > 450 msec
NOTES:

The QTc is the QT interval corrected for heart rate according to Bazett’s 
formula (QTcB), Fridericia’s formula (QTcF), and/or another method, machine-
read or manually over-read.

The specific formula that will be used to determine eligibility and 
discontinuation for an individual subject should be determined prior to initiation 
of the study. In other words, several different formulae cannot be used to 
calculate the QTc for an individual subject and then the lowest QTc value used 
to include or discontinue the subject from the trial.

For purposes of data analysis, QTcB, QTcF, another QT correction formula, or a 
composite of available values of QTc will be used as specified in the Reporting 
and Analysis Plan (RAP).
Section 5.4:  Withdrawal/Stopping Criteria
Rationale for change: Addition of withdrawal criteria.
Subjects may be withdrawn from the study for any of the following reasons:

A subject may withdraw from study treatment at any time at his/her own request, 
or may be withdrawn at any time at the discretion of the investigator for safety, 
behavioural or administrative reasons. If a subject withdraws from the study, 
he/she may request destruction of any samples taken, and the investigator must 
document this in the site study records. 

If a subjects oxygen saturation falls below 65% at any point during the hypoxia
challenge. 

If the subject experiences worsening shortness of breath or other symptoms, 
which in the opinion of the investigator are consistent with altitude sickness.

The Sponsor may request a subject withdraw for reasons such as significant 
protocol deviations (after discussion with the investigator).

Study is terminated by the Sponsor.
A subject will be considered to have prematurely withdrawn from the investigational 
product if they do not complete all doses in the treatment phase having received the first 
dose of investigational product, for any reason.
 
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12.6.2.
Protocol Amendment 02 (07-Mar-2017) from Protocol Amendment 
01 (24-Feb-2017)
This is a global amendment.
12.6.2.1.
Summary of Changes and Rationale for Amendment
This is a substantial protocol amendment to:

Reduce the number of participants in the study from approximately 35 healthy 
volunteers to approximately 25 healthy volunteers.
This is a non-substantial protocol amendment to:

Remove some of the exploratory biomarkers.

Add a spirometry assessment at screening.

Add a pre-dose pulse oximetry assessment.

Add continuous ECG telemetry.

Move the immunogenicity screening sample to Pre-dose in Treatment Period 1.

Remove height and weight assessments from the follow-up visit.

Clarify the sequence and priority of assessments.  

Correct typographical errors.
See Section 12.6.2.2 below for a rationale for each change.
12.6.2.2.
List of Specific Changes
Protocol synopsis for study 204987
Protocol synopsis updated to reflect changes in the main body of the protocol.
Section 3:  Objectives/Endpoints
Rationale for change:  Removal of some of the exploratory biomarkers.  SP-D will be 
analysed and reported, and additional biomarkers may be analysed, as data permit.
 
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Objectives
Endpoints
Exploratory 

To evaluate the effect of a single IV 
dose of GSK2586881 on ventilatory 
parameters in healthy volunteers during 
exercise in hypoxic conditions.

Change from baseline of oxygen 
consumption (VO2), carbon dioxide 
production (CO2) and other parameters 
as data permit.

To evaluate the effect of a single IV 
dose of GSK2586881 on peptide 
hormone responses to hypoxia and 
exercise.

Baseline levels and changes in response 
to hypoxia and exercise in kinins (e.g. 
des-Arg-bradykinin), apelins (e.g. 
Apelin 13, pyr1-Apelin, 13) and other 
systems (e.g. dynorphin A) as data 
permit.

To evaluate the pharmacodynamic 
activity of a single IV dose of 
GSK2586881 in healthy volunteers 
during exercise in hypoxic conditions.

Change from baseline in other  
biomarkers which may include Atrial 
Naturetic peptide (ANP), Brain 
Naturetic Peptide (NT-proBNP), 
Troponin I, Surfactant Protein D (SP-
D) , IL-6 and/or additional analytes to 
be determined.

To evaluate Pharmacogenetics.

Evaluate I/D polymorphisms in the 
Angiotensin Converting Enzyme 
(ACE) gene and analyse the impact on 
Ang II (and possibly other RAS 
peptides), hypoxic pulmonary 
vasoconstriction and responses to 
GSK2586881 administration.
Section 4.3:  Type and Number of Subjects
Rationale for change: The removal of some exploratory biomarkers, led to a re-
assessment of the sample size; given that the larger prior sample size was to optimise 
data collection to include exploratory biomarkers. The sample size has been reduced 
from 35 to 25 enrolled subjects (30 to 20 completed subjects), because precision 
estimates show that a difference of between 3 and 5 mmHg in PASP (the primary 
endpoint) could be detected with an acceptable level of precision based on 20 completed 
subjects (see Section 9.2).
Approximately 35 25 subjects healthy volunteers will be randomised such that 
approximately 30 20 evaluable subjects complete the study (the target of 30 20 may be 
revised following the sample size re-estimation, see Section 9.2.2).
 
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Section 4.5:  Dose Justification
Rationale for change:  Additional subjects have been dosed with GSK2586881 since the 
protocol was finalised in September 2016.
GSK2586881 has been studied in 21 healthy subjects as single, intravenous doses over 
30 minutes from 0.1 mg/kg to 1.2 mg/kg, and in repeated daily doses for up to six days of 
0.4 mg/kg once a day.  In addition, ARDS patients have received four doses of 
GSK2586881: 0.1 mg/kg, 0.2 mg.kg, 0.4 mg/kg and 0.8 mg/kg over a 24 hour period 
(n=5) or 0.4 mg/kg BID twice daily for 3 days (n=19). In a concluded (but not yet 
reported) investigator-sponsored study in Pulmonary Arterial Hypertension (PAH) 
(Study 204696), 5 subjects have received a single dose of either 0.2 mg/kg or 0.4 
mg/kgOne subject with Pulmonary Arterial Hypertension (PAH) has received a single 
dose of 0.2 mg/kg.
Section 5.1:  Inclusion Criteria
Rationale for change:  Addition of a spirometry test at screening to ensure normal lung 
function before hypoxic challenge and exercise test.
TYPE OF SUBJECT 
2. Healthy as determined by the investigator or medically qualified designee based on a 
medical evaluation including medical history, physical examination, spirometry,
laboratory tests and cardiac monitoring.
Section 5.1:  Inclusion Criteria
Rationale for change:  Correction of typographical errors.
SEX
8. Male or female (non child bearing potential)
Male subjects with female partners of child bearing potential must comply with the 
following contraception requirements from the time of first dose of study medication 
until at least five half-lives of study medication OR for a cycle of spermatogenesis 
following five terminal half-lives after the last dose of study medication.
h. Vasectomy with documentation of azoospermia.  
i. Male condom plus partner use of one of the contraceptive options below:

Contraceptive subdermal implant 

Intrauterine device or intrauterine system 

Oral Contraceptive, either combined or progestogen alone [Hatcher, 2007a] 
Injectable progestogen [Hatcher, 2007a]
 
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
Contraceptive vaginal ring [Hatcher, 2007a]

Percutaneous contraceptive patches [Hatcher, 2007a]
This is an all-inclusive list of those methods that meet the following GSK definition of 
highly effective: having a failure rate of less than 1% per year when used consistently and 
correctly and, when applicable, in accordance with the product label. For non-product 
methods (e.g. male sterility), the investigator determines what is consistent and correct 
use. The GSK definition is based on the definition provided by the International 
Conference on Harmonization (ICH) [ICH, M3 (R2) 2009].
The investigator is responsible for ensuring that subjects understand how to properly use 
these methods of contraception.
This is an all-inclusive list of those methods that meet the following GSK definition of 
highly effective: having a failure rate of less than 1% per year when used consistently and 
correctly and, when applicable, in accordance with the product label.  For non-product 
methods (e.g. male sterility), the investigator determines what is consistent and correct 
use.  The GSK definition is based on the definition provided by the International
Conference on Harmonization (ICH) [ICH, M3 (R2) 2009].
The investigator is responsible for ensuring that subjects understand how to properly use 
these methods of contraception.
Females: 
A female subject is eligible to participate if she is not pregnant (as confirmed by a 
negative urine human chorionic gonadotrophin (hCG) test), not lactating, and the 
following condition applies:
Non-reproductive potential defined as:

Pre-menopausal females with one of the following:

Documented tubal ligation

Documented hysteroscopic tubal occlusion procedure with follow-up 
confirmation of bilateral tubal occlusion 

Hysterectomy

Documented Bilateral Oophorectomy

Postmenopausal defined as 12 months of spontaneous amenorrhea [in 
questionable cases a blood sample with simultaneous follicle stimulating 
hormone (FSH) and estradiol levels consistent with menopause (refer to 
laboratory reference ranges for confirmatory levels)].  Females on hormone 
replacement therapy (HRT) and whose menopausal status is in doubt will be 
required to use one of the highly effective contraception methods if they wish to 
continue their HRT during the study.  Otherwise, they must discontinue HRT to 
allow confirmation of post-menopausal status prior to study enrolment.
The investigator is responsible for ensuring that subjects understand how to properly use 
 
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these methods of contraception.
Section 5.4.1:  Study Stopping Criteria
Rationale for change:  The overall sample size has been reduced from 35 to 25 enrolled
subjects (30 to 20 completed subjects), so the interim analysis will now be completed 
after 10 subjects have completed the study, rather than 15.   
An interim analysis is planned after approximately 15 10 subjects have completed 
treatment periods 1 and 2 and the study may be stopped if a reasonable change in PASP 
is not observed after dosing with GSK2586881 or if review of the safety data suggests a 
change in the benefit-risk profile. The decision to stop the study will be made by the core 
members of the GSK study team.
Section 5.4.2:  QTc Stopping Criteria
Rationale for change:  QTc Stopping Criteria removed from Section 7.2.5, and inserted 
into Section 5.4 with the other subject stopping criteria.
The same QT correction formula must be used for each individual subject to 
determine discontinuation from the study.  For example, if a subject is eligible for 
the protocol based on QTcB, then QTcB must be used for discontinuation of this 
individual subject as well.
A subject that meets either bulleted criterion below will be withdrawn from the 
study.

QTcB or QTcF >500 msec,

Change from baseline: QTc >60 msec
The QTc should be based on single or averaged QTc values of triplicate ECGs 
obtained over a brief (e.g. 5-10 minute) recording period.
Section 6.1:  Investigational Product and Other Study Treatment
Rationale for change:  Order of treatment sequences altered to reflect GSK’s standard 
practice to list placebo first.
Table 1
Description of sequences
Sequence
Period 1 
Period 2
AB
GSK2586881Saline Placebo
Saline PlaceboGSK2586881
BA
Saline PlaceboGSK2586881
GSK2586881Saline Placebo
 
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Section 7:  Study Assessments and Procedures
Rationale for change:  Addition of ventilatory parameters to the list of assessments, and 
clarification that echocardiograms should be taken as close as possible to the nominal 
time-point (rather than blood draws), because they are the primary endpoint.

If assessments are scheduled for the same nominal time, THEN the assessments 
should occur in the following order:
1.
Ventilatory parameters
2.
Echocardiograms
3.
12-lead ECG
4.
vital signs
5.
blood draws  
Note: The timing of the assessments should allow the blood draw to occur at the 
exact echocardiogram to be performed as close as possible to the nominal time.
Section 7.1:  Time and Events Table
Rationale for change:  

Height and weight removed at follow-up (not required).

Spirometry added at screening (see justification in Section 5.1).

Immunogenicity moved from screening to Day 1, Treatment Period 1.

Removal of exploratory ventilatory parameters after exercise, as this assessment 
would delay the echocardiogram, which is the primary endpoint.

Addition of telemetry throughout the treatment periods.

Correction of typographical errors.
 
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Section 7.1.1:  Screening and Follow up
Procedure 
Screening1
(up to 28 days prior to 
Treatment Period 1, Day 1)
Follow up
(7-10 days post 
last dose)
Notes
Informed consent
X
Inclusion and exclusion criteria
X
Demography
X
Full physical exam, including height and weight
X
X
Height and weight to be measured at screening only.  Weight at screening 
will be used for dosing calculation.
Alcohol, Drugs of Abuse, Smoking test
X
Medical history (includes substance usage  
[and family history of premature CV disease])
X
Substances: Drugs, Alcohol, tobacco
Past and current medical conditions [including 
cardiovascular medical history]
X
Serum OR urine pregnancy test (WCBP)
X
HIV, Hep B and Hep C screen
X
Laboratory assessments (include liver 
chemistries)
X
X
Non Fasting 
Immunogenicity
X
X
12-lead ECG
X
X
Triplicate ECG required at screening.
Vital signs
X
X
Triplicate vital signs required at screening. 
Spirometry
X
Echocardiogram
X
Concomitant Medication review 
X
X
Hypoxia chamber plus exercise 
X
Tolerance to 4000m for 10 mins followed by followed by incremental exercise 
testing to determine maximum oxygen uptake (VO2max) and calculate 70% of 
VO2max for the (to be used for the exercise challenge during the 
Treatment Periods).  
Pharmacogenetic sample (PGx)
X
Can be taken any time after consent has been signed. Only required once and 
is optional. 
AE/SAE review
X
X
As per timings detailed in Section 7.2.1.1
1.
Screening assessments are allowed to be conducted on more than one day
 
 
 
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Section 7.1.2:  Treatment Period 1 and 2
Procedure
Treatment Period 1 and 2 (Washout 3-14 days)
Notes
Times relative to 
start of dosing
Hypoxic Challenge ~80 min
(Times relative to entry to 
Chamber)
Pre-dose
0h
15 min
15-45 min
0-60 min
60 min
60-70 min
Immediately after 
exercise
30m rest On exit 
from chamber
After 30 min rest
60 min after exit 
from Chamber 
Randomisation
X
Randomisation can occur up to the day before 
the first treatment period
Brief physical exam 
X
Vital signs
X
X
X5
X
Immunogenicity
X
Treatment period 2 only 
12-lead ECG
X
X
X
Echocardiogram
X
X
X
X
X
Echocardiogram duration approx 5 min
Subject enters chamber
X
Subject enters chamber approximately 30 min 
after study treatment
Study Treatment (Dosing) 
X
Subject leaves chamber
X
Subject leaves chamber after the fourth 
echocardiogram, blood samples and vital signs 
have been taken.
Exercise challenge
X
For approx 5-10 minutes
Ventilatory parameters
X
X
X
X1
X
Measurements to be taken at the same time as 
the2 min before echocardiograms. During the 
exercise challenge, an ECG integrated with the 
ventilatory assessment will be carried out.
Pulse Oximetry
(O2 saturation)
--------------------------------------------------------------------------------------------------------
Will be continuously monitored for safety. A 
measurement should be recorded at time of each 
echocardiogram post-treatment and databased.
Telemetry
--------------------------------------------------------------------------------------------------------
Will be continuously monitored for safety.
 
 
 
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Procedure
Treatment Period 1 and 2 (Washout 3-14 days)
Notes
Times relative to 
start of dosing
Hypoxic Challenge ~80 min
(Times relative to entry to 
Chamber)
Pre-dose
0h
15 min
15-45 min
0-60 min
60 min
60-70 min
Immediately after 
exercise
30m rest On exit 
from chamber
After 30 min rest
60 min after exit 
from Chamber 
RAS Biomarkers
X
X1
X2
X3
X2
X2
X4
X2
Other BiomarkersSP-D
X
X1
X2
X3
X2
X2
X4
X2
PK sampling
X
X1
X2
X3
X2
X2
X4
X2
AE/SAE review
============================================================
Concomitant medication review
X
1.
To be taken at the end of exercise Take at the end of the infusion
2.
Taken immediately after echocardiogram.
3.
Immediately before entering the chamber
4.
To be taken as soon as possible after leaving chamber
5.
On this occasion ONLY, vital signs to be taken after the blood draw.
 
 
 
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Section 7.2.1.3:  Follow-up of AEs and SAEs
Rationale for change:  Deletion of reference to AEs of special interest, as no AEs of 
special interest have been defined in the protocol.
After the initial AE/SAE report, the investigator is required to proactively follow each 
subject at subsequent visits/contacts.  All SAEs, and non-serious AEs of special interest 
(as defined in Section 4.6.1) will be followed until resolution, until the condition 
stabilizes, until the event is otherwise explained, or until the subject is lost to follow-up 
(as defined in Section 5.4). Further information on follow-up procedures is given in 
Appendix 4.
Section 7.2.2:  Physical Exams
Rationale for change:  Height and Weight removed from follow-up visit, as not required.

A complete physical examination will include, at a minimum, assessment of the 
Cardiovascular, Respiratory, Gastrointestinal and Neurological systems. Height and 
weight will also be measured and recorded, at screening only. This will be carried 
out at screening and follow up. 
Section 7.2.3:  Vital Signs
Rationale for change:  Correction of typographical errors.

Triplicate measurements will be taken at screening, and single measurements at 
other time-points.  Three readings of blood pressure and pulse rate will be taken.
The first reading should be rejected.  Second and third readings should be averaged 
to give the measurement to be recorded in the CRF. (Triplicate measurements will 
only be taken at screening and single measurements to be taken after that).
Section 7.2.4:  Electrocardiogram (ECG)
Rationale for change:  QTc Stopping Criteria removed from Section 7.2.5, and inserted 
into Section 5.4 with the other subject stopping criteria.

Triplicate 12-lead ECGs will be obtained at screening.  At all other time-points, a 
single 12-lead ECGs will be obtained at each time point during the study using an 
ECG machine that automatically calculates the heart rate and measures PR, QRS, 
QT, and QTc intervals.  Refer to Section 5.4.2 for QTc withdrawal criteria and 
additional QTc readings that may be necessary.

ECG to be measured in a semi-supine position after 5 minutes rest.

The same QT correction formula must be used for each individual subject for all 
QTc data being collected for data analysis.  Safety ECGs and other non-
protocol specified ECGs are an exception.
 
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7.2.5 QTc Stopping Criteria

The same QT correction formula must be used for each individual subject to 
determine eligibility for and discontinuation from the study.  This formula may not 
be changed or substituted once the subject has been enrolled.

For example, if a subject is eligible for the protocol based on QTcB, then QTcB must 
be used for discontinuation of this individual subject as well.

Once the QT correction formula has been chosen for a subject’s eligibility, the same 
formula must continue to be used for that subject for all QTc data being collected for 
data analysis.  Safety ECGs and other non-protocol specified ECGs are an exception.  

The QTc should be based on single or averaged QTc values of triplicate 
electrocardiograms obtained over a brief (e.g. 5-10 minute) recording period.
A subject that meets either bulleted criterion below will be withdrawn from the study.

QTcB or QTcF > 500 msec,

Change from baseline: QTc >60 msec
Section 7.2.5:  Clinical Safety Laboratory Assessments
Rationale for change:  Correction of typographical errors.  Addition of urea to clinical 
chemistry parameters, to allow the calculation of BUN.
All protocol required laboratory assessments, as defined in Table 2, must be conducted in 
accordance with the Protocol Time and Events Schedule. Laboratory requisition forms 
must be completed and samples must be clearly labelled with the subject number, 
protocol number, site/centre number, and visit date. Details for the preparation and 
shipment of samples will be provided by the laboratory and are detailed in the laboratory 
manual. Reference ranges for all safety parameters will be provided to the site by the 
laboratory responsible for the assessments.
If additional non-protocol specified laboratory assessments are performed at the 
institution’s local laboratory and result in a change in subject management or are 
considered clinically significant by the investigator (e.g., SAE or AE or dose 
modification) the results must be recorded in the CRF.
Refer to the SRM for appropriate processing and handling of samples to avoid duplicate 
and/or additional blood draws.
Haematology, clinical chemistry, urinalysis and additional parameters to be tested are 
listed in Table 2. 
 
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Table 2
Protocol Required Safety Laboratory Assessments
Laboratory 
Assessments
Parameters
Haematology
Platelet Count
RBC Indices:
WBC count with Differential:
RBC Count
MCV
Neutrophils
Hemoglobin
MCH
Lymphocytes
Hematocrit
Monocytes
Eosinophils
Basophils
Clinical 
Chemistry 1
BUN
Potassium
AST (SGOT)
Total and direct bilirubin
Urea
Sodium
ALT (SGPT)
Total Protein
Creatinine
Calcium
Alkaline phosphatise
Albumin
Glucose 
Routine 
Urinalysis

Specific gravity

pH, glucose, protein, blood and ketones by dipstick

Microscopic examination (if blood or protein is abnormal)
Other 
Screening 
Tests

HIV

Hepatitis B (HBsAg)

Hepatitis C (Hep C antibody)

Alcohol, smoking and drug screen (to include at minimum: 
amphetamines, barbiturates, cocaine, opiates, cannabinoids, 
benzodiazepines and cotinine) performed at site

Urine hCG Pregnancy test (as needed) 2
NOTES :
1. Details of Liver Chemistry Stopping Criteria and Required Actions and Follow-Up 
Assessments after liver stopping or monitoring event are given in Section 5.4.2 and 
Appendix 2.
2. Local urine testing will be standard for the protocol unless serum testing is required 
by local regulation or ethics committee.
Section 7.3.1:  Exercise Challenge
Rationale for change:  Clarification of exercise test.
Subjects will perform an exercise challenge at 70% of maximum VO2 uptake on a cycle 
ergometer within the hypoxia chamber for 10 minutes as detailed in the SRM.
Subjects must complete a minimum of 5 minutes exercise at 70% of maximumVO2 
uptake (calculated from the incremental exhaustive exercise test at the screening 
visit).
 
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Section 7.5:  Ventilatory parameters 
Rationale for change:  Clarification of ventilatory parameter assessment.
Ventilatory parameters will be measured as detailed in the Time and Events table 
(Section 7.1). 
Ventilatory parameters will be recorded for 2 minutes before echocardiograms.  
The second minute of the recording will be averaged and used for data analysis.
Measurements may include change from baseline of oxygen consumption (VO2), carbon 
dioxide production (CO2), total tidal volume, inspiratory tidal volume, expiratory 
tidal volume, total respiratory time, inspiratory time, expiratory time, duty cycle, 
mean respiratory flow and respiratory rate and other parameters as data permit.
Further details can be found in the SRM
Section 7.7:  Telemetry
Rationale for change:  Addition of telemetry.
Continuous ECG monitoring will occur via telemetry during both treatment 
periods.
Section 7.9.1:  Renin-angiotensin system biomarkers
Rationale for change:  Clarification of archiving procedure.
RAS peptides including, but not limited to, AngII, Ang(1-7) and Ang(1-5) may be 
analysed as data permit.  Raw data will be archived at the Bioanalytical Site 
(Bioanalytical Site detailed in the SRM).  
Section 7.9.2:  Surfactant Protein-D and other biomarkers
Rationale for change:  Removal of some exploratory biomarkers.
SP-D will be analysed.  Raw data will be archived at the Bioanalytical Site 
(Bioanalytical Site to be detailed in the SRM).  Additional analytes may be analysed, 
as data permit.  Peptide hormones such as Kinins (e.g. des-Arg-bradykinin), apelins 
(e.g. Apelin 13, pyr1-Apelin, 13) and other systems (e.g. dynorphin A) may be analysed 
as data permit.
Atrial Naturetic peptide (ANP), Brain Naturetic Peptide (NT-proBNP), Troponin I, 
Surfactant Protein D, IL-6 and/or additional analytes to be determined may also be 
analysed as data permit.
 
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Section 9.2:  Sample Size Considerations
Rationale for change:  Refer to rationale stated for Sections 4.3 and 5.4.1.
The sample size of 30 20 patients is based on logistical considerations and is not based on 
formal sample size calculations.  However, estimates of precision for the treatment 
difference in the primary endpoint are presented for context (Note: precision in this 
context is defined as one half of the width of the 95% confidence interval).  A sample 
size re-estimation is planned after 15 10 subjects. 
Section 9.2.2:  Sample Size Re-estimation
Rationale for change:  Refer to rationale stated for Sections 4.3 and 5.4.1.
A sample size re-estimation will be conducted at the interim analysis (see Section 9.3.2). 
The purpose of the sample size re-estimation is to determine whether the total number of 
subjects can be reduced below the anticipated 3020, based on treatment comparison 
between GSK2586881 and Placebo in change from pre-dose PASP to hypoxic/exercised 
PASP (i.e. T3-T0). The sample size re-estimation is to be considered advisory, and taken 
into account together with other considerations.
Section 9.3.1:  Analysis Populations
Rationale for change:  Correction of typographical errors.
Intent-to-Treat (ITT) Population: This population will comprise all randomised subjects, 
excluding those who were randomised in error. A subject who is recorded as a screen 
failure, run-in failure, or stabilisation failure, but is randomised and does not receive a 
dose of study treatment, is considered to be randomised in error. Any other subject who 
receives a randomisation number will be considered to have been randomised. This will 
constitute the primary population for all efficacy and safety and pharmacodynamic
analyses.
Section 9.3.2:  Interim Analysis
Rationale for change:  Refer to rationale stated for Sections 4.3 and 5.4.1.
An interim analysis is planned after 15 10 subjects have completed the following critical 
assessments:

PASP at T0 and T3 for both study periods

Oxygen saturation at T0 and T3 for both study periods

Adverse events 
The interim analysis will use the following study data:

PASP at time T0 and T3 for both periods, for the first 15 10 subjects
 
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
Oxygen saturation at T0 and T3 for both periods, for the first 15 10 subjects

Adverse events for the first 15 10 subjects

Angiotensin biomarkerRAS peptide concentrations for the first 5 subjects (to 
allow time for the samples to be analysed by the external lab).
The interim analysis will use a data snapshot that has been cleaned to the best extent 
allowed by the timeframes (i.e. the interim data will not be fully cleaned or fully QC’d 
data and there will not be a locked database).
The aims of the interim analysis, and the endpoints to be used to address them, are as 
follows:

Using the primary endpoint (treatment differences between GSK2586881 and 
Placebo in change from pre-dose PASP to hypoxic/exercised PASP [T3-T0]):
o
To decide whether to continue the study or stop based on futility, and
o
to conduct an advisory sample-size re-estimation with the view to 
potentially reduce the number of subjects participating in the study below 
3020.

Using secondary endpoints:
o
to estimate treatment differences between GSK2586881 and Placebo in 
change from pre-dose oxygen saturation to hypoxic/exercised oxygen 
saturation [T3-T0], with a view to stopping the study if there is evidence 
that GSK2586881 causes a reduction in oxygen saturation in healthy 
volunteers. As a non-binding guide high posterior probability of observing 
5% absolute differences in mean oxygenation saturation values between 
placebo and active arms would be of concern; but clinical judgement 
would override any statistical methods if, for example, the majority of 
subjects displayed consistent patterns of reductions e.g. between 2-3%).
o
to compare adverse events within the two treatment groups and explore 
any potential safety signals that may emerge
To assess the operating characteristics of the interim analysis decisions to be made based 
on the primary endpoint, a simulation was carried out to estimate the relative proportion 
of studies reaching conclusions to stop for futility, continue with no change to the sample 
size, and to continue with a reduced sample size, under various different scenarios of the 
true treatment effect. Broadly speaking, the aim of the simulation was to confirm that (in 
an overwhelming majority of cases) a decision to stop for futility would be reached in the 
case of no true treatment effect and a decision to continue (perhaps with reduced sample 
size) would be reached in the case of a true treatment effect.
 
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Simulated datasets of PASP at baseline (i.e. normoxic and at rest) and under hypoxia and 
exercise for 15 10 subjects, each receiving both treatments in sequence, were generated 
using the following assumptions:

15 10 simulated subjects were randomised to one of the two available treatment 
sequences (see Section 6.2) using block randomisation with block size of 4 records

PASP at baseline and under hypoxia and exercise for both treatment groups (a total of 
four PASP measurements per subject) were sampled from a multivariate normal 
distribution, using values for mean PASP, standard deviation of PASP and within-
subject correlation of PASP as described below.

Mean PASP was 30 mmHg at baseline (i.e. normoxic and at rest) for both treatments, 
and 45 mmHg under hypoxia and exercise for Placebo (as in Section 9.2.1). For 
GSK2586881, mean PASP under hypoxia and exercise was (45 - Δ) mmHg, where Δ 
(the mean treatment difference) was varied according to four different scenarios:
o
no treatment difference (Δ = 0 mmHg)
o
weak treatment difference of a magnitude of half the clinically meaningful 
difference (Δ = 2.5 mmHg)
o
minimum clinically meaningful difference (Δ = 5 mmHg)
o
overwhelming treatment difference one-and-a-half times the clinically 
meaningful difference (Δ = 7.5 mmHg)

SD of PASP was 2.81 mmHg at baseline and 4.30 mmHg under hypoxia and 
exercise, for both treatment groups (as in Section 9.2.1) 

The within-subject correlation of PASP was unknown, therefore four different 
scenarios of within-subject correlation were evaluated: zero correlation, low 
correlation (0.3), high correlation (0.6) and very high correlation (0.9) (as in Section 
9.2.1). Within-subject correlation of PASP was assumed to be compound symmetric 
(i.e. the same correlation was used for each of the six possible pairs of the four PASP 
measurements within each subject).

It was assumed that there would be no effect of period in the simulation, i.e. it was 
assumed that it would make no difference if the measurement was taken from the first 
or second chronological period in the treatment sequence.
Modelling took on a three-step process, with decisions after each. Firstly, the treatment 
difference and its associated standard error was then estimated for the dataset of 15 10
simulated subjects using a mixed effects linear regression model, including covariates for 
period, treatment, period baseline and subject baseline (the mean of the two period 
baselines) as fixed effects and subject as a random effect. If the sign of treatment 
difference arising from the simulated data was in the wrong direction (i.e. the simulated 
outcome for GSK2586881 was worse than for Placebo), then the simulated study was 
stopped for futility.
 
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Secondly, in the alternative case that the simulated treatment difference was in favour of 
GSK2586881 over Placebo, a posterior probability of success (where success was defined 
as a 97.5% posterior probability of the treatment difference being in favour of 
GSK2586881 over Placebo) was evaluated for 30 20 subjects. This was evaluated using a 
t-distribution, with the mean and standard deviation taken as the treatment difference and 
standard error (multiplied by a factor of the square root of 15 10 to estimate the standard 
deviation) from step one, respectively.  If this posterior probability was less than 0.2, then 
the study was stopped for futility as being unlikely to show any benefit of GSK2586881 
over Placebo.
Thirdly, provided that the simulated study hadn't been stopped for futility in either of the 
first two steps, posterior probabilities of success were calculated for N ranging from 15
10 to 29 19 subjects. If any of these posterior probabilities of success were greater than or 
equal to 0.9, then the study was continued with a reduced sample size equal to the lowest 
N at which that threshold was reached. Otherwise, the conclusion from the simulated 
interim analysis would be to continue the study with unchanged sample size.
This whole process (simulating data for 15 10 subjects, modelling the treatment 
difference, evaluating posterior probabilities of success and simulating the decision-
making process) was replicated 10000 times for each scenario, with the decision ("futile", 
"no change to N" or "reduce N") recorded for each iteration. Each combination of the 
four treatment difference scenarios and the four correlation scenarios was evaluated for a 
total of 16 scenarios in all.
The estimated proportions of each decision being reached under each of the 16 scenarios 
are presented in Table 4.
Table 4 Operating characteristics of interim analysis at N=10 under four scenarios 
of treatment effect and four scenarios of within-subject correlation
Frequency of decisions (%)
Treatment 
effect 
Scenario
Within-subject 
correlation of PASP
Futile
Continue with 20
30 subjects
Continue with 
reduced sample 
size
Δ=0 mmHg (no treatment difference)
0.0
87 85%
13 15%
0 1%
0.3
87 85%
13 15%
1%
0.6
85%
15%
0 1%
0.9
86 85%
14%
0 1%
Δ=2.5 mmHg (weak treatment effect, less than clinically meaningful difference)
0.0
4431%
50 60%
9 6%
0.3
3624%
56 65%
11 9%
0.6
2110%
63 66%
25 16%
0.9
1 0%
319%
91 68%
Δ=5 mmHg (good treatment effect, at threshold of clinical meaningful difference)
0.0
9 2%
60 46%
31 52%
0.3
4 1%
54 35%
42 64%
0.6
1 0%
31 11%
68 89%
 
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Frequency of decisions (%)
Treatment 
effect 
Scenario
Within-subject 
correlation of PASP
Futile
Continue with 20
30 subjects
Continue with 
reduced sample 
size
0.9
0%
0%
100%
Δ=7.5 mmHg (very strong treatment effect)
0.0
1 0%
32 10%
67 90%
0.3
0%
18 2%
82 98%
0.6
0%
3 0%
96 100%
0.9
0%
0%
100%
These results suggest primarily that if there is no true treatment difference between 
GSK2586881 and Placebo, the study would be stopped for futility 8587% of the time 
(irrespective of within-subject correlation of PASP). A drug with a weak treatment effect 
would most likely result in the study being continued without change or stopped for 
futility (except in the case where within-subject correlation is 0.9, which is presented here 
as an extreme case, unlikely to occur in practice). If the true treatment effect is at the 
clinically relevant threshold of 5 mmHg, then the study is highly unlikely to be stopped 
for futility and may indicate being reduced in sample size.
Section 9.4:  Key Elements of Analysis Plan
Rationale for change:  Correction of typographical errors.
Each subject will undergo two treatment periods in this crossover study, each one of 
which being subdivided into five key sub-epochs (labelled T0-T4) as follows:

T0: Pre-dose (period baseline)

T1: Post-dose, normoxic, at rest, pre-challenge

T2: Hypoxic, at rest

T3: Hypoxic, immediately after exercise

T4: Post-challenge, normoxic, at rest
This follows the principle illustrated in the diagram of echocardiograph measurements 
(Figure 2).
Pharmacodynamic endpoints PASP and Oxygen Saturation will be assigned to T0 thru 
T4 timepoints based on when they happened relative to the sequence of events that the 
subject undertakes during the course of the study day.  Biomarkers will be collected at 
times T0 thru T4, plus additional time-points.
Pharmacokinetic endpoints will be timed based on elapsed time since dose 
administration.
 
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In addition to T0 being defined as the period baseline, an overall subject baseline will be 
defined as the mean of the two T0 measurements (one from each period).
Change from baseline at time points T1 - T4 will be calculated as the difference between 
the measurement at the time point in question and the period baseline.  In general, 
statistical modelling of changes from baseline will be done using a Bayesian mixed 
effects regression model, including covariates for period, treatment, period baseline and 
subject baseline (the mean of the two period baselines).  as fixed effects and s Subject 
will be fitted as a random effect and non-informative priors will be used for model 
parameters. A compound symmetric covariance structure within each subject-period-
treatment cell will be assumed to account for repeated measurements a) inherent in the 
two-period crossover design and b) due to the four post-baseline timepoints within each 
treatment period.
Section 12.2:  Appendix 2: Liver Safety Required Actions and Follow up Assessments
Rationale for change:  Correction of typographical error.
Footnote 4:  PK sample may not be required for subjects known to be receiving placebo or non-GSK comparator 
treatments. Record the date/time of the PK blood sample draw and the date/time of the last dose of study treatment 
prior to blood sample draw on the CRF. If the date or time of the last dose is unclear, provide the subject’s best 
approximation. If the date/time of the last dose cannot be approximated OR a PK sample cannot be collected in the 
time period indicated above, do not obtain a PK sample. Instructions for sample handling and shipping are in the SRM.
Section 12.4.1:  Definition of Adverse Events
Rationale for change:  Removal of AE definitions related to efficacy, because this is not a 
patient study.
Events meeting AE definition include:

Any abnormal laboratory test results (hematology, clinical chemistry, or urinalysis) 
or other safety assessments (e.g., ECGs, radiological scans, vital signs 
measurements), including those that worsen from baseline, and felt to be clinically 
significant in the medical and scientific judgement of the investigator.

Exacerbation of a chronic or intermittent pre-existing condition including either an 
increase in frequency and/or intensity of the condition.

New conditions detected or diagnosed after study treatment administration even 
though it may have been present prior to the start of the study.

Signs, symptoms, or the clinical sequelae of a suspected interaction.

Signs, symptoms, or the clinical sequelae of a suspected overdose of either study 
treatment or a concomitant medication (overdose per se will not be reported as an 
AE/SAE unless this is an intentional overdose taken with possible suicidal/self-
harming intent.  This should be reported regardless of sequelae).

"Lack of efficacy" or "failure of expected pharmacological action" per se will not be 
reported as an AE or SAE.  However, the signs and symptoms and/or clinical 
sequelae resulting from lack of efficacy will be reported if they fulfil the definition 
 
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of an AE or SAE.

The signs and symptoms and/or clinical sequelae resulting from lack of efficacy will 
be reported if they fulfil the definition of an AE or SAE.  Also, "lack of efficacy" or 
"failure of expected pharmacological action" also constitutes an AE or SAE.
 
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The GlaxoSmithKline group of companies
204987
1
TITLE PAGE
Division: Worldwide Development
Information Type: Protocol Amendment
Title:
The effects of GSK2586881 on the responses to acute hypoxia 
and exercise
Compound Number:
GSK2586881
Development Phase:
I
Effective Date:
24-FEB-2017
Protocol Amendment Number:  01
Author (s):
 
 
Revision Chronology
GlaxoSmithKline
Document Number
Date
Version
2016N283626_00
2016-SEP-23
Original
2016N283626_01
2017-FEB-24
Amendment No. 1
Additional Inclusion Criteria (Section 5.2) and Subject Stopping Criteria (Section 5.4) 
added in response to comments from BfArM.
A summary of changes is presented in Appendix 6.
Copyright 2017 the GlaxoSmithKline group of companies.  All rights reserved.  
Unauthorised copying or use of this information is prohibited.
 
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PPD

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MEDICAL MONITOR/SPONSOR INFORMATION PAGE
Medical Monitor/SAE Contact Information: 
Role
Name
Day Time Phone 
Number and email 
address
After-hours 
Phone/Cell/
Pager Number
Fax 
Number
Site Address
Primary 
Medical 
Monitor 
709 Swedeland 
Road
UW2531
King of Prussia, 
PA  19406 USA
Secondary 
Medical 
Monitor
Gunnels 
Wood Road, 
Stevenage, 
Hertfordshire, 
SG1 2NY, UK
SAE
contact
information
[Medical
monitor
as 
above]
Sponsor Legal Registered Address: 
GlaxoSmithKline Research & Development Limited
980 Great West Road
Brentford
Middlesex, TW8 9GS
UK
In some countries, the clinical trial sponsor may be the local GlaxoSmithKline Affiliate 
Company (or designee). If applicable, the details of the alternative Sponsor and contact 
person in the territory will be provided to the relevant regulatory authority as part of the 
clinical trial application.   
Regulatory Agency Identifying Number(s):  2016-002465-55
 
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INVESTIGATOR PROTOCOL AGREEMENT PAGE
For protocol 204987
I confirm agreement to conduct the study in compliance with the protocol, as amended by 
this protocol amendment.
I acknowledge that I am responsible for overall study conduct. I agree to personally 
conduct or supervise the described study.
I agree to ensure that all associates, colleagues and employees assisting in the conduct of 
the study are informed about their obligations. Mechanisms are in place to ensure that site 
staff receives the appropriate information throughout the study. 
Investigator Name:
Investigator Address:
Investigator Phone Number:
Investigator Signature
Date
 
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TABLE OF CONTENTS
PAGE
1.
PROTOCOL SYNOPSIS FOR STUDY 204987........................................................8
2.
INTRODUCTION....................................................................................................13
2.1.
Study Rationale ..........................................................................................14
3.
OBJECTIVE(S) AND ENDPOINT(S) ......................................................................16
4.
STUDY DESIGN ....................................................................................................18
4.1.
Overall Design ............................................................................................18
4.2.
Treatment Arms and Duration.....................................................................18
4.3.
Type and Number of Subjects.....................................................................19
4.4.
Design Justification.....................................................................................20
4.5.
Dose Justification........................................................................................20
4.6.
Benefit:Risk Assessment ............................................................................20
4.6.1.
Risk Assessment .........................................................................21
4.6.2.
Benefit Assessment.....................................................................23
4.6.3.
Overall Benefit:Risk Conclusion...................................................23
5.
SELECTION OF STUDY POPULATION AND WITHDRAWAL CRITERIA .............23
5.1.
Inclusion Criteria.........................................................................................23
5.2.
Exclusion Criteria........................................................................................26
5.3.
Screening/Baseline/Run-in Failures............................................................28
5.4.
Withdrawal/Stopping Criteria.......................................................................28
5.4.1.
Study Stopping Criteria................................................................29
5.4.2.
Liver Chemistry Stopping Criteria ................................................29
5.4.2.1.
Study Treatment Restart or Rechallenge....................30
5.5.
Subject and Study Completion....................................................................30
6.
STUDY TREATMENT ............................................................................................30
6.1.
Investigational Product and Other Study Treatment....................................30
6.2.
Planned Dose Adjustments.........................................................................31
6.3.
Blinding.......................................................................................................32
6.4.
Packaging and Labeling..............................................................................33
6.5.
Preparation/Handling/Storage/Accountability..............................................33
6.6.
Compliance with Study Treatment Administration.......................................33
6.7.
Treatment of Study Treatment Overdose....................................................34
6.8.
Treatment after the End of the Study ..........................................................34
6.8.1.
Meals and Dietary Restrictions ....................................................34
6.8.2.
Caffeine, Alcohol, and Tobacco ...................................................34
6.8.3.
Activity .........................................................................................35
6.9.
Concomitant Medications and Non-Drug Therapies....................................35
6.9.1.
Permitted Medications and Non-Drug Therapies..........................35
6.9.2.
Prohibited Medications and Non-Drug Therapies.........................35
7.
STUDY ASSESSMENTS AND PROCEDURES .....................................................36
7.1.
Time and Events Table...............................................................................37
7.1.1.
Screening and Follow up .............................................................37
7.1.2.
Treatment Period 1 and 2 ............................................................38
7.2.
Safety .........................................................................................................40
 
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7.2.1.
Adverse Events (AE) and Serious Adverse Events (SAEs)..........40
7.2.1.1.
Time period and Frequency for collecting AE 
and SAE information...................................................40
7.2.1.2.
Method of Detecting AEs and SAEs ...........................41
7.2.1.3.
Follow-up of AEs and SAEs........................................41
7.2.1.4.
Regulatory Reporting Requirements for SAEs............41
7.2.2.
Physical Exams ...........................................................................42
7.2.3.
Vital Signs....................................................................................42
7.2.4.
Electrocardiogram (ECG).............................................................42
7.2.5.
QTc Stopping Criteria ..................................................................42
7.2.6.
Clinical Safety Laboratory Assessments ......................................43
7.3.
Hypoxia Challenge......................................................................................44
7.3.1.
Exercise Challenge......................................................................45
7.4.
Echocardiogram..........................................................................................45
7.5.
Ventilatory parameters................................................................................45
7.6.
Pulse Oximetry ...........................................................................................46
7.7.
Pharmacokinetics .......................................................................................46
7.7.1.
Blood Sample Collection..............................................................46
7.7.2.
Sample Analysis ..........................................................................46
7.8.
Biomarker(s)/Pharmacodynamic Markers ...................................................46
7.8.1.
Renin-angiotensin system biomarkers .........................................46
7.8.2.
Other Biomarkers.........................................................................46
7.9.
Genetics .....................................................................................................47
7.9.1.
Blood sample collection ...............................................................47
7.10.
Immunogenicity...........................................................................................47
7.10.1.
Sample collection.........................................................................47
7.10.2.
Sample analysis...........................................................................47
8.
DATA MANAGEMENT ...........................................................................................48
9.
STATISTICAL CONSIDERATIONS AND DATA ANALYSES .................................48
9.1.
Hypotheses.................................................................................................48
9.2.
Sample Size Considerations.......................................................................48
9.2.1.
Sample Size Assumptions ...........................................................49
9.2.2.
Sample Size Re-estimation..........................................................50
9.3.
Data Analysis Considerations .....................................................................51
9.3.1.
Analysis Populations....................................................................51
9.3.2.
Interim Analysis ...........................................................................52
9.3.3.
Multiple Comparisons and Multiplicity ..........................................56
9.4.
Key Elements of Analysis Plan ...................................................................56
9.4.1.
Pharmacokinetic Analyses...........................................................57
10. STUDY GOVERNANCE CONSIDERATIONS........................................................57
10.1.
Posting of Information on Publicly Available Clinical Trial Registers............57
10.2.
Regulatory and Ethical Considerations, Including the Informed 
Consent Process ........................................................................................57
10.3.
Quality Control (Study Monitoring) ..............................................................58
10.4.
Quality Assurance.......................................................................................59
10.5.
Study and Site Closure ...............................................................................59
10.6.
Records Retention......................................................................................60
10.7.
Provision of Study Results to Investigators, Posting of Information 
on Publically Available Clinical Trials Registers and Publication .................60
 
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11. REFERENCES.......................................................................................................62
12. APPENDICES........................................................................................................65
12.1.
Appendix 1: Abbreviations and Trademarks................................................65
12.2.
Appendix 2: Liver Safety Required Actions and Follow up 
Assessments ..............................................................................................68
12.3.
Appendix 3: Genetic Research ...................................................................70
12.4.
Appendix 4: Definition of and Procedures for Recording, Evaluating, 
Follow-Up and Reporting of Adverse Events...............................................73
12.4.1.
Definition of Adverse Events........................................................73
12.4.2.
Definition of Serious Adverse Events...........................................74
12.4.3.
Definition of Cardiovascular Events .............................................76
12.4.4.
Recording of AEs and SAEs ........................................................76
12.4.5.
Evaluating AEs and SAEs............................................................77
12.4.6.
Reporting of SAEs to GSK...........................................................78
12.5.
Appendix 5: Modified List of Highly Effective Methods for Avoiding 
Pregnancy and Collection of Pregnancy Information...................................80
12.5.1.
Modified List of Highly Effective Methods for Avoiding 
Pregnancy ...................................................................................80
12.5.2.
Collection of Pregnancy Information ............................................81
12.5.3.
References ..................................................................................82
12.6.
Appendix 6:  Protocol Changes...................................................................83
12.6.1.
Protocol Amendment 01 (24-Feb-2017) from Original 
Protocol  (23-Sep-2016)...............................................................83
12.6.1.1.
Summary of Changes and Rationale for 
Amendment................................................................83
12.6.1.2.
List of Specific Changes .............................................83
 
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1.
PROTOCOL SYNOPSIS FOR STUDY 204987
Rationale
The purpose of this study is to examine how GSK2586881, a recombinant human ACE2 
peptide, modulates the acute hypoxic pulmonary vasoconstriction (HPV) response in 
healthy volunteers. 
HPV is an acute physiological response that plays a fundamental role in maintaining 
optimal arterial oxygen (PaO2) levels in health and in pathophysiological settings such as 
acute respiratory distress syndrome (ARDS) by facilitating re-distribution of pulmonary 
blood flow to areas of ventilated lung. The literature supports a role for the renin 
angiotensin system (RAS) in driving acute HPV and while there is a strong biological 
rationale for modulation of RAS in the treatment of ARDS patients, therapeutic 
strategies aimed at RAS may have unintended, negative consequences for ARDS patients 
if they blunt the normal HPV response and negatively impact on arterial oxygenation 
(PaO2).  Thus, from a safety (and efficacy) perspective it is important to understand the 
impact of modulation of the RAS system by GSK2586881 on the acute HPV response.
 
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Objective(s)/Endpoint(s)
Objectives
Endpoints
Primary

To evaluate the effect of a single IV 
dose of GSK2586881 on the HPV 
response in healthy volunteers during 
exercise under hypoxic conditions.

Change from baseline of Pulmonary 
Artery Systolic Pressure (PASP) 
measured via Echocardiography.
Secondary

To evaluate the effect of a single IV 
dose GSK2586881 on RAS peptide 
responses. 

To evaluate the safety of a single IV 
dose of GSK2586881 in healthy 
volunteers.

To evaluate the pharmacokinetics of a 
single IV dose of GSK2586881.

Effect of GSK2586881 on baseline 
levels and changes in response to 
hypoxia and exercise of RAS peptides 
(e.g. Ang II, Ang(1-7), Ang(1-5)).

Vital signs (heart rate, systolic and 
diastolic blood pressure), oxygen 
saturation, 12-lead ECGs, AEs, 
immunogenicity and clinical laboratory 
assessments and continuous pulse 
oximetry. 

Plasma concentrations of GSK2586881 
and derived pharmacokinetic 
parameters.
 
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Objectives
Endpoints
Exploratory 

To evaluate the effect of a single IV 
dose of GSK2586881 on ventilatory 
parameters in healthy volunteers during 
exercise in hypoxic conditions.

To evaluate the effect of a single IV 
dose of GSK2586881 on peptide 
hormone responses to hypoxia and 
exercise.

To evaluate the pharmacodynamic 
activity of a single IV dose of 
GSK2586881 in healthy volunteers 
during exercise in hypoxic conditions.

To evaluate Pharmacogenetics 

Change from baseline of oxygen 
consumption (VO2), carbon dioxide 
production (CO2) and other parameters
as data permit.

Baseline levels and changes in response
to hypoxia and exercise in kinins (e.g. 
des-Arg-bradykinin), apelins (e.g. 
Apelin 13, pyr1-Apelin, 13) and other 
systems (e.g. dynorphin A) as data 
permit.

Change from baseline in other  
biomarkers which may include Atrial 
Naturetic peptide (ANP), Brain 
Naturetic Peptide (NT-proBNP), 
Troponin I, Surfactant Protein D, IL-6 
and/or additional analytes to be 
determined.
Evaluate I/D polymorphisms in the 
Angiotensin Converting Enzyme 
(ACE) gene and analyse the impact on 
Ang II (and possibly other RAS 
peptides), hypoxic pulmonary 
vasoconstriction and responses to 
GSK2586881 administration.
Overall Design
The study will be single-centre , randomised, placebo-controlled and double blind
(sponsor open). Subjects will be randomised to receive a single IV dose of GSK2586881 
or saline in a crossover design. 
A schematic of the study is shown below. Echocardiograms approximate timings are 
indicated by bold arrows.  
 
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APPROXIMATE TIMING OF SIMULATED ALTITUDE AND 
ECHOCARDIOGRAM MEASUREMENTS (BLACK ARROWS) 
DURING TREATMENT PERIODS 1 AND 2.
Treatment Groups, Randomisation Arms and Duration
The study is intended to follow a double blind (sponsor open) two-period cross-over 
design.
Treatment Group A: GSK2586881 0.8 mg/kg, administered as a single IV dose. . 
Treatment Group B: matching volume of placebo administered as a single IV dose. 
Subjects will receive both treatments during the course of the study, and will be 
randomised to one of two sequences, each of which describes the order in which those 
treatments are received:
Sequence 1: AB: GSK2586881 in the first period followed by placebo in the second.
Sequence 2: BA: Placebo in the first period followed by GSK2586881 in the second.
The total study duration for each subject is expected to be a maximum of 56 days.
 
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Type and Number of Subjects
Approximately 35 subjects will be enrolled to ensure that a minimum of 30 subjects 
complete all dosing and critical assessments (the target of 30 may be revised by the 
sample size re-estimation).
If subjects prematurely discontinue the study, additional replacement subjects will not be 
recruited in order to preserve randomisation integrity.  
Analysis
This study is designed to estimate the effect of GSK2586881 relative to placebo on 
change from baseline in PASP following exercise under hypoxic conditions. No formal 
hypothesis will be tested. Point estimates will be calculated together with corresponding 
95% confidence intervals (or credible intervals if utilising a Bayesian framework) for the 
difference between the mean of the test treatment and the mean of the reference 
treatment.
Analysis of PASP: Statistical modelling of changes from baseline (Ti-T0) will be done 
using a Bayesian mixed effects regression model, including covariates for period, 
treatment, period baseline and subject baseline (the mean of the two period baselines) as 
fixed effects and subject as a random effect. A compound symmetric covariance structure 
within each subject-period-treatment cell will be assumed to account for repeated 
measurements a) inherent in the two-period crossover design and b) due to the four post-
baseline timepoints within each treatment period. Non-informative priors will be used for 
the model parameters. Posterior distributions will be obtained for the GSK2586881 Vs 
Placebo comparisons at each of the post dosing timepoints (T1-T4). These distributions 
will be used to produce several posterior probability statements; the most important being 
the probability that the change from baseline in PASP is reduced by the GSK2586881at 
time T3. 
Oxygenation saturation will also be analysed in a similar way; although of interest is the 
posterior probability that the study drug causes (absolute) reductions in oxygenation 
saturation in excess of 5%.
An interim analysis is planned after 15 subjects have completed period 1 and 2 
assessments to i) evaluate safety and tolerability (SAE, AE and Oxygenation saturation), 
ii) determine whether the study should stop for futility based on expected PASP 
outcomes if the study were allowed to complete recruitment and iii) Re-estimate the 
sample size based using the observed variance parameters.
 
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2.
INTRODUCTION
GSK2586881 is a purified intravenous formulation of soluble recombinant human  
angiotensin converting enzyme type 2 (rhACE2) which is expressed in Chinese Hamster  
Ovary cells. Angiotensin converting enzyme type 2 (ACE2) is a zinc carboxypeptidase 
involved in the Renin-Angiotensin System  (RAS) that controls blood pressure, 
electrolytes, and intravascular fluid volume. A key function of ACE2 is believed to be the 
cleavage of Angiotensin II (Ang II) to Ang (1-7), which have opposing physiological 
roles. Elevated levels of Ang II are associated with vasoconstriction, inflammation, 
fibrosis, vascular leak, and sodium absorption. Ang (1-7) appears to be a counter-
regulatory protein in the RAS; associated with vasodilation, anti-proliferation, anti-
inflammation, and reduced vascular leak, as noted in Figure 1 below [Paul, 1992; Santos, 
2005; Suzuki, 2003].
Figure 1
Renin Angiotensin System
Angiotensinogen
Angiotensin I (1-10)
Angiotensin II(1-8)
Angiotensin (1-9)
Angiotensin (1-7)
Renin
ACE 1
Aldosterone
Vascular leak
Vasoconstriction
Pro-inflammatory
Pro-fibrotic/apoptotic
Sodium/water retention
ACE 1
ACE 2
ACE 2
Reduced vascular leak
Vasodilatation
Anti-inflammatory
Anti-proliferation/apoptotic
Ang II binds to two distinct receptors called AT-1 and AT-2, with the AT-1 receptor 
mediating the vasoconstrictive, proliferative and pro-inflammatory actions of Ang II. The 
function of the AT-2 receptor has not been fully elucidated. Ang (1-7) initiates its effects 
by binding to the Mas-receptor, and also acts by inhibiting the activity of the 
carboxyterminal domain of angiotensin converting enzyme (ACE), which prevents ACE 
from fully acting on its substrates Angiotensin I and bradykinin.
ACE and Angiotensin II has been implicated in the pathogenesis of  the acute respiratory 
distress syndrome (ARDS, and pulmonary hypertension. It has been observed that 
circulating Ang II levels and lung ACE levels are increased in humans with ARDS and 
pulmonary hypertension. It has also been shown that the DD ACE polymorphism, which 
is associated with higher ACE activity, is associated with susceptibility to development 
of lung injury and worsened outcome (mortality) in patients with ARDS [Marshall, 2002] 
and to the development of pulmonary hypertension [Abraham, 2003]
 
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It is expected that the reduction of Ang II and simultaneous formation of Ang (1-7) 
should have positive impacts in ARDS and on pulmonary haemodynamics in patients 
with pulmonary hypertension. This dual action can be achieved by ACE2, and thus, an 
enhancement of the activity of this enzyme is seen as promising approach for the 
treatment of diseases and conditions with an imbalance of the RAS system, insufficient 
natural ACE2 activity, and pathologically elevated Ang II levels or decreased Ang (1-7) 
such as is observed in ALI/ARDS [Tom, 2001; Idell, 1987; Santos, 2003; Wenz, 2000] 
and pulmonary hypertension [Maron, 2014]
This study will demonstrate how GSK2586881 modulates the acute HPV response in 
healthy volunteers. 
2.1.
Study Rationale
Hypoxic pulmonary vasoconstriction (HPV) is an acute physiological response that plays 
a fundamental role in maintaining optimal arterial oxygen (PaO2) levels in health and in 
pathophysiological settings such as acute respiratory distress syndrome (ARDS) by 
facilitating re-distribution of pulmonary blood flow to areas of ventilated lung. However, 
in many ARDS patients with pulmonary microvascular injury and dystonia, the normal 
HPV reflex is compromised resulting in the mismatching of perfusion (Q) and ventilation 
(VA) and formation of areas of low perfusion to ventilated alveoli (high VA/Q; 
physiological deadspace), or perfusion of alveoli with minimal or no ventilation (low 
V/Q; physiological shunt).  
The literature is conflicting as to the role of the RAS in modulating the HPV response; 
however, the majority of reports support a role for the RAS in driving acute HPV (Cargil, 
1996; Kiely, 1996). While there is a strong biological rationale for modulation of the 
RAS in the treatment of ARDS patients, therapeutic strategies aimed at RAS may have 
unintended, negative consequences for ARDS patients if they impact on PaO2 and 
produce a blunted HPV response. Surprisingly, there are scant data regarding the effect of 
RAS modulation on HPV, V-Q matching or PaO2 in healthy human volunteers.
Inhibition of the acute HPV response would be expected to promote blood flow to areas 
of poorly-ventilated lung resulting in an increase in venous admixture and a reduction in 
PaO2 levels. In the context of acute lung injury, correction of any V/Q mismatch would 
be expected to be beneficial with respect to maintaining and improving PaO2 levels. 
Conversely, inhibition of HPV by pharmacological agents might be expected to worsen 
V/Q matching and compromise PaO2 levels. Thus, from a safety (and efficacy) 
perspective it is vital to understand the impact of modulation of the RAS system on the 
acute HPV response and subsequent PaO2.
Recombinant human ACE2 (rhACE2) delivered intravenously to pigs inhibits the HPV 
response to acute hypoxic challenge assessed by inhibition of mean pulmonary artery 
pressures and pulmonary vascular resistance. There was also a strong trend to increased 
shunt with administration of rhACE2; however PaO2 was not significantly affected. The 
authors concluded that the increased shunt may not have been sufficient to result in a 
reduction in PaO2 (Kleinsasser, 2012). 
 
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An elegant study by Wagner and colleagues demonstrated the importance of end arterial 
capillary diffusion limitations on PaO2 levels in healthy volunteers during hypoxia ± 
exercise (Torre-Bueno, 1985). Diffusion limitation made a significant contribution to 
PaO2 levels particularly under conditions where exercise and hypoxia were combined. In 
addition, V/Q mismatching was suggested to increase with the combined stresses of 
exercise and hypoxia resulting in significantly more arterial oxygen desaturation than 
observed with either stressor by itself.
The main goals of this study are to examine whether GSK2586881 modulates the acute 
HPV response in healthy volunteers with a subsequent impact on O2 saturation.  Should 
the application of GSK2586881 lead to accentuated arterial oxygen desaturation, further 
clinical studies to examine the therapeutic efficacy of GSK2586881 in acute lung injury 
should be approached with caution. Conversely, a reduction in HPV without augmented 
hypoxemia would provide supporting evidence that GSK2586881 could have a positive 
impact in patients with pulmonary hypertension.
 
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3.
OBJECTIVE(S) AND ENDPOINT(S)
Objectives
Endpoints
Primary

To evaluate the effect of a single IV 
dose of GSK2586881 on the HPV 
response in healthy volunteers during 
exercise under hypoxic conditions.

Change from baseline of Pulmonary 
Artery Systolic Pressure (PASP) 
measured via Echocardiography.
Secondary

To evaluate the effect of a single IV 
dose GSK2586881 on RAS peptide 
responses. 

To evaluate the safety of a single IV 
dose of GSK2586881 in healthy 
volunteers.

To evaluate the pharmacokinetics of a 
single IV dose of GSK2586881.

Effect of GSK2586881 on baseline 
levels and changes in response to 
hypoxia and exercise of RAS peptides 
(e.g. Ang II, Ang(1-7), Ang(1-5)).

Vital signs (heart rate, systolic and 
diastolic blood pressure), oxygen 
saturation, 12-lead ECGs, AEs, 
immunogenicity and clinical laboratory 
assessments and continuous pulse 
oximetry. 

Plasma concentrations of GSK2586881 
and derived pharmacokinetic 
parameters.
 
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Objectives
Endpoints
Exploratory 

To evaluate the effect of a single IV 
dose of GSK2586881 on ventilatory 
parameters in healthy volunteers during 
exercise in hypoxic conditions.

To evaluate the effect of a single IV 
dose of GSK2586881 on peptide 
hormone responses to hypoxia and 
exercise.

To evaluate the pharmacodynamic 
activity of a single IV dose of 
GSK2586881 in healthy volunteers 
during exercise in hypoxic conditions.

To evaluate Pharmacogenetics 

Change from baseline of oxygen 
consumption (VO2), carbon dioxide 
production (CO2) and other parameters
as data permit.

Baseline levels and changes in response
to hypoxia and exercise in kinins (e.g. 
des-Arg-bradykinin), apelins (e.g. 
Apelin 13, pyr1-Apelin, 13) and other 
systems (e.g. dynorphin A) as data 
permit.

Change from baseline in other  
biomarkers which may include Atrial 
Naturetic peptide (ANP), Brain 
Naturetic Peptide (NT-proBNP), 
Troponin I, Surfactant Protein D, IL-6 
and/or additional analytes to be 
determined.
Evaluate I/D polymorphisms in the 
Angiotensin Converting Enzyme 
(ACE) gene and analyse the impact on 
Ang II (and possibly other RAS 
peptides), hypoxic pulmonary 
vasoconstriction and responses to 
GSK2586881 administration.
 
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4.
STUDY DESIGN
4.1.
Overall Design
This is a single-centre, randomised, placebo-controlled  and double blind (sponsor open), 
two-period crossover study in healthy subjects. 
The subjects will be required to attend the unit for a screening visit, treatment period 1, 
treatment period 2 and a follow up visit.
4.2.
Treatment Arms and Duration
Figure 2
Subject participation flow
The subjects must participate in the procedures detailed in the Time and Events Table 
(Section 7.1) and the timings of the simulated altitude, exercise and echocardiograms is 
shown in Figure 3. 
 
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Figure 3
Approximate timing of simulated altitude and echocardiogram 
measurements (black arrows) during  Treatment Periods 1 and 2
There will be a washout period of 3-14 days between treatments to ensure biomarkers 
return to pre-challenge baseline. Subjects then return to the site and repeat the same 
procedures as above, except that they will receive the treatment (GSK2586881 or Saline) 
that they did not receive in the first period.
Follow Up
This will occur up to 10 days after the end of the second treatment period. During the 
visit various safety tests will be conducted (see time and events table in Section 7.1). 
The total study duration for each subject is expected to be a maximum of 56 days.
4.3.
Type and Number of Subjects
Approximately 35 subjects healthy volunteers will be randomised such that 
approximately 30 evaluable subjects complete the study (the target of 30 may be revised 
following the sample size re-estimation) see Section 9.2.2).
If subjects prematurely discontinue the study, additional replacement subjects will not be 
recruited in order to preserve randomisation integrity.
 
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4.4.
Design Justification
The study design is based on a paper published by Ricart, 2005 and is considered to be 
feasible. The study will provide important information on whether GSK2586881 
modulates the acute HPV response in healthy volunteers.  In addition, the study will 
include assessments of PK and PD effects of GSK2586881.  This will be achieved by 
assessing blood levels of GSK2586881 and RAS peptide responses throughout the 
duration of the hypoxia challenges.
The study will be placebo controlled (saline) so each subject can be used as their own 
control.
4.5.
Dose Justification
GSK2586881 has been studied in 21 healthy subjects as single, intravenous doses over 30 
minutes from 0.1 mg/kg to 1.2 mg/kg, and in repeated daily doses for up to six days of 
0.4 mg/kg once a day.  In addition, ARDS patients have received four doses of 
GSK2586881: 0.1 mg/kg, 0.2 mg.kg, 0.4 mg/kg and 0.8 mg/kg over a 24 hour period 
(n=5) or 0.4 mg/kg BID twice daily for 3 days (n=19). One subject with Pulmonary 
Arterial Hypertension (PAH) has received a single dose of 0.2 mg/kg.
A population PK model for GSK2586881 was derived from data obtained in healthy 
subjects and ARDS patients and showed that the systemic PK profile was adequately 
described by a two-compartment first order elimination model and that the PK profile 
was independent of population (health subjects or ARDS patients).  Furthermore the 
PKPD response (AngII) in healthy subjects and ARDS patients was consistent with a 
single direct Emax model after accounting for differences in baseline AngII 
concentrations between healthy subjects and ARDS patients.  
Based on the population PK/PD model described above, single intravenous doses of 0.4 -
1.2 mg/kg GSK2586881 are predicted to reduce elevated levels of AngII (baseline AngII 
consistent with an ARDS population) to levels consistent with that observed in healthy 
subjects for the duration of the hypoxic challenge (approx 2.25h). The dose of 0.8 mg/kg 
has been selected to ensure maximal reduction of AngII levels, whilst maintaining dosing 
volumes within acceptable limits, and will further aid the understanding of the PK/PD 
relationship for GSK2586881.
4.6.
Benefit:Risk Assessment
Summaries of findings from both clinical and non-clinical studies conducted with 
GSK2586881 can be found in the Investigator’s Brochure (GlaxoSmithKline Document 
Number 2010N108777_00, 2015).  The following section outlines the risk assessment 
and mitigation strategy for this protocol:  
 
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4.6.1.
Risk Assessment
Potential Risk of Clinical Significance
Summary of Data/Rationale for Risk
Mitigation Strategy
Investigational Product (IP) [GSK2586881]
Cardiovascular risk
Potential Reproductive/embryofetal risks
Potential for Immunogenicity
Potential for rash
During preclinical testing a brief period of 
non-sustained ventricular tachycardia was 
observed in one monkey receiving a dose of 
20.8 mg/kg/day.
Preclinical studies have not been performed
There has been no induction of an immune 
response to rhACE2 in either of the clinical 
studies to date in healthy subjects or 
participants with ARDS.
In study ACE114622, rash was reported 
more frequently in subjects receiving 
GSK2586881, although only one event was 
considered drug-related.
The dose used in this study is much 
lower.and well below the No observed 
adverse effect level (NOAEL) for the 14 
day repeat dose cynomolgus monkeys of 8 
mg/kg/day.  
Women of childbearing potential will be 
excluded from the study.
Patients will have routine monitoring of any 
immunological response that may occur.  If 
an immunological response is seen the 
patient will be asked to return for further 
monitoring and assessment(s).
Patients will be monitored for rash in the 
clinical trials.
 
 
 
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Potential Risk of Clinical Significance
Summary of Data/Rationale for Risk
Mitigation Strategy
Study Procedures
Effects of hypoxia (light headiness, 
headaches, nausea)
The subjects will be exposed to hypoxic 
conditions for approximately 90 minutes 
with a simulated altitude of 4000m 
The subjects will be continuously observed 
and monitored with telemetry and pulse 
oximetry. Stopping criteria are included in 
the protocol. 
 
 
 
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4.6.2.
Benefit Assessment
There will be no intended therapeutic clinical benefit to the subjects taking part in the 
study as it is a healthy volunteer study. However, subjects will undergo a medical 
evaluation during screening including physical exams, ECGs and laboratory assessments 
which may provide important health information. 
By taking part in this study the subject will be contributing to the development of 
GSK2586881 for the treatment of pulmonary hypertension and ARDS. 
4.6.3.
Overall Benefit:Risk Conclusion
The design of the study is considered low risk to the subjects and justified based on the 
work carried out by other researchers, the safety information from the nonclinical studies 
and the two previous clinical trials carried out on GSK2586881. 
5.
SELECTION OF STUDY POPULATION AND 
WITHDRAWAL CRITERIA
Specific information regarding warnings, precautions, contraindications, adverse events, 
and other pertinent information on the GSK investigational product or other study 
treatment that may impact subject eligibility is provided in the IB.
Deviations from inclusion and exclusion criteria are not allowed because they can 
potentially jeopardize the scientific integrity of the study, regulatory acceptability or 
subject safety. Therefore, adherence to the criteria as specified in the protocol is essential.
5.1.
Inclusion Criteria
A subject will be eligible for inclusion in this study only if all of the following criteria 
apply:
AGE
1. Between 18 and 40 years of age inclusive, at the time of signing the informed 
consent.
TYPE OF SUBJECT 
2. Healthy as determined by the investigator or medically qualified designee based on a 
medical evaluation including medical history, physical examination, laboratory tests 
and cardiac monitoring.
A subject with a clinical abnormality or laboratory parameter(s) which is/are not 
specifically listed in the inclusion or exclusion criteria, outside the reference range for 
the population being studied may be included only if the investigator [in consultation 
with the Medical Monitor if required] agree and document that the finding is unlikely 
to introduce additional risk factors and will not interfere with the study procedures. 
Note:  Screened subjects with laboratory values outside of the normal range may be 
 
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repeated once for inclusion into the study at the discretion of the Investigator.
3. Screening echocardiogram of good quality, without clinically significant 
abnormalities, and with mild-moderate tricuspid regurgitation sufficient for the 
reliable estimation of PASP, as determined by the echocardiography core laboratory 
or responsible cardiologist.
Screening PASP within the normal range according to site standards.
4. Subjects have not resided at an altitude >1500m for more than 7 days in the last  4 
month
5. Able to complete all study procedures.
6.
Any contraindication (orthopaedic, cardiac etc.) to perform exercise on a bicycle 
ergometer.
WEIGHT
7. Body weight 50-100 kg (inclusive).
SEX
8. Male or female (non CBP)
Male subjects with female partners of child bearing potential must comply with the 
following contraception requirements from the time of first dose of study medication 
until at least five half-lives of study medication OR for a cycle of spermatogenesis 
following five terminal half-lives after the last dose of study medication.
a. Vasectomy with documentation of azoospermia.  
b. Male condom plus partner use of one of the contraceptive options below:

Contraceptive subdermal implant 

Intrauterine device or intrauterine system 

Oral Contraceptive, either combined or progestogen alone [Hatcher, 2007a] 
Injectable progestogen [Hatcher, 2007a]

Contraceptive vaginal ring [Hatcher, 2007a]

Percutaneous contraceptive patches [Hatcher, 2007a]
This is an all-inclusive list of those methods that meet the following GSK definition of 
highly effective: having a failure rate of less than 1% per year when used consistently and 
correctly and, when applicable, in accordance with the product label. For non-product 
methods (e.g., male sterility), the investigator determines what is consistent and correct 
use. The GSK definition is based on the definition provided by the International 
Conference on Harmonization (ICH) [ICH, M3 (R2) 2009].”
 
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The investigator is responsible for ensuring that subjects understand how to properly use 
these methods of contraception.
This is an all inclusive list of those methods that meet the GSK definition of highly 
effective: having a failure rate of less than 1% per year when used consistently and, 
correctly and, when applicable, in accordance with the product label.  For non-product 
methods (e.g. male sterility), the investigator determines what is consistent and correct 
use. The GSK definition is based on the definition provided by ICH [ICH, M3 (R2) 
2009].
The investigator is responsible for ensuring that subjects understand how to properly use 
these methods of contraception.
Females: 
A female subject is eligible to participate if she is not pregnant (as confirmed by a 
negative urine human chorionic gonadotrophin (hCG) test), not lactating, and the 
following condition applies:
Non-reproductive potential defined as:
Pre-menopausal females with one of the following:
Documented tubal ligation
Documented hysteroscopic tubal occlusion procedure with follow-up 
confirmation of bilateral tubal occlusion 
Hysterectomy
Documented Bilateral Oophorectomy
Postmenopausal defined as 12 months of spontaneous amenorrhea [in 
questionable cases a blood sample with simultaneous follicle stimulating 
hormone (FSH) and estradiol levels consistent with menopause (refer to 
laboratory reference ranges for confirmatory levels)].  Females on hormone 
replacement therapy (HRT) and whose menopausal status is in doubt will be 
required to use one of the highly effective contraception methods if they wish to 
continue their HRT during the study.  Otherwise, they must discontinue HRT to 
allow confirmation of post-menopausal status prior to study enrolment.
The investigator is responsible for ensuring that subjects understand how to properly use 
these methods of contraception.
INFORMED CONSENT
9. Capable of giving signed informed consent as described in Section 7.2 which includes 
compliance with the requirements and restrictions listed in the consent form and in 
this protocol.
 
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5.2.
Exclusion Criteria
A subject will not be eligible for inclusion in this study if any of the following criteria 
apply:
CONCURRENT CONDITIONS/MEDICAL HISTORY (INCLUDES LIVER 
FUNCTION AND QTc INTERVAL) 
1. ALT >1.5x Upper limit of normal (ULN).
2. Bilirubin >1.5xULN (isolated bilirubin >1.5xULN is acceptable if bilirubin is 
fractionated and direct bilirubin <35%).
3. Current or chronic history of liver disease, or known hepatic or biliary abnormalities 
(with the exception of Gilbert's syndrome or asymptomatic gallstones).
4. Prior history of altitude sickness.
5. Recently been scuba diving (within 1 week before screening).
6. QTc > 450 msec
NOTES:

The QTc is the QT interval corrected for heart rate according to Bazett’s 
formula (QTcB), Fridericia’s formula (QTcF), and/or another method, machine-
read or manually over-read.

The specific formula that will be used to determine eligibility and 
discontinuation for an individual subject should be determined prior to initiation 
of the study. In other words, several different formulae cannot be used to 
calculate the QTc for an individual subject and then the lowest QTc value used 
to include or discontinue the subject from the trial.

For purposes of data analysis, QTcB, QTcF, another QT correction formula, or a 
composite of available values of QTc will be used as specified in the Reporting 
and Analysis Plan (RAP).
CONCOMITANT MEDICATIONS
7.
Unable to refrain from prescription or non-prescription drugs, including agents active 
in the central nervous system, vitamins, herbal and dietary supplements (including St 
John’s Wort) within 7 days (or 14 days if the drug is a potential enzyme inducer) or 5 
half-lives (whichever is longer) prior to the first dose of study medication and 
throughout the study, unless in the opinion of the Investigator and/or GSK Medical 
Monitor (if needed) the medication will not interfere with the study procedures or 
compromise subject safety.
 
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RELEVANT HABITS
8.
History of regular alcohol consumption within 6 months of the study defined as:

An average weekly intake of >21 units for males or >14 units for females. 
One unit is equivalent to 8 g of alcohol: a half-pint (~240 ml) of beer, 1 glass 
(125 ml) of wine or 1 (25 ml) measure of spirits
9.
Urinary cotinine levels indicative of smoking or history or regular use of tobacco- or 
nicotine-containing products within 6 months prior to screening
CONTRAINDICATIONS 
10. History of sensitivity to any of the study medications, or components thereof or a 
history of drug or other allergy that, in the opinion of the investigator or Medical 
Monitor, contraindicates their participation.
DIAGNOSTIC ASSESSMENTS AND OTHER CRITERIA
11. Presence of hepatitis B surface antigen (HBsAg), positive hepatitis C antibody test
result at screening or within 3 months prior to first dose of study treatment. For 
potent immunosuppressive agents, subjects with presence of hepatitis B core 
antibody (HBcAb) should also be excluded.
12. A positive pre-study drug/alcohol screen.
13. A positive test for HIV antibody.
14. Where participation in the study would result in donation of blood or blood products
in excess of 500 ml within 56 days.
15. The subject has participated in a clinical trial and has received an investigational
product within the following time period prior to the first dosing day in the current
study: 30 days, 5 half-lives or twice the duration of the biological effect of the
investigational product (whichever is longer).
16. Exposure to more than four new chemical entities within 12 months prior to the first 
dosing day.
 
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5.3.
Screening/Baseline/Run-in Failures
Screen failures are defined as subjects who consent to participate in the clinical trial but 
are never subsequently randomised. In order to ensure transparent reporting of screen 
failure subjects, meet the Consolidated Standards of Reporting Trials (CONSORT) 
publishing requirements, and respond to queries from Regulatory authorities, a minimal 
set of screen failure information is required including Demography, Screen Failure 
details, Eligibility Criteria, and Serious Adverse Events (Section 7.2.1.4).
Subjects that are not enrolled into the study within the allotted screening window may be 
re-screened once. If re-screening is performed, subjects are assigned a different unique 
subject Identification (ID) number for the re-screening, and all screening procedures must 
be repeated.
See the SRM for specific details.
5.4.
Withdrawal/Stopping Criteria
Subjects may be withdrawn from the study for any of the following reasons:A subject 
may withdraw from study treatment at any time at his/her own request, or may be 
withdrawn at any time at the discretion of the investigator for safety, behavioural or 
administrative reasons. If a subject withdraws from the study, he/she may request 
destruction of any samples taken, and the investigator must document this in the site 
study records. 

If a subjects oxygen saturation falls below 65% at any point during the hypoxia 
challenge. 

If the subject experiences worsening shortness of breath or other symptoms, 
which in the opinion of the investigator are consistent with altitude sickness.

The Sponsor may request a subject withdraw for reasons such as significant 
protocol deviations (after discussion with the investigator).

Study is terminated by the Sponsor.
A subject will be considered to have prematurely withdrawn from the investigational 
product if they do not complete all doses in the treatment phase having received the first 
dose of investigational product, for any reason.
Once a subject has discontinued investigational product the subject may not re-enter the 
study. Dosing of the subjects with the investigational product may be stopped at any time, 
at the request of the subject or at the discretion of the Investigator (i.e. if clinically 
significant adverse events should occur). Withdrawal due to adverse events will be 
distinguished from withdrawal for other reasons.
If a subject decides to withdraw or is withdrawn by the Investigator, the reasons for 
withdrawal and the results of any relevant tests will be recorded in the Case Report Form 
(CRF) and the planned follow-up procedures will be performed, where possible.
 
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The following actions must be taken in relation to a subject who fails to attend the clinic 
for a required study visit:

The site must attempt to contact the subject and re-schedule the missed visit as 
soon as possible. 

The site must counsel the subject on the importance of maintaining the assigned 
visit schedule and ascertain whether or not the subject wishes to and/or should 
continue in the study. 

In cases where the subject is deemed ‘lost to follow up’, the investigator or 
designee must make every effort to regain contact with the subject (where 
possible, 3 telephone calls and if necessary a certified letter to the subject’s last 
known mailing address or local equivalent methods). These contact attempts 
should be documented in the subject’s medical record. 

Should the subject continue to be unreachable, only then will he/she be considered 
to have withdrawn from the study with a primary reason of “Lost to Follow-up”.
5.4.1.
Study Stopping Criteria
An interim analysis is planned after approximately 15 subjects have completed treatment 
periods 1 and 2 and the study may be stopped if a reasonable change in PASP is not 
observed after dosing with GSK 2586881 or if review of the safety data suggests a 
change in the benefit-risk profile. The decision to stop the study will be made by the core 
members of the GSK study team.
Safety data that is collected on a continuous basis (oxygen saturation  and telemetry) will 
be monitored live on site to determine whether a subject tolerates the hypoxia/exercise 
challenge; study procedures may be aborted on safety grounds if, in the Investigator's 
opinion, any of these measurements reach unsafe levels. The simulated altitude within the 
chamber may be reduced if too many participants fail to tolerate the challenge, and the 
study may be stopped if participants fail to tolerate the challenge at the minimum altitude. 
The full criteria for this procedure (which may lead to the study being stopped) are 
described in Section 7.3.
In addition, the study may be stopped at the interim analysis for a safety signal in oxygen 
saturation under hypoxia and exercise, combined with a lack of evidence of mechanistic 
effect on Angiotensin biomarkers (Ang II, Ang 1-7 and Ang 1-5). Full details on stopping 
criteria are described together with the full procedure for the interim analysis in Section 
9.3.2.
5.4.2.
Liver Chemistry Stopping Criteria
Liver chemistry stopping and increased monitoring criteria have been designed to 
assure subject safety and evaluate liver event etiology (in alignment with the Food and 
Drug Administration (FDA) premarketing clinical liver safety guidance). 
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guid
ances/UCM174090.pdf
 
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Study treatment will be discontinued for a subject if liver chemistry stopping criteria are
met.
Phase I Liver Chemistry Stopping Criteria – Liver Stopping Event Algorithm
Continue Study Treatment 
Discontinue Study Treatment 
*INR value not applicable to subjects on anticoagulants 
ALT ≥3xULN 
No
Yes
Must refer to Liver Safety Required Actions and Follow up Assessments  section in the Appendix
Report as an SAE if possible Hy’s Law case: ALT≥3xULN and  Bilirubin≥2xULN (>35% direct)  or 
INR>1.5, if measured*
Liver Safety Required Actions and Follow up Assessments Section can be found in
Appendix 2.
5.4.2.1.
Study Treatment Restart or Rechallenge
Study treatment restart or rechallenge after liver chemistry stopping criteria are met by 
any subject participating in this study is not allowed.
5.5.
Subject and Study Completion
A completed subject is one who has completed all phases of the study including the 
follow-up visit.
The end of the study is defined as the last subjects last visit.
6.
STUDY TREATMENT
6.1.
Investigational Product and Other Study Treatment
The term ‘study treatment’ is used throughout the protocol to describe any combination 
of products received by the subject as per the protocol design. Study treatment may 
therefore refer to the individual study treatments or the combination of those study 
treatments.
 
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Study Treatment
Product name:
(Generic name and trade)
GSK2586881
Placebo
[Formulation description:]
rhACE2
Normal Saline (0.9%)
Dosage form:
IV
IV
Unit dose strength(s)/Dosage 
level(s):
0.8 mg/kg
Saline Placebo
Route of Administration E.g. oral, 
for IV infusion, for IV injection, 
intravitreal use etc
Intravenous
Intravenous
Dosing instructions:
Infuse over 3-5 minutes
Infuse over 3-5 minutes
[Physical description:]
Clear colourless liquid 
Clear colourless liquid
At Screening a unique Subject Number (CRF number) will be assigned to any subject 
who has at least one Screening procedure performed, other than informed consent. The 
unique Subject Number will be used to identify individual subjects during the course of 
the study.
Subjects who meet screening eligibility criteria will be assigned to one of the sequences 
listed in Table 1 below, in accordance with the randomisation schedule generated by 
Clinical Statistics, prior to the start of the study, using validated internal software. Once 
assigned, this number must not be reassigned to any other subject in the study.
Table 1
Description of sequences
Sequence
Period 1 
Period 2
AB
GSK2586881
Saline Placebo
BA
Saline Placebo
GSK2586881
The subjects will be randomised using a central randomisation procedure created by 
GSK. 
Further details on how and when a subject is allocated a randomisation number and the 
subject numbering convention is in the SRM
6.2.
Planned Dose Adjustments
No dose adjustments are allowed.
 
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6.3.
Blinding
This will be double blind (sponsor open) study. All study staff involved in clinical 
assessments (which includes the investigator, sub-investigators, other site staff), and the 
subject will be blinded to the treatment allocated to individual subjects. An unblinded 
qualified staff member will be required at site to prepare the study treatment for dosing. 
The unblindedstaff member is not permitted to communicate the subject’s treatment 
allocation to blinded site staff. Selected study team members working for the sponsor 
(and delegates if programming activities are outsourced) will be unblinded to perform the 
interim analysis. This will include the medical monitor, study statistician, study 
programmer (and delegates) and study pharmacokineticist. Access to unblinded data will 
be kept to the minimum set of individuals required to implement any interim analyses but 
may include GSK management/review committees if alterations to the study conduct are 
required. Details of who were unblinded to what data and when will be included in the 
clinical study report.
The following will apply: 

The investigator or treating physician may unblind a subject’s treatment 
assignment only in the case of an emergency OR in the event of a serious 
medical condition when knowledge of the study treatment is essential for the 
appropriate clinical management or welfare of the subject as judged by the 
investigator. 

Investigators have direct access to the subject’s individual study treatment. 

It is preferred (but not required) that the investigator first contacts the Medical 
Monitor or appropriate GSK study personnel to discuss options before unblinding 
the subject’s treatment assignment. 

If GSK personnel are not contacted before the unblinding, the investigator must 
notify GSK as soon as possible after unblinding, but without revealing the 
treatment assignment of the unblinded subject, unless that information is 
important for the safety of subjects currently in the study. 

The date and reason for the unblinding must be fully documented in the  CRF 
A subject whose treatment sequence assignment is unblinded for emergency reasons (as 
described above) will not be permitted to continue in the study (due to the emergency 
requiring unblinding rather than the unblinding itself). The event or condition that led to 
the unblinding will be recorded in the CRF as the primary reason for discontinuation.
A subject whose treatment sequence assignment is inadvertently unblinded (either to 
investigative staff or the subject themselves) will be permitted to remain in the study, 
although the accidental unblinding will be recorded as a protocol deviation and hence the 
subject will be subject to review as to their inclusion in analyses as per the procedures set 
out in Section 9.3.1.
 
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6.4.
Packaging and Labeling
The contents of the label will be in accordance with all applicable regulatory 
requirements.
6.5.
Preparation/Handling/Storage/Accountability
A description of the methods and materials required for GSK2586881 will be detailed in 
a Study Specific Technical Agreement/Memo (TTS) or Pharmacy Manual which will be 
accompanied by a Quality Agreement.

The investigator or designee must confirm appropriate temperature conditions 
have been maintained during transit for all study treatment received and any 
discrepancies are reported and resolved before use of the study treatment.

Only subjects enrolled in the study may receive study treatment and only 
authorized site staff may supply or administer study treatment.  All study 
treatments must be stored in a secure environmentally controlled and monitored 
(manual or automated) area in accordance with the labelled storage conditions 
with access limited to the investigator and authorized site staff. 

The investigator, institution, or the head of the medical institution (where 
applicable) is responsible for study treatment accountability, reconciliation, and 
record maintenance (i.e. receipt, reconciliation and final disposition records).  

Further guidance and information for final disposition of unused study treatment 
are provided in the Study Reference Manual (SRM). 

Under normal conditions of handling and administration, study treatment is not 
expected to pose significant safety risks to site staff.  Take adequate precautions to 
avoid direct eye or skin contact and the generation of aerosols or mists. In the case 
of unintentional occupational exposure notify the monitor, Medical Monitor 
and/or GSK study contact.

A Material Safety Data Sheet (MSDS)/equivalent document describing 
occupational hazards and recommended handling precautions either will be 
provided to the investigator, where this is required by local laws, or is available 
upon request from GSK.
6.6.
Compliance with Study Treatment Administration
When the individual dose for a subject is prepared from a bulk supply, the preparation of 
the dose will be confirmed by a second member of the study site staff. 
When subjects are dosed at the site, they will receive study treatment directly from the 
investigator or designee, under medical supervision.  The date and time of each dose 
administered in the clinic will be recorded in the source documents.  The dose of study 
treatment and study subject identification will be confirmed at the time of dosing by a 
member of the study site staff other than the person administering the study treatment.  
 
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GSK2586881 and the saline placebo will be intravenously administered to subjects at the 
site.  Administration will be documented in the source documents and reported in the 
CRF.
6.7.
Treatment of Study Treatment Overdose
For this study, any dose of GSK2586881 > 1.5 mg/kg within a 24 hour time period 
will be considered an overdose.
GSK does not recommend specific treatment for an overdose. The investigator will use 
clinical judgment to treat any overdose.
In the event of an overdose the investigator or treating physician should:
1.
contact the Medical Monitor immediately
2.
closely monitor the subject for adverse events (AEs)/serious adverse events (SAEs) 
and laboratory abnormalities until GSK2586881can no longer be detected 
systemically (at least 3 days for GSK2586881).
3.
obtain a plasma sample for pharmacokinetic (PK) analysis within 1 day from the date 
of the last dose of study treatment if requested by the Medical Monitor (determined 
on a case-by-case basis)
4.
document the quantity of the excess dose as well as the duration of the overdosing in 
the CRF.
Decisions regarding dose interruptions or modifications will be made by the investigator 
in consultation with the Medical Monitor based on the clinical evaluation of the subject.
6.8.
Treatment after the End of the Study
Subjects will not receive any additional treatment from GSK after completion of the 
study because only healthy volunteers are eligible for study participation.
6.8.1.
Meals and Dietary Restrictions

No dietary restrictions prior to first treatment.
6.8.2.
Caffeine, Alcohol, and Tobacco

During each dosing session, subjects will abstain from caffeine for 12 hours prior to 
the start of dosing until collection of the final pharmacokinetic and or 
pharmacodynamic sample during each session. 

During each dosing session, subjects will abstain from alcohol for 12 hours prior to 
the start of dosing until collection of the final pharmacokinetic and or 
pharmacodynamic sample during each session. 

Use of tobacco products is not allowed as outlined in the exclusion criteria. 
 
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6.8.3.
Activity
Subjects will abstain from strenuous exercise for 24 hours prior to screening and each 
treatment period  Subjects may participate in light recreational activities between the 
planned study procedures (e.g., watch television, read).
6.9.
Concomitant Medications and Non-Drug Therapies
6.9.1.
Permitted Medications and Non-Drug Therapies
Paracetamol, at doses of 2 grams/day is permitted for use any time during the study. 
Other concomitant medication may be considered on a case by case basis by the 
investigator in consultation with the Medical Monitor if required.
6.9.2.
Prohibited Medications and Non-Drug Therapies
Subjects must abstain from taking prescription or non-prescription drugs (including 
vitamins and dietary or herbal supplements), within 7 days (or 14 days if the drug is a 
potential enzyme inducer) or 5 half-lives (whichever is longer) prior to the first dose of 
study medication until completion of the follow-up visit, unless in the opinion of the 
Investigator and sponsor the medication will not interfere with the study.
 
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7.
STUDY ASSESSMENTS AND PROCEDURES
Protocol waivers or exemptions are not allowed with the exception of immediate safety 
concerns. Therefore, adherence to the study design requirements, including those 
specified in the Time and Events Table, are essential and required for study conduct.
This section lists the procedures and parameters of each planned study assessment.  The 
exact timing of each assessment is listed in the Time and Events Table Section 7.1
The following points must be noted: 

If assessments are scheduled for the same nominal time, THEN the assessments 
should occur in the following order:
1. Echocardiograms
2. 12-lead ECG
3. vital signs
4. blood draws  
Note: The timing of the assessments should allow the blood draw to occur at the 
exact nominal time.

The timing and number of planned study assessments, including: safety,
echocardiogram, pharmacokinetic, pharmacodynamic/biomarker or other 
assessments may be altered during the course of the study based on newly 
available data (e.g., to obtain data closer to the time of peak plasma 
concentrations) to ensure appropriate monitoring. 

The change in timing or addition of time points for any planned study 
assessments must be documented in a Note to File which is approved by the
relevant GSK study team member and then archived in the study sponsor and 
site study files, but this will not constitute a protocol amendment. 

The Institutional Review Board (IRB)/IEC will be informed of any safety issues 
that require alteration of the safety monitoring scheme or amendment of the 
Informed Consent Form. 

No more than 500 mL of blood will be collected over the duration of the study, 
including any extra assessments that may be required.
 
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7.1.
Time and Events Table
7.1.1.
Screening and Follow up
Procedure 
Screening1
(up to 28 days prior to 
Treatment Period 1, Day 
1)
Follow up
(7- 10 days 
post lastdose)
Notes
Informed consent
X
Inclusion and exclusion criteria
X
Demography
X
Full physical exam including height and 
weight
X
X
Weight at screening will be used for dosing calculation.
Alcohol, DoA , Smoking test
X
Medical history (includes substance usage  
[and family history of premature CV disease])
X
Substances: [Drugs, Alcohol, tobacco]
Past and current medical conditions  
[including cardiovascular medical history]
X
[Serum OR urine] pregnancy test ( WCBP)
X
HIV, Hep B and Hep C screen
X
Laboratory assessments (include liver 
chemistries 
X
X
Non Fasting 
Immunogenicity
X
X
12-lead ECG)
X
X
Triplicate ECG required at screening.
Vital signs)
X
X
Triplicate vital signs required at screening. 
Echocardiogram
X
Concomitant Medication review 
X
X
Hypoxia chamber plus exercise 
X
Tolerance to 4000m for 10 mins followed by followed by incremental exercise 
testing to determine  maximum oxygen uptake (VO2max) and calculate 70% of 
VO2max for the exercise challenge d 
Pharmacogenetic sample (PGx)
X
Can be taken any time after consent has been signed. Only required once and is 
optional. 
AE/SAE review
X
X
As per timings detailed in Section 7.2.1.1
1.
Screening assessments are allowed to be conducted on more than one day
 
 
 
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7.1.2.
Treatment Period 1 and 2
Procedure
Treatment Period 1 and 2 (Washout 3-14 days)
Notes
Times relative to 
dosing
Hypoxia (Times relative to 
entry to Chamber)
Predose
0h
15 m 
15-45m
0-60m
60m
60-70m
Immediately after 
exercise
30m rest on exit 
from chamber
After 30 mins 
rest
60 minutes after 
exit from 
Chamber 
Randomisation
X
Randomisation can occur up to the day before 
the first treatment period
Brief physical exam 
X
Vital signs
X
X
X
X
Immunogenicity
X
Treatment period 2 only 
12-lead ECG
X
X
X
Echocardiogram
X
X
X
X
X
Echo duration approx 5 mins
Subject enters chamber
X
Subject enters chamber approximately 30 
minutes after study treatment
Study Treatment (Dosing) 
X
Subject leaves chamber
X
Subject leaves chamber after the fourth 
echocardiogram and vital signs have been taken.
Exercise challenge
X
For approx 5-10 minutes
Ventilatory parameters
X
X
X
X1
X
Measurements to be taken at the same time as 
the Echocardiograms. During the exercise 
challenge, an ECG integrated with the ventilatory 
assessment will be carried out. 
Pulse Oximetry
(O2 saturation)
------------------------------------------------------------------------------------------------
Will be continuously monitored for safety. 
Measurement should be recorded at time of each 
echocardiogram post-treatment and databased.
RAS Biomarkers
X
X2
X3
X4
X3
X3
X5
X3
Other Biomarkers
X
X2
X3
X4
X3
X3
X5
X3
PK sampling
X
X2
X3
X4
X3
X3
X5
X3
 
 
 
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Procedure
Treatment Period 1 and 2 (Washout 3-14 days)
Notes
Times relative to 
dosing
Hypoxia (Times relative to 
entry to Chamber)
Predose
0h
15 m 
15-45m
0-60m
60m
60-70m
Immediately after 
exercise
30m rest on exit 
from chamber
After 30 mins 
rest
60 minutes after 
exit from 
Chamber 
AE/SAE review
============================================================
Concomitant medication review
X
1.
To be taken at the end of exercise 
2.
Take at the end of the infusion
3.
Taken immediately after echocardiogram 
4.
Immediately before entering the chamber
5.
To be taken as soon as possible after leaving chamber
 
 
 
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After written informed consent, screening assessments will be performed as outlined in 
the Time and Events Table (Section 7.1).
The following demographic parameters will be captured: year of birth, sex, race and 
ethnicity.
Medical/medication/family history will be assessed as related to the inclusion/exclusion 
criteria listed in Section 5.
Cardiovascular medical history/risk factors (as detailed in the CRF) will be assessed at 
screening.
Cardiorespiratory fitness during bicycle exercise and hypoxia tolerance will be assessed.
Procedures conducted as part of the subject’s routine clinical management (e.g. blood 
count) and obtained prior to signing of informed consent may be utilized for Screening or 
baseline purposes provided the procedure meets the protocol-defined criteria and has 
been performed in the timeframe of the study.
7.2.
Safety
Planned time points for all safety assessments are listed in the Time and Events Table 
(Section 7.1).  Additional time points for safety tests such as vital signs, physical exams 
and laboratory safety tests may be added during the course of the study based on newly 
available data to ensure appropriate safety monitoring.
7.2.1.
Adverse Events (AE) and Serious Adverse Events (SAEs)
The definitions of an AE or SAE can be found in Appendix 4.
The investigator and their designees are responsible for detecting, documenting and 
reporting events that meet the definition of an AE or SAE. 
7.2.1.1.
Time period and Frequency for collecting AE and SAE information

Any SAEs assessed as related to study participation (e.g., protocol-mandated 
procedures, invasive tests, or change in existing therapy) or related to a GSK 
product will be recorded from the time a subject consents to participate in the 
study up to and including any follow-up contact. 

AEs will be collected from the start of Study Treatment until the follow-up 
contact (see Section 7.2.1.3), at the timepoints specified in the Time and Events 
Table (Section 7.1).

Medical occurrences that begin prior to the start of study treatment but after 
obtaining informed consent may be recorded on the Medical History/Current 
Medical Conditions section of the CRF.

All SAEs will be recorded and reported to GSK within 24 hours, as indicated in 
Appendix 4.
 
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
Investigators are not obligated to actively seek AEs or SAEs in former study 
subjects. However, if the investigator learns of any SAE, including a death, at any 
time after a subject has been discharged from the study, and he/she considers the 
event reasonably related to the study treatment or study participation, the 
investigator must promptly notify GSK.
NOTE: The method of recording, evaluating and assessing causality of AEs and SAEs 
plus procedures for completing and transmitting SAE reports to GSK are provided in 
Appendix 4
7.2.1.2.
Method of Detecting AEs and SAEs
Care will be taken not to introduce bias when detecting AEs and/or SAEs. Open-ended 
and non-leading verbal questioning of the subject is the preferred method to inquire about 
AE occurrence.  Appropriate questions include:

“How are you feeling?” 

“Have you had any (other) medical problems since your last visit/contact?” 

“Have you taken any new medicines, other than those provided in this study, since 
your last visit/contact?” 
7.2.1.3.
Follow-up of AEs and SAEs
After the initial AE/SAE report, the investigator is required to proactively follow each 
subject at subsequent visits/contacts.  All SAEs, and non-serious AEs of special interest 
(as defined in Section 4.6.1) will be followed until resolution, until the condition 
stabilizes, until the event is otherwise explained, or until the subject is lost to follow-up 
(as defined in Section 5.4). Further information on follow-up procedures is given in 
Appendix 4.
7.2.1.4.
Regulatory Reporting Requirements for SAEs
Prompt notification by the investigator to GSK of SAEs related to study treatment (even 
for non- interventional post-marketing studies) is essential so that legal obligations and 
ethical responsibilities towards the safety of subjects and the safety of a product under 
clinical investigation are met. 
GSK has a legal responsibility to notify both the local regulatory authority and other 
regulatory agencies about the safety of a product under clinical investigation.  GSK will 
comply with country specific regulatory requirements relating to safety reporting to the 
regulatory authority, Institutional Review Board (IRB)/Independent Ethics Committee 
(IEC) and investigators.
Investigator safety reports are prepared for suspected unexpected serious adverse 
reactions according to local regulatory requirements and GSK policy and are forwarded 
to investigators as necessary.
 
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An investigator who receives an investigator safety report describing a SAE(s) or other 
specific safety information (e.g., summary or listing of SAEs) from GSK will file it with 
the IB and will notify the IRB/IEC, if appropriate according to local requirements.
7.2.2.
Physical Exams

A complete physical examination will include, at a minimum, assessment of the 
Cardiovascular, Respiratory, Gastrointestinal and Neurological systems. Height 
and weight will also be measured and recorded. This will be carried out at 
screening and follow up. 

A brief physical examination will include, at a minimum assessments of the skin,
lungs, cardiovascular system, and abdomen (liver and spleen). To be carried out at 
the start of each period. 

Investigators should pay special attention to clinical signs related to previous 
serious illnesses.
7.2.3.
Vital Signs

Vital signs will be measured in semi-supine position after 5 minutes rest and will 
include temperature, systolic and diastolic blood pressure and pulse rate. Three 
readings of blood pressure and pulse rate will be taken. 

First reading should be rejected.

Second and third readings should be averaged to give the measurement to be 
recorded in the CRF. (Triplicate measurements will only be taken at screening and 
single measurements to be taken after that).
7.2.4.
Electrocardiogram (ECG)

Triplicate 12-lead ECGs will be obtained at screening. At all other time-points a 
single 12-lead ECGs will be obtained at each time point during the study using an 
ECG machine that automatically calculates the heart rate and measures PR, QRS, 
QT, and QTc intervals.  Refer to Section 7.2.5 for QTc withdrawal criteria and 
additional QTc readings that may be necessary.

ECG to be measured in a semi-supine position after 5 minutes rest.
7.2.5.
QTc Stopping Criteria

The same QT correction formula must be used for each individual subject to 
determine eligibility for and discontinuation from the study.  This formula may 
not be changed or substituted once the subject has been enrolled.

For example, if a subject is eligible for the protocol based on QTcB, then QTcB 
must be used for discontinuation of this individual subject as well.

Once the QT correction formula has been chosen for a subject’s eligibility, the 
same formula must continue to be used for that subject for all QTc data being 
collected for data analysis.  Safety ECGs and other non-protocol specified 
ECGs are an exception.  
 
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
The QTc should be based on single or averaged QTc values of triplicate 
electrocardiograms obtained over a brief (e.g., 5-10 minute) recording period
A subject that meets either bulleted criterion below will be withdrawn from the study.

QTcB or QTcF > 500 msec,

Change from baseline: QTc >60 msec
7.2.6.
Clinical Safety Laboratory Assessments
All protocol required laboratory assessments, as defined in Table 2, must be conducted in 
accordance with the Protocol Time and Events Schedule. Laboratory requisition forms 
must be completed and samples must be clearly labelled with the subject number, 
protocol number, site/centre number, and visit date. Details for the preparation and 
shipment of samples will be provided by the laboratory and are detailed in the laboratory 
manual. Reference ranges for all safety parameters will be provided to the site by the 
laboratory responsible for the assessments.
If additional non-protocol specified laboratory assessments are performed at the 
institution’s local laboratory and result in a change in subject management or are 
considered clinically significant by the investigator (e.g., SAE or AE or dose 
modification) the results must be recorded in the CRF.
Refer to the SRM for appropriate processing and handling of samples to avoid duplicate 
and/or additional blood draws.
Haematology, clinical chemistry, urinalysis and additional parameters to be tested are 
listed in Table 2. 
 
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Table 2
Protocol Required Safety Laboratory Assessments
Laboratory 
Assessments
Parameters
Haematology
Platelet Count
RBC Indices:
WBC count with Differential:
RBC Count
MCV
Neutrophils
Hemoglobin
MCH
Lymphocytes
Hematocrit
Monocytes
Eosinophils
Basophils
Clinical 
Chemistry 1
BUN
Potassium
AST (SGOT)
Total and direct 
bilirubin
Creatinine
Sodium
ALT (SGPT)
Total Protein
Glucose 
Calcium
Alkaline phosphatise
Albumin
Routine 
Urinalysis

Specific gravity

pH, glucose, protein, blood and ketones by dipstick

Microscopic examination (if blood or protein is abnormal)
Other 
Screening 
Tests

HIV

Hepatitis B (HBsAg)

Hepatitis C (Hep C antibody)

Alcohol, smoking and drug screen (to include at minimum: 
amphetamines, barbiturates, cocaine, opiates, cannabinoids, 
benzodiazepines and cotinine) performed at site

Urine hCG Pregnancy test (as needed) 2
NOTES :
1.
Details of Liver Chemistry Stopping Criteria and Required Actions and Follow-Up 
Assessments after liver stopping or monitoring event are given in Section 5.4.2 and 
Appendix 2.
2.
Local urine testing will be standard for the protocol unless serum testing is required 
by local regulation or ethics committee.
All laboratory tests with values that are considered clinically significantly abnormal 
during participation in the study or within 3 days after the last dose of study treatment 
should be repeated until the values return to normal or baseline.  If such values do not 
return to normal within a period judged reasonable by the investigator, the etiology
should be identified and the sponsor notified.
7.3.
Hypoxia Challenge
Each subject will be inside the hypoxia chamber for approximately 80 minutes per 
period, during which time they will be under the full 4000m ± 10%. hypoxic conditions 
 
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If three or more subjects do not tolerate the hypoxic challenge, either due to symptoms or 
O2 saturation of <65%, then the simulated altitude will be adjusted in decrements of 
500m (i.e. from 4000m to 3500m) for all remaining subjects to a minimum of 3000m.
Further details about the hypoxia challenge is detailed in the SRM. 
7.3.1.
Exercise Challenge
Subjects will perform an exercise challenge at 70% of maximum VO2 uptake on a cycle 
ergometer within the hypoxia chamber for 10 minutes as detailed in the SRM.
Subjects must complete a minimum of 5 minutes exercises at 70% of maximummax 
maxVO2 uptake.
Further details about the exercise challenge is detailed in the SRM. 
7.4.
Echocardiogram
Echocardiograms will be taken as detailed in the Time and Events table (Section 7.1). 
Echocardiograms will be obtained with the subject resting supine or lying on their left 
side. 
PASP will be measured and recorded.
PASP will be determined by measuring maximal tricuspid regurgitation velocity and 
applying the modified Bernoulli equation to convert this value into pressure values. 
Estimated right atrial pressure (RAP) must be added to this obtained value.
Further details about the PASP measurement is detailed in the SRM. 
Additional echocardiograms may be obtained for each subject as needed (in the 
judgement of the Investigator and GSK Medical Monitor if required.
Further details can be found in the SRM.  
7.5.
Ventilatory parameters
Ventilatory parameters will be measured as detailed in the Time and Events table 
(Section 7.1). 
Measurements may include change from baseline of oxygen consumption (VO2), carbon 
dioxide production (CO2) and other parameters as data permit
Further details can be found in the SRM.  
 
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7.6.
Pulse Oximetry
Oxygen saturation will be monitored continuously via pulse oximetry as detailed in the 
SRM. Measurements to be taken at the same time as the echocardiograms and recorded in 
the eCRF. 
7.7.
Pharmacokinetics
7.7.1.
Blood Sample Collection
Blood samples for pharmacokinetic (PK) analysis of GSK2586881 will be collected at 
the time points indicated in the Time and Events Table (Section 7.1).  The actual date and 
time of each blood sample collection will be recorded.  
The timing of PK samples may be altered and/or PK samples may be obtained at 
additional time points to ensure thorough PK monitoring.  
Details of PK blood sample collection (including volume to be collected), processing, 
storage and shipping procedures are provided in the SRM.
7.7.2.
Sample Analysis
Plasma analysis will be performed under the control of PTS, In Vitro/In Vivo 
Translations (IVIVT) Department and Third Party Resourcing (TPR), GlaxoSmithKline. 
The details of the Bioanalytical Laboratory will be included in the Study Reference 
Manual (SRM). Concentrations of GSK2586881 will be determined in plasma samples 
using the currently approved bioanalytical methodology. Raw data will archived at the 
Bioanalytical Site (to be detailed in the SRM).
7.8.
Biomarker(s)/Pharmacodynamic Markers
Blood samples for biomarker/PD analysis will be collected at the time points indicated in,
the Time and Events Table (Section 7.1).  The actual date and time of each blood sample 
collection will be recorded.  The timing of biomarker/PD samples may be altered and/or 
samples may be obtained at additional time points to ensure thorough monitoring.  
Details of biomarker/PD blood sample collection (including volume to be collected), 
processing, storage and shipping procedures are provided in the SRM.
7.8.1.
Renin-angiotensin system biomarkers
RAS peptides including but not limited to AngII, Ang(1-7) and Ang(1-5) may be 
analysed as data permit. 
7.8.2.
Other Biomarkers
Peptide hormones such as Kinins (e.g. des-Arg-bradykinin), apelins (e.g. Apelin 13, 
pyr1-Apelin, 13) and other systems (e.g. dynorphin A) may be analysed as data permit.
 
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Atrial Naturetic peptide (ANP), Brain Naturetic Peptide (NT-proBNP), Troponin I, 
Surfactant Protein D, IL-6 and/or additional analytes to be determined may also be 
analysed as data permit.
7.9.
Genetics
Information regarding genetic research is included in Appendix 3.
Genetic sampling is optional. Subjects can refuse PGx sampling but will still be allowed 
to participate in the study. 
7.9.1.
Blood sample collection
Blood samples to investigate the association between the loss of function polymorphism 
rs1799752, representing the I/D polymorphism, in intron 16 of the Angiotensin 
Converting Enzyme (ACE) gene and Ang II (and possibly other RAS peptides) and 
hypoxic pulmonary vasoconstriction will be collected as specified in the Time and Events 
Table (Section 7.1). 
Further information for blood sample collection, processing, storage and shipping 
procedures are provided in the SRM. 
Information regarding genetic research is included in Appendix 3.
7.10.
Immunogenicity
7.10.1.
Sample collection
Blood samples for immunogenicity analysis will be collected at the time points indicated 
in Section 7.1, Time and Events Table. Additional visits to obtain immunogenicity 
samples may be required in the unlikely event that subjects develop a clinically relevant 
immunoglobulin response to the drug as described in the SRM.
Details of immunogenicity blood sample collection (including volume to be collected), 
processing, storage and shipping procedures are provided in the SRM.
7.10.2.
Sample analysis
Immunogenicity analysis will be performed under the management of Clinical 
Immunology, Biopharm R&D, GlaxoSmithKline. All pre-dose and post-dose samples 
will be first tested for Anti-ACE2 binding antibodies by screening and confirmation assay 
steps. The post-dose samples tested positive for anti-ACE2 binding antibodies will be 
further characterized for anti-ACE2 neutralizing antibodies. Both positive incidences for 
anti-ACE2 binding and neutralizing antibodies will be reported.
 
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8.
DATA MANAGEMENT

For this study subject data will be entered into GSK defined CRFs, transmitted 
electronically to GSK or designee and combined with data provided from other 
sources in a validated data system.  

Management of clinical data will be performed in accordance with applicable 
GSK standards and data cleaning procedures to ensure the integrity of the data, 
e.g., removing errors and inconsistencies in the data.

Adverse events and concomitant medications terms will be coded using MedDRA 
(Medical Dictionary for Regulatory Activities) and an internal validated 
medication dictionary, GSKDrug.  

CRFs (including queries and audit trails) will be retained by GSK, and copies will 
be sent to the investigator to maintain as the investigator copy.  Subject initials 
and day/month of birth will not be collected or transmitted to GSK according to 
GSK policy.
9.
STATISTICAL CONSIDERATIONS AND DATA 
ANALYSES
9.1.
Hypotheses
The focus of this study is on the exploration the effect of GSK2586881 on a range of 
echocardiography, pulse oximetry, biomarker, safety and PK endpoints, when subjecting 
healthy volunteers to an exercise challenge under hypoxic conditions. No formal 
statistical hypotheses are being tested. A Bayesian statistical analysis framework with 
non-informative priors for model parameters (unless otherwise specified) will be used to 
obtain posterior distributions for effects of interest. These posterior distributions will be 
used to obtain a number of probability statements about the magnitude of treatment 
effects (e.g. Probability of any treatment related reduction in PASP, or Probability that 
the treatment related reduction in PASP 5 mmHg).
A rule of thumb for end of “study success” is if the probability of any treatment related 
reduction in PASP (T3-T0) exceeds 0.95 (success is also conditional on the probability of 
(absolute) treatment related reductions in oxygen saturation exceeding 5% being small).
9.2.
Sample Size Considerations
The sample size of 30 patients is based on logistical considerations and is not based on 
formal sample size calculations. However, estimates of precision for the treatment 
difference in the primary endpoint are presented for context. (Note: precision in this 
context is defined as one half of the width of the 95% confidence interval.) A sample size 
re-estimation is planned after 15 subjects. 
 
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9.2.1.
Sample Size Assumptions
The precision of the primary treatment comparison (change from baseline PASP to 
hypoxic/exercise PASP) was estimated using simulation. PASP data points were 
simulated for each subject: normoxic at rest, and hypoxic after exercise, each for two 
study periods, giving a total of four PASP measurements for each subject. The four PASP 
measurements were drawn from a multivariate normal distribution to allow for different 
levels of within-subject correlation. One simulated study with a given sample size (N) 
was created by repeating this process of generating individual subject data N times, 
randomly allocating each subject to a treatment sequence in a 1:1 ratio, and calculating 
the half-width of the confidence interval of the treatment difference in change from 
baseline in PASP from that simulated dataset (using a linear mixed effects model 
including period baseline, subject baseline, treatment and period as fixed effects, and 
subject as a random effect). A full simulation run consisted of 1000 iterations of 
simulated studies, and a final estimate for precision was calculated as the mean precision 
across the 1000 iterations.
The following assumptions were made regarding the mean and Standard Deviation (SD) 
of PASP based on data from Antoni, 2005 

Mean PASP was 30 mmHg at baseline (i.e. normoxic and at rest) and 45 mmHg 
under hypoxia and exercise

SD of PASP was 2.81 mmHg at baseline and 4.30 mmHg under hypoxia and exercise

As the purpose of this simulation was to estimate precision by evaluating the SD of 
the treatment difference rather than the mean, there was no treatment effect assumed 
in the simulations

The within-subject correlation of PASP was unknown, therefore four different 
scenarios of within-subject correlation were evaluated: zero correlation, low 
correlation (0.3), high correlation (0.6) and very high correlation (0.9).

A range of sample sizes was considered: from 5 to 10 in increments of 1, and then up 
to 40 in increments of 5. The table below shows a subset of these; the figure includes 
them all.
Based on these assumptions, the estimated precisions for these sample sizes and under 
these scenarios of within-subject correlation were as follows (smaller number for 
precision denotes more precise estimates):
 
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Table 3
Estimated precision of treatment comparisons of change from 
baseline in PASP (mmHg) for a range of sample sizes and within-
subject correlation scenarios
Within-subject correlation
Sample size (N)
0
0.3
0.6
0.9
10
4.35
3.83
2.92
1.48
20
2.76
2.40
1.83
0.91
30
2.22
1.91
1.46
0.72
40
1.91
1.63
1.23
0.62
Figure 4 illustrates precision estimates under the full range of sample sizes considered 
(from 5 to 40), and for all within-subject correlation scenarios. The red line at 5 mmHg is 
superimposed to indicate a rough guide to the magnitude of a clinically meaningful 
difference.
Figure 4
Sensitivity of study precision to sample size and within subject 
correlation of PASP
9.2.2.
Sample Size Re-estimation
A sample size re-estimation will be conducted at the interim analysis (see Section 9.3.2). 
The purpose of the sample size re-estimation is to determine whether the total number of 
subjects can be reduced below the anticipated 30, based on treatment comparison 
between GSK2586881 and Placebo in change from pre-dose PASP to hypoxic/exercised 
 
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PASP (i.e. T3-T0). The sample size re-estimation is to be considered advisory, and taken 
into account together with other considerations. These will include:

ensuring sufficient data is collected on secondary endpoints,

non-conclusive safety data at the time of interim analysis (e.g. a weak signal of a 
reduction in oxygen saturation data that would require the full set of remaining 
subjects to be able to reach a conclusion),

speed of recruitment.
9.3.
Data Analysis Considerations
Data will be listed and summarised according to GSK integrated data standards library 
(IDSL) reporting standards where applicable.  Complete details will be provided in the 
Reporting and Analysis Plan (RAP).
The key endpoints referred to in the text below comprise PASP measured by 
echocardiography, oxygen saturation measured by continuous pulse oximetry, RAS 
peptides and safety data.
9.3.1.
Analysis Populations
All Subjects Screened Population: This population contains all subjects that complete at 
least one Visit 1 (Screening) procedure. This population will be used for the summary of 
subject disposition (including reasons for screening failures, run-in failures, and 
stabilization failures) and for the listing of AEs and SAEs for non-randomised subjects.
Intent-to-Treat (ITT) Population: This population will comprise all randomised subjects, 
excluding those who were randomised in error. A subject who is recorded as a screen 
failure, run-in failure, or stabilisation failure, but is randomised and does not receive a 
dose of study treatment, is considered to be randomised in error. Any other subject who 
receives a randomisation number will be considered to have been randomised. This will 
constitute the primary population for all efficacy and safety analyses.
Pharmacokinetic (PK) population: This population will comprise all subject in the ITT
Population for whom a PK sample was obtained and analysed and on active treatment.
In addition to the above populations, the effect of important protocol violations, including 
any subjects who failed the inclusion/exclusion criteria, may be assessed by means of 
sensitivity analyses. A blind review of all protocol violations will be performed prior to 
DBF in order to identify any important deviations and consequently identify any subjects 
who will be excluded from such sensitivity analyses.
 
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9.3.2.
Interim Analysis
An interim analysis is planned after 15 subjects have completed the following critical 
assessments:

PASP at T0 and T3 for both study periods

Oxygen saturation at T0 and T3 for both study periods

Adverse events 
The interim analysis will use the following study data:

PASP at time T0 and T3 for both periods, for the first 15 subjects

Oxygen saturation at T0 and T3 for both periods, for the first 15 subjects

Adverse events for the first 15 subjects

Angiotensin biomarker concentrations for the first 5 subjects (to allow time for 
the samples to be analysed by the external lab).
The interim analysis will use a data snapshot that has been cleaned to the best extent 
allowed by the timeframes (i.e. the interim data will not be fully cleaned or fully QC’d 
data and there will not be a locked database).
The aims of the interim analysis, and the endpoints to be used to address them, are as 
follows:

Using the primary endpoint (treatment differences between GSK2586881 and 
Placebo in change from pre-dose PASP to hypoxic/exercised PASP [T3-T0]):
o
To decide whether to continue the study or stop based on futility, and
o
to conduct an advisory sample-size re-estimation with the view to 
potentially reduce the number of subjects participating in the study below 
30.

Using secondary endpoints:
o
to estimate treatment differences between GSK2586881 and Placebo in 
change from pre-dose oxygen saturation to hypoxic/exercised oxygen 
saturation [T3-T0], with a view to stopping the study if there is evidence 
that GSK2586881 causes a reduction in oxygen saturation in healthy 
volunteers. As a non-binding guide high posterior probability of observing 
5% absolute differences in mean oxygenation saturation values between 
placebo and active arms would be of concern; but clinical judgement 
would override any statistical methods if, for example, the majority of 
subjects displayed consistent patterns of reductions e.g. between 2-3%).
 
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o
to compare adverse events within the two treatment groups and explore 
any potential safety signals that may emerge
To assess the operating characteristics of the interim analysis decisions to be made based 
on the primary endpoint, a simulation was carried out to estimate the relative proportion 
of studies reaching conclusions to stop for futility, continue with no change to the sample 
size, and to continue with a reduced sample size, under various different scenarios of the 
true treatment effect. Broadly speaking, the aim of the simulation was to confirm that (in 
an overwhelming majority of cases) a decision to stop for futility would be reached in the 
case of no true treatment effect and a decision to continue (perhaps with reduced sample 
size) would be reached in the case of a true treatment effect.
Simulated datasets of PASP at baseline (i.e. normoxic and at rest) and under hypoxia and 
exercise for 15 subjects, each receiving both treatments in sequence, were generated 
using the following assumptions:

15 simulated subjects were randomised to one of the two available treatment 
sequences (see Section 6.2) using block randomisation with block size of 4 records

PASP at baseline and under hypoxia and exercise for both treatment groups (a total of 
four PASP measurements per subject) were sampled from a multivariate normal 
distribution, using values for mean PASP, standard deviation of PASP and within-
subject correlation of PASP as described below.

Mean PASP was 30 mmHg at baseline (i.e. normoxic and at rest) for both treatments, 
and 45 mmHg under hypoxia and exercise for Placebo (as in Section 9.2.1). For 
GSK2586881, mean PASP under hypoxia and exercise was (45 - Δ) mmHg, where Δ 
(the mean treatment difference) was varied according to four different scenarios:
o
no treatment difference (Δ = 0 mmHg)
o
weak treatment difference of a magnitude of half the clinically meaningful 
difference (Δ = 2.5 mmHg)
o
minimum clinically meaningful difference (Δ = 5 mmHg)
o
overwhelming treatment difference one-and-a-half times the clinically 
meaningful difference (Δ = 7.5 mmHg)

SD of PASP was 2.81 mmHg at baseline and 4.30 mmHg under hypoxia and 
exercise, for both treatment groups (as in Section 9.2.1) 

The within-subject correlation of PASP was unknown, therefore four different 
scenarios of within-subject correlation were evaluated: zero correlation, low 
correlation (0.3), high correlation (0.6) and very high correlation (0.9) (as in Section 
9.2.1). Within-subject correlation of PASP was assumed to be compound symmetric 
(i.e. the same correlation was used for each of the six possible pairs of the four PASP 
measurements within each subject).
 
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
It was assumed that there would be no effect of period in the simulation, i.e. it was 
assumed that it would make no difference if the measurement was taken from the first 
or second chronological period in the treatment sequence.
Modelling took on a three-step process, with decisions after each. Firstly, the treatment 
difference and its associated standard error was then estimated for the dataset of 15 
simulated subjects using a mixed effects linear regression model, including covariates for 
period, treatment, period baseline and subject baseline (the mean of the two period 
baselines) as fixed effects and subject as a random effect. If the sign of treatment 
difference arising from the simulated data was in the wrong direction (i.e. the simulated 
outcome for GSK2586881 was worse than for Placebo), then the simulated study was 
stopped for futility.
Secondly, in the alternative case that the simulated treatment difference was in favour of 
GSK2586881 over Placebo, a posterior probability of success (where success was defined 
as a 97.5% posterior probability of the treatment difference being in favour of 
GSK2586881 over Placebo) was evaluated for 30 subjects. This was evaluated using a t-
distribution, with the mean and standard deviation taken as the treatment difference and 
standard error (multiplied by a factor of the square root of 15 to estimate the standard 
deviation) from step one respectively, and . If this posterior probability was less than 0.2, 
then the study was stopped for futility as being unlikely to show any benefit of 
GSK2586881 over Placebo.
Thirdly, provided that the simulated study hadn't been stopped for futility in either of the 
first two steps, posterior probabilities of success were calculated for N ranging from 15 to 
29 subjects. If any of these posterior probabilities of success were greater than or equal to 
0.9, then the study was continued with a reduced sample size equal to the lowest N at 
which that threshold was reached. Otherwise, the conclusion from the simulated interim 
analysis would be to continue the study with unchanged sample size.
This whole process (simulating data for 15 subjects, modelling the treatment difference, 
evaluating posterior probabilities of success and simulating the decision-making process) 
was replicated 1000 times for each scenario, with the decision ("futile", "no change to N" 
or "reduce N") recorded for each iteration. Each combination of the four treatment 
difference scenarios and the four correlation scenarios was evaluated for a total of 16 
scenarios in all.
The estimated proportions of each decision being reached under each of the 16 scenarios 
are presented in Table 4.
 
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Table 4
Operating characteristics of interim analysis under four scenarios of 
treatment effect and four scenarios of within-subject correlation
Frequency of decisions (%)
Treatment 
effect 
Scenario
Within-subject 
correlation of PASP
Futile
Continue with 30 
subjects
Continue with 
reduced sample 
size
Δ=0 mmHg (no treatment difference)
0.0
87%
13%
0%
0.3
87%
13%
1%
0.6
85%
15%
0%
0.9
86%
14%
0%
Δ=2.5 mmHg (weak treatment effect, less than clinically meaningful difference)
0.0
31%
60%
9%
0.3
24%
65%
11%
0.6
10%
66%
25%
0.9
0%
9%
91%
Δ=5 mmHg (good treatment effect, at threshold of clinical meaningful difference)
0.0
2%
46%
52%
0.3
1%
35%
64%
0.6
0%
11%
89%
0.9
0%
0%
100%
Δ=7.5 mmHg (very strong treatment effect)
0.0
0%
10%
90%
0.3
0%
2%
98%
0.6
0%
0%
100%
0.9
0%
0%
100%
These results suggest primarily that if there is no true treatment difference between 
GSK2586881 and Placebo, the study would be stopped for futility 85-87% of the time 
(irrespective of within-subject correlation of PASP). A drug with a weak treatment effect 
would most likely result in the study being continued without change or stopped for 
futility (except in the case where within-subject correlation is 0.9, which is presented here 
as an extreme case, unlikely to occur in practice). If the true treatment effect is at the 
clinically relevant threshold of 5 mmHg, then the study is highly unlikely to be stopped 
for futility and may indicate being reduced in sample size.
Secondarily, it should be noted that the higher the within-subject correlation, then the 
higher the probability of success. This is because the more correlation there is in 
measurements within the same individual, the less variability there will be in change from 
baseline. Results for correlations of 0.0 and 0.9 are presented as extreme cases unlikely to 
occur in practice, though the exact strength of within-subject correlation of PASP 
(particularly under different stressed conditions) is not known.
Full details of the interim analysis will be supplied in the RAP.
 
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9.3.3.
Multiple Comparisons and Multiplicity
As this is an early-phase exploratory study, no adjustment for multiple comparisons will 
be made. Treatment comparisons will be presented as effect sizes with 95% confidence 
intervals.
9.4.
Key Elements of Analysis Plan
Each subject will undergo two treatment periods in this crossover study, each one of 
which being subdivided into five sub-epochs (labelled T0-T4) as follows:

T0: Pre-dose (period baseline)

T1: Post-dose, normoxic, at rest, pre-challenge

T2: Hypoxic, at rest

T3: Hypoxic, immediately after exercise

T4: Post-challenge, normoxic, at rest
This follows the principle illustrated in the diagram of echocardiograph measurements 
(Figure 2).
Pharmacodynamic endpoints will be assigned to T0 thru T4 timepoints based on when 
they happened relative to the sequence of events that the subject undertakes during the 
course of the study day.
Pharmacokinetic endpoints will be timed based on elapsed time since dose 
administration.
In addition to T0 being defined as the period baseline, an overall subject baseline will be 
defined as the mean of the two T0 measurements (one from each period).
Change from baseline at time points T1 - T4 will be calculated as the difference between 
the measurement at the time point in question and the period baseline.In general, 
statistical modelling of changes from baseline will be done using a Bayesian mixed 
effects regression model, including covariates for period, treatment, period baseline and 
subject baseline (the mean of the two period baselines) as fixed effects and subject as a 
random effect (non-informative priors for model parameters). A compound symmetric 
covariance structure within each subject-period-treatment cell will be assumed to account 
for repeated measurements a) inherent in the two-period crossover design and b) due to 
the four post-baseline timepoints within each treatment period.
PASP data will be summarized by treatment and time-point in tabular and graphical 
format. A Bayesian mixed effects regression model (as described above) will be fitted 
(using non-informative priors for the model parameters), and an estimate of the mean 
change from baseline in PASP for each treatment group and post-baseline timepoint, 
 
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together with its 95% credible interval, will be obtained.  Estimates for treatment 
differences will also be presented. Data may be log-transformed if necessary.
Details of the analysis of other endpoints will be described in the RAP.
9.4.1.
Pharmacokinetic Analyses
Pharmacokinetic analysis will be performed by, or under the auspices, of Clinical 
Pharmacology Modelling and Simulation Depertment with GlasxoSmithKline.  Plasma 
GSK2586881 concnetration-time data will be analysed by non-compartmental methods 
with WinNonLin V6.3 or greater.  Calculations will be based on the actual sampling 
times recorded during the study.
From the plasma concentration-time data, the following pharmacokinetic parameters will 
be determined, as data permit: maximum observed plasma concentration (Cmax), time to 
Cmax (tmax), area under the plasma concentration-time curve over the study period 
[nominally AUC(0-2.5h) post-dose], AUC over the hypoxia challenge (nominally 
AUC(0.5-2.0h post-dose), plasma clearance (CL), volume of distribution (V) and 
apparent terminal phase half-life (t1/2), if data permit.  Other PK parameters may also be 
determined.
Pharmacokinetic data will be presented in graphical and/or tabular form and will be
summarized descriptively. All pharmacokinetic data will be stored in the Archives, 
GlaxoSmithKline Pharmaceuticals, R&D. 
The relationship between the RAS biomarkers and other pharmacodynamic endpoints 
(echocardiography and pulse oximetry) and GSK2586881 concentrations and/or PK 
parameters may also be explored, if appropriate.
If appropriate, a population PK analysis may also be conducted, in addition the plasma 
concentration-time data may be merged with historical data and analysed as part of a 
population PK meta-analysis.
10.
STUDY GOVERNANCE CONSIDERATIONS
10.1.
Posting of Information on Publicly Available Clinical Trial 
Registers
Study information from this protocol will be posted on publicly available clinical trial 
registers before enrollment of subjects begins.
10.2.
Regulatory and Ethical Considerations, Including the 
Informed Consent Process
Prior to initiation of a site, GSK will obtain favourable opinion/approval from the 
appropriate regulatory agency to conduct the study in accordance with ICH Good Clinical 
Practice (GCP) and applicable country-specific regulatory requirements.
 
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The study will be conducted in accordance with all applicable regulatory requirements, 
and with GSK policy.
The study will also be conducted in accordance with ICH Good Clinical Practice (GCP), 
all applicable subject privacy requirements, and the guiding principles of the current 
version of the Declaration of Helsinki.  This includes, but is not limited to, the following:

IRB/IEC review and favorable opinion/approval of the study protocol and 
amendments as applicable

Obtaining signed informed consent

Investigator reporting requirements (e.g. reporting of AEs/SAEs/protocol 
deviations to IRB/IEC)

GSK will provide full details of the above procedures, either verbally, in writing, 
or both.

Signed informed consent must be obtained for each subject prior to participation 
in the study

The IEC/IRB, and where applicable the regulatory authority, approve the clinical 
protocol and all optional assessments, including genetic research.  

Optional assessments (including those in a separate protocol and/or under separate 
informed consent) and the clinical protocol should be concurrently submitted for 
approval unless regulation requires separate submission.  

Approval of the optional assessments may occur after approval is granted for the 
clinical protocol where required by regulatory authorities.  In this situation, 
written approval of the clinical protocol should state that approval of optional 
assessments is being deferred and the study, with the exception of the optional 
assessments, can be initiated.
10.3.
Quality Control (Study Monitoring)

In accordance with applicable regulations including GCP, and GSK procedures, 
GSK monitors will contact the site prior to the start of the study to review with the 
site staff the protocol, study requirements, and their responsibilities to satisfy 
regulatory, ethical, and GSK requirements.  

When reviewing data collection procedures, the discussion will also include 
identification, agreement and documentation of data items for which the CRF will 
serve as the source document.

Source documents provide evidence for the existence of the participant and 
substantiate the integrity of the data collected. Source documents are filed at the 
investigator’s site.

Data entered in the eCRFs that are transcribed from source documents must be 
consistent with the source documents or the discrepancies must be explained. The 
investigator may need to request previous medical records or transfer records, 
depending on the study; also current medical records must be available.
 
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GSK will monitor the study and site activity to verify that the:

Data are authentic, accurate, and complete.

Safety and rights of subjects are being protected.

Study is conducted in accordance with the currently approved protocol and any 
other study agreements, GCP, and all applicable regulatory requirements.
The investigator and the head of the medical institution (where applicable) agrees to 
allow the monitor direct access to all relevant documents
10.4.
Quality Assurance

To ensure compliance with GCP and all applicable regulatory requirements, GSK 
may conduct a quality assurance assessment and/or audit of the site records, and 
the regulatory agencies may conduct a regulatory inspection at any time during or 
after completion of the study. 

In the event of an assessment, audit or inspection, the investigator (and institution) 
must agree to grant the advisor(s), auditor(s) and inspector(s) direct access to all 
relevant documents and to allocate their time and the time of their staff to discuss 
the conduct of the study, any findings/relevant issues and to implement any 
corrective and/or preventative actions to address any findings/issues identified.
10.5.
Study and Site Closure

Upon completion or premature discontinuation of the study, the GSK monitor will 
conduct site closure activities with the investigator or site staff, as appropriate, in 
accordance with applicable regulations including GCP, and GSK Standard 
Operating Procedures.

GSK reserves the right to temporarily suspend or prematurely discontinue this 
study at any time for reasons including, but not limited to, safety or ethical issues 
or severe non-compliance. For multicenter studies, this can occur at one or more 
or at all sites.  

If GSK determines such action is needed, GSK will discuss the reasons for taking 
such action with the investigator or the head of the medical institution (where 
applicable).  When feasible, GSK will provide advance notification to the 
investigator or the head of the medical institution, where applicable, of the 
impending action.

If the study is suspended or prematurely discontinued for safety reasons, GSK will 
promptly inform all investigators, heads of the medical institutions (where 
applicable) and/or institution(s) conducting the study. GSK will also promptly 
inform the relevant regulatory authorities of the suspension or premature 
discontinuation of the study and the reason(s) for the action.  

If required by applicable regulations, the investigator or the head of the medical 
institution (where applicable) must inform the IRB/IEC promptly and provide the 
reason for the suspension or premature discontinuation.
 
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10.6.
Records Retention

Following closure of the study, the investigator or the head of the medical 
institution (where applicable) must maintain all site study records (except for 
those required by local regulations to be maintained elsewhere), in a safe and 
secure location.  

The records must be maintained to allow easy and timely retrieval, when needed 
(e.g., for a GSK audit or regulatory inspection) and must be available for review 
in conjunction with assessment of the facility, supporting systems, and relevant 
site staff.  

Where permitted by local laws/regulations or institutional policy, some or all of 
these records can be maintained in a format other than hard copy (e.g., microfiche, 
scanned, electronic); however, caution needs to be exercised before such action is 
taken.  

The investigator must ensure that all reproductions are legible and are a true and 
accurate copy of the original and meet accessibility and retrieval standards, 
including re-generating a hard copy, if required.  Furthermore, the investigator 
must ensure there is an acceptable back-up of these reproductions and that an 
acceptable quality control process exists for making these reproductions.

GSK will inform the investigator of the time period for retaining these records to 
comply with all applicable regulatory requirements.  The minimum retention time 
will meet the strictest standard applicable to that site for the study, as dictated by 
any institutional requirements or local laws or regulations, GSK 
standards/procedures, and/or institutional requirements.  

The investigator must notify GSK of any changes in the archival arrangements, 
including, but not limited to, archival at an off-site facility or transfer of 
ownership of the records in the event the investigator is no longer associated with 
the site.
10.7.
Provision of Study Results to Investigators, Posting of 
Information on Publically Available Clinical Trials Registers 
and Publication
Where required by applicable regulatory requirements, an investigator signatory will be 
identified for the approval of the clinical study report.  The investigator will be provided 
reasonable access to statistical tables, figures, and relevant reports and will have the 
opportunity to review the complete study results at a GSK site or other mutually-
agreeable location.
GSK will also provide the investigator with the full summary of the study results.  The 
investigator is encouraged to share the summary results with the study subjects, as 
appropriate.
GSK will provide the investigator with the randomisation codes for their site only after 
completion of the full statistical analysis.
 
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The procedures and timing for public disclosure of the results summary and for 
development of a manuscript for publication will be in accordance with GSK Policy.
A manuscript will be progressed for publication in the scientific literature if the results 
provide important scientific or medical knowledge.
 
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11.
REFERENCES
Abraham WT, Raynolds MV, Badesch DB, Wynne KM, Groves BM, Roden RL,et al..
Angiotensin-converting enzyme DD genotype in patients with primary pulmonary 
hypertension: increased frequency and association with preserved haemodynamics.  J 
Renin Angiotensin Aldosterone Syst. 2003 Mar;4(1):27-30.
Antoni Ricart, Jaume Maristany, Núria Fort, Conxita Leal, Teresa Pagés, and Ginés 
Viscor. High Altitude Medicine & Biology. March 2005, 6(1): 43-49. 
doi:10.1089/ham.2005.6.43
Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, et al. The American-
European consensus conference on ARDS: definitions, mechanisms, relevant outcomes, 
and clinical trial coordination. Am J Respir Crit Care Med. 1994;49:818-822. 
Cargil RI, Lipworth BJ. Lisinopril attenuates acute hypoxic pulmonary vasoconstriction 
in humans. Chest. 1996 Feb;109(2):424-9/
GlaxoSmithKline Document Number 2010N108777_00 Study ID GSK2586881. 
Investigator's Brochure for GSK2586881 (formerly known as APN01)– A Soluble 
Recombinant Human Angiotensin Converting Enzyme 2 (rhACE2). Report Date 16-
FEB-2011. 
Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F, Kowal D, editors. 
Contraceptive Technology. 19th edition. New York: Ardent Media, 2007(a): 24. Table 3-
2.
Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F, Kowal D, editors. 
Contraceptive Technology. 19th edition. New York: Ardent Media, 2007(b): 28.
ICH Topic M3 (R2)  Non-clinical safety studies for the conduct of human clinical trials 
and marketing authorisation for pharmaceuticals, 2009
Idell S, Kueppers, F, Lippmann, M, Rosen, H, Niederman, M, Fein, A. ACE elevated in 
ARDS BAL. Angiotensin converting enzyme in bronchoalveolar lavage in ARDS. Chest. 
1987;91:52-56.
Kiely DG, Cargill RI, Lipworth BJ (1996) Effects of hypercapnia on hemodynamic, 
inotropic, lusitropic, and electrophysiologic indices in humans. Chest 109:1215–1221
Kiely DG1, Cargill RI, Wheeldon NM, Coutie WJ, Lipworth BJ. Haemodynamic and 
endocrine effects of type 1 angiotensin II receptor blockade in patients with hypoxaemic 
cor pulmonale. Cardiovasc Res. 1997 Jan;33(1):201-8.
Kleinsasser A1, Pircher I, Treml B, Schwienbacher M, Schuster M, Janzek E, Loibner H, 
Penninger JM, Loeckinger A. Recombinant angiotensin-converting enzyme 2 suppresses 
pulmonary vasoconstriction in acute hypoxia. Wilderness Environ Med. 2012 
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Maron BA, Leopold JA. The role of the renin-angiotensin-aldosterone system in the 
pathobiology of pulmonary arterial hypertension (2013 Grover Conference series. Pulm 
Circ. 2014 Jun;4(2):200-10. doi: 10.1086/675984  
Marshall RP, Webb S, Bellingan GJ, Montgomery HE, Chaudhari B, Chambers RJ, , GJ
et al. Angiotensin converting enzyme insertion/deletion polymorphism is associated with 
susceptibility and outcome in acute respiratory distress syndrome. Am. J. Resp. Crit. Care 
Med. 2002;166:646-650. 
Paul M, Bachmann J, Ganten D. Angiotensin II-induced vasoconstriction and sodium 
resorption. The Tissue Renin-Angiotensin System in Cardiovascular Disease. Trends 
Cardiovasc. Med. 1992;2:94-99. 
Ricart A1, Maristany J, Fort N, Leal C, Pagés T, Viscor G. Effects of sildenafil on the 
human response to acute hypoxia and exercise. High Alt Med Biol. 2005 Spring;6(1):43-
9.
Rubenfeld GD, Caldwell E, Peabody E. Incidence and Outcomes of Acute Lung Injury. N 
Engl J Med. 2005;353:1685-1693. 
Santos RAS, Ferreira AJ, Pinheiro SVB, Sampaio WO, Touyz R, Campangole-Santos 
MJ. Counter-regulatory effects of ANG (1-7) in ANG II. Angiotensin(1-7) and its 
receptor as potential targets for cardiovascular drugs’ Expert Op. Investig. Drugs. 
2005;1019:1031. 
Santos RAS, Simoes e Silva, AC, Maric C, Silva DMR, Machado RP, de Buhr I, et al. 
ANG (1-7) as the agonist of mas. ‘Angiotensin (1-7) is an endogenous ligand for the G-
protein coupled receptor Mas’ Proc. Natl. Acad. Sci. USA. 2003;100:8258-8263. 
Suzuki Y, Ruiz-Ortega, M., Lorenzo, O., Ruperez, M., Esteban, V., Egido, J. 
Inflammatory and pro-fibrotic activity of ANG II. ) Inflammation and Angiotensin II. Int. 
J. Biochem. Cell Biol. 2003;35:881-900. 
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes 
as compared with traditional tidal volumes for acute lung injury and the acute respiratory 
distress syndrome. N Engl J Med. 2000;342:1301-1308. 
The ARDS Network Authors for the ARDS network. Ketoconzaole for Early Treatment 
of Acute Lung Injury and Acute Respiratory Distress Syndrome. JAMA. 2000;283:1995-
2002. 
Tom B, deVries R, Saxena PR, Danser J. ANG (1-7) inhibiting ACE and modifying 
Bradykinin responses. Bradykinin potentiation by angiotensin (1-7) and ACE inhibitors 
correlates with C- and N-terminal blockade’ Hypertension. 2001;38:95-99.
Torre-Bueno JR, Wagner PD, Saltzman HA, Gale GE, Moon RE. Diffusion limitation in 
normal humans during exercise at sea level and simulated altitude. J Appl Physiol (1985). 
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Wenz M, Hoffmann B, Bohlender J, Kaczmarczyk G. ANG II elevated in ARDS. 
Anfgiotensin II formation and endothelin clearance in ARDS patients in supine and prone 
positions. Intensive Care Med. 2000;26:292-298. 
Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP, deBoisblanc 
B,et al.. Pulmonary-Artery versus Central Venous Catheter to Guide Treatment of Acute 
Lung Injury. N Engl J Med. 2006;25:354(21):2213-24. Epub 2006 May 21.
Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B,et 
al. Comparison of Two Fluid-Management Strategies in Acute Lung Injury. N Engl J 
Med. 2006;354(24):2564-75. Epub 2006 May 21.
 
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12.
APPENDICES
12.1.
Appendix 1: Abbreviations and Trademarks
Abbreviations
ACE2
Angiotensin converting enzyme type 2
AE
Adverse Event
ALI
Acute Lung Injury
ALT
Alanine aminotransferase (SGPT)
Ang II
Angiotensin II
ANP
Atrial Naturetic peptide
ARDS
Acute respiratory distress syndrome
AST
Aspartate aminotransferase (SGOT)
AUC
Area under concentration-time curve
BID
Bi-Daily
BUN
Blood urea nitrogen
CBP
Child Bearing Potential
CL
Clearance
CO2
Carbon dioxide
CONSORT
Consolidated Standards of Reporting Trials
CRF
Case Report Form
CV
Cardiovascular
DNA
Deoxyribonucleic acid
ECG
Electrocardiogram
eCRF
Electronic case report form
FDA
Food and Drug Administration
FRP
Females of Reproductive Potential
GCP
Good Clinical Practice
GLP
Good Laboratory Practice
GSK
GlaxoSmithKline
HBcAb
Hepatitis B core antibody
HBsAg
Hepatitis B surface antigen
hCG
Human chorionic gonadotropin
HIV
Human Immunodeficiency Virus
HPLC
High performance liquid chromatography
HPV
Hypoxic pulmonary vasoconstriction
IB
Investigator’s Brochure
ICH
International Conference on Harmonization of Technical 
Requirements for Registration of Pharmaceuticals for 
Human Use
ID
Identification
IEC
Independent Ethics Committee
IgG
Immunoglobulin G
IND
Investigational New Drug
IP
Investigational Product
 
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IRB
Institutional Review Board
ITT
Intent-to-Treat
IV
Intravenous
IVIVT
In Vitro/In Vivo Translations
Kg
Kilogram
LDH
Lactate dehydrogenase
LFTs
Liver function tests
m
Meters
MCH
Mean corpuscular hemogloin
MCV
Mean corpuscular volume
MedDRA
Medical Dictionary for Regulatory Activities
mg
Milligrams
mL
Milliliter
MSDS
Material Safety Data Sheet
msec
Milliseconds
NOAEL
No observed adverse effect level
NT-proBNP
Brain Naturetic Peptide
O2
Oxygen
PaO2
Partial Pressure of Oxygen in arterial blood
PAH
Pulmonary Arterial Hypertension
PASP
Pulmonary Artery Systolic Pressure
PD
Pharmacodynamic
PGx
Pharmacogenetics
PK
Pharmacokinetic
Q
Perfusion
QC
Quality control
QTcB
QT duration corrected for heart rate by Bazett’s formula
QTcF
QT duration corrected for heart rate by Fridericia’s formula
RAP
Reporting and Analysis Plan
RAS
Renin-Angiotensin System
RBC
Red blood cells
rhACE2
Recombinant human angiotensin converting enzyme type 2
RNA
Ribonucleic acid
SAE
Serious adverse event(s)
SD
Standard deviation
SRM
Study Reference Manual
TPR
Third Party Resourcing
TTS
Technical Terms of Supply
t½
Terminal phase half-life
tmax
Time of occurrence of Cmax
V
Volume of Distribution
VA
Ventilation
VO2
Oxygen Consumption
 
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Trademark Information
Trademarks of the GlaxoSmithKline 
group of companies
Trademarks not owned by the 
GlaxoSmithKline group of companies
NONE
MedDRA
WinNonlin
 
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12.2.
Appendix 2: Liver Safety Required Actions and Follow up 
Assessments
Phase I Liver chemistry stopping criteria have been designed to assure subject safety and 
to evaluate liver event etiology (in alignment with the FDA premarketing clinical liver 
safety guidance).
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guid
ances/UCM174090.pdf.
Phase I liver chemistry stopping criteria and required follow up assessments
Liver Chemistry Stopping Criteria – Liver Stopping Event
ALT-absolute
ALT≥3xULN
If  ALT≥3xULN AND bilirubin1,2 2xULN (>35% direct bilirubin) or  INR >1.5, 
Report as an SAE.
See additional Actions and Follow Up Assessments listed below
Required Actions and Follow up Assessments following Liver Stopping Event
Actions
Follow Up Assessments

Immediately discontinue study treatment

Report the event to GSK within 24 hours

Complete the liver event CRF, and complete 
an SAE data collection tool if the event also 
meets the criteria for an SAE2

Perform liver event follow up assessments 

Monitor the subject until liver chemistries 
resolve, stabilise, or return to within baseline
(see MONITORING below)
MONITORING:
If ALT≥3xULN AND bilirubin 2xULN  or INR 
>1.5

Repeat liver chemistries (include ALT, AST, 
alkaline phosphatase, bilirubin) and perform 
liver event follow up assessments within  24 
hrs

Monitor subjects twice weekly until liver 
chemistries resolve, stabilise or return to 
within baseline

A specialist or hepatology consultation is 

Viral hepatitis serology3

Obtain INR and recheck with each liver 
chemistry assessment until the 
transaminases values show downward 
trend.

Blood sample for pharmacokinetic (PK) 
analysis, obtained 24 hours after last dose

Serum creatine phosphokinase (CPK) and 
lactate dehydrogenase (LDH).

Fractionate bilirubin, if total 
bilirubin2xULN

Obtain complete blood count with 
differential to assess eosinophilia

Record the appearance or worsening of 
clinical symptoms of liver injury, or 
hypersensitivity, on the AE report form

Record use of concomitant medications on 
the concomitant medications report form
including acetaminophen, herbal remedies, 
other over the counter medications.
 
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Liver Chemistry Stopping Criteria – Liver Stopping Event
recommended
If ALT≥3xULN AND bilirubin < 2xULN  and 
INR ≤1.5:

Repeat liver chemistries (include ALT, AST, 
alkaline phosphatase, bilirubin) and perform
liver event follow up assessments within 24-
72 hrs

Monitor subjects weekly until liver 
chemistries resolve, stabilize or return to 
within baseline

Record alcohol use on the liver event 
alcohol intake case report form
If ALT≥3xULN AND bilirubin 2xULN  or 
INR >1.5:

Anti-nuclear antibody, anti-smooth muscle 
antibody, Type 1 anti-liver kidney 
microsomal antibodies, and quantitative 
total immunoglobulin G (IgG or gamma 
globulins).

Serum acetaminophen adduct HPLC assay 
(quantifies potential acetaminophen 
contribution to liver injury in subjects with 
definite or likely acetaminophen use in the 
preceding week [James, 2009]. NOTE: not 
required in China.

Liver imaging (ultrasound, magnetic 
resonance, or computerised tomography) 
and /or liver biopsy to evaluate liver 
disease; complete Liver Imaging and/or 
Liver Biopsy CRF forms.
1.
Serum bilirubin fractionation should be performed if testing is available. If serum bilirubin fractionation is not 
immediately available, discontinue study treatment for that subject if ALT 3xULN and bilirubin 2xULN. 
Additionally, if serum bilirubin fractionation testing is unavailable, record presence of detectable urinary bilirubin on 
dipstick, indicating direct bilirubin elevations and suggesting liver injury. 
2.
All events of ALT 3xULN and bilirubin 2xULN (>35% direct bilirubin) or ALT 3xULN and INR>1.5, if INR 
measured, which may indicate severe liver injury (possible ‘Hy’s Law’), must be reported as an SAE (excluding 
studies of hepatic impairment or cirrhosis); INR measurement is not required and the threshold value stated will 
not apply to subjects receiving anticoagulants
3.
Includes: Hepatitis A IgM antibody; Hepatitis B surface antigen and Hepatitis B Core Antibody (IgM); Hepatitis C 
RNA; Cytomegalovirus IgM antibody;  Epstein-Barr viral capsid antigen IgM antibody (or if unavailable, obtain 
heterophile antibody or monospot testing);  Hepatitis E IgM antibody 
4.
PK sample may not be required for subjects known to be receiving placebo or non-GSK comparator treatments.  
Record the date/time of the PK blood sample draw and the date/time of the last dose of study treatment prior to 
blood sample draw on the CRF. If the date or time of the last dose is unclear, provide the subject’s best 
approximation. If the date/time of the last dose cannot be approximated OR a PK sample cannot be collected in 
the time period indicated above, do not obtain a PK sample. Instructions for sample handling and shipping are in 
the SRM.
References
James LP, Letzig L, Simpson PM, Capparelli E, Roberts DW, Hinson JA,et al.. 
Pharmacokinetics of Acetaminophen-Adduct in Adults with Acetaminophen Overdose 
and Acute Liver Failure. Drug Metab Dispos 2009; 37:1779-1784.
 
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12.3.
Appendix 3: Genetic Research
Genetics – Background
Naturally occurring genetic variation may contribute to inter-individual variability in 
response to medicines, as well as an individual's risk of developing specific diseases. 
Genetic factors associated with disease characteristics may also be associated with 
response to therapy, and could help to explain some clinical study outcomes. For 
example, genetic variants associated with age-related macular degeneration (AMD) are 
reported to account for much of the risk for the condition [Gorin, 2012] with certain 
variants reported to influence treatment response [Chen, 2012]. Thus, knowledge of the 
genetic etiology of disease may better inform understanding of disease and the 
development of medicines. Additionally, genetic variability may impact the 
pharmacokinetics (absorption, distribution, metabolism, and elimination), or 
pharmacodynamics (relationship between concentration and pharmacologic effects or the 
time course of pharmacologic effects) of a specific medicine and/or clinical outcomes 
(efficacy and/or safety) observed in a clinical study.
Genetic Research Objectives and Analyses
The objectives of the genetic research are to investigate the relationship between genetic 
variants and: 

Response to medicine, including [any treatment regimens under investigation in 
this study] or any concomitant medicines;
Genetic data may be generated while the study is underway or following completion of 
the study.  Genetic evaluations may include focused candidate gene approaches and/or 
examination of a large number of genetic variants throughout the genome (whole genome 
analyses). Genetic analyses will utilize data collected in the study and will be limited to 
understanding the objectives highlighted above.  Analyses may be performed using data 
from multiple clinical studies to investigate these research objectives.
Appropriate descriptive and/or statistical analysis methods will be used. A detailed 
description of any planned analyses will be documented in a Reporting and Analysis Plan 
(RAP) prior to initiation of the analysis. Planned analyses and results of genetic 
investigations will be reported either as part of the clinical RAP and study report, or in a 
separate genetics RAP and report, as appropriate.
Study Population
Any subject who is enrolled in the study can participate in genetic research.  Any subject 
who has received an allogeneic bone marrow transplant must be excluded from the 
genetic research.
Study Assessments and Procedures
A key component of successful genetic research is the collection of samples during 
clinical studies. Collection of samples, even when no a priori hypothesis has been 
 
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identified, may enable future genetic analyses to be conducted to help understand 
variability in disease and medicine response.  

A 6 ml blood sample will be taken for Deoxyribonucleic acid (DNA) extraction. 
A blood sample is collected at the baseline visit, after the subject has been 
randomised and provided informed consent for genetic research. Instructions for 
collection and shipping of the genetic sample are described in the laboratory 
manual. The DNA from the blood sample may undergo quality control analyses to 
confirm the integrity of the sample. If there are concerns regarding the quality of 
the sample, then the sample may be destroyed. The blood sample is taken on a 
single occasion unless a duplicate sample is required due to an inability to utilize 
the original sample.  
The genetic sample is labelled (or “coded”) with the same study specific number used to 
label other samples and data in the study.   This number can be traced or linked back to 
the subject by the investigator or site staff. Coded samples do not carry personal 
identifiers (such as name or social security number). 
Samples will be stored securely and may be kept for up to 15 years after the last subject 
completes the study, or GSK may destroy the samples sooner.  GSK or those working 
with GSK (for example, other researchers) will only use samples collected from the study 
for the purpose stated in this protocol and in the informed consent form.  Samples may be 
used as part of the development of a companion diagnostic to support the GSK medicinal 
product.
Subjects can request their sample to be destroyed at any time.
Informed Consent
Subjects who do not wish to participate in the genetic research may still participate in the 
study.  Genetic informed consent must be obtained prior to any blood being taken.
Subject Withdrawal from Study
If a subject who has consented to participate in genetic research withdraws from the 
clinical study for any reason other than being lost to follow-up, the subject will be given a 
choice of one of the following options concerning the genetic sample, if already 
collected:

Continue to participate in the genetic research in which case the genetic DNA 
sample is retained

Discontinue participation in the genetic research and destroy the genetic DNA 
sample 
If a subject withdraws consent for genetic research or requests sample destruction for any 
reason, the investigator must complete the appropriate documentation to request sample 
destruction within the timeframe specified by GSK and maintain the documentation in 
the site study records. 
 
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Genotype data may be generated during the study or after completion of the study and 
may be analyzed during the study or stored for future analysis. 

If a subject withdraws consent for genetic research and genotype data has not been 
analyzed, it will not be analyzed or used for future research.  

Genetic data that has been analyzed at the time of withdrawn consent will 
continue to be stored and used, as appropriate. 
Screen and Baseline Failures
If a sample for genetic research has been collected and it is determined that the subject 
does not meet the entry criteria for participation in the study, then the investigator should 
instruct the subject that their genetic sample will be destroyed. No forms are required to 
complete this process as it will be completed as part of the consent and sample 
reconciliation process.  In this instance a sample destruction form will not be available to 
include in the site files.
Provision of Study Results and Confidentiality of Subject’s Genetic Data
GSK may summarize the genetic research results in the clinical study report, or 
separately and may publish the results in scientific journals. 
GSK may share genetic research data with other scientists to further scientific 
understanding in alignment with the informed consent. GSK does not inform the subject, 
family members, insurers, or employers of individual genotyping results that are not 
known to be relevant to the subject’s medical care at the time of the study, unless 
required by law. This is due to the fact that the information generated from genetic 
studies is generally preliminary in nature, and therefore the significance and scientific 
validity of the results are undetermined.  Further, data generated in a research laboratory 
may not meet regulatory requirements for inclusion in clinical care.
Chen H, Yu KD, Xu GZ. Association between Variant Y402H in Age-Related Macular 
Degeneration (AMD) Susceptibility Gene CFH and Treatment Response of AMD: A 
Meta-Analysis. PloS ONE 2012; 7: e42464
Gorin MB. Genetic insights into age-related macular degeneration: Controversies 
addressing risk, causality, and therapeutics. Mol. Asp. Med. 2012; 33: 467-486.
 
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12.4.
Appendix 4: Definition of and Procedures for Recording, 
Evaluating, Follow-Up and Reporting of Adverse Events
12.4.1.
Definition of Adverse Events
Adverse Event Definition:

An AE is any untoward medical occurrence in a patient or clinical investigation 
subject, temporally associated with the use of a medicinal product, whether or not 
considered related to the medicinal product.

NOTE: An AE can therefore be any unfavorable and unintended sign (including an 
abnormal laboratory finding), symptom, or disease (new or exacerbated) temporally 
associated with the use of a medicinal product.
Events meeting AE definition include:

Any abnormal laboratory test results (hematology, clinical chemistry, or urinalysis) 
or other safety assessments (e.g., ECGs, radiological scans, vital signs 
measurements), including those that worsen from baseline, and felt to be clinically 
significant in the medical and scientific judgement of the investigator.

Exacerbation of a chronic or intermittent pre-existing condition including either an 
increase in frequency and/or intensity of the condition.

New conditions detected or diagnosed after study treatment administration even 
though it may have been present prior to the start of the study.

Signs, symptoms, or the clinical sequelae of a suspected interaction.

Signs, symptoms, or the clinical sequelae of a suspected overdose of either study 
treatment or a concomitant medication (overdose per se will not be reported as an 
AE/SAE unless this is an intentional overdose taken with possible suicidal/self-
harming intent.  This should be reported regardless of sequelae).

"Lack of efficacy" or "failure of expected pharmacological action" per se will not be 
reported as an AE or SAE.  However, the signs and symptoms and/or clinical 
sequelae resulting from lack of efficacy will be reported if they fulfil the definition 
of an AE or SAE.

The signs and symptoms and/or clinical sequelae resulting from lack of efficacy will 
be reported if they fulfil the definition of an AE or SAE.  Also, "lack of efficacy" or 
"failure of expected pharmacological action" also constitutes an AE or SAE.
Events NOT meeting definition of an AE include:

Any clinically significant abnormal laboratory findings or other abnormal safety 
assessments which are associated with the underlying disease, unless judged by the 
 
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investigator to be more severe than expected for the subject’s condition.

The disease/disorder being studied or expected progression, signs, or symptoms of 
the disease/disorder being studied, unless more severe than expected for the subject’s 
condition.

Medical or surgical procedure (e.g., endoscopy, appendectomy): the condition that 
leads to the procedure is an AE.

Situations where an untoward medical occurrence did not occur (social and/or 
convenience admission to a hospital).

Anticipated day-to-day fluctuations of pre-existing disease(s) or condition(s) present 
or detected at the start of the study that do not worsen.
12.4.2.
Definition of Serious Adverse Events
If an event is not an AE per definition above, then it cannot be an SAE even if serious 
conditions are met (e.g., hospitalization for signs/symptoms of the disease under study, 
death due to progression of disease, etc).
Serious Adverse Event (SAE) is defined as any untoward medical occurrence that, 
at any dose:
a.
Results in death
b.
Is life-threatening
NOTE:
The term 'life-threatening' in the definition of 'serious' refers to an event in which the 
subject was at risk of death at the time of the event.  It does not refer to an event, which 
hypothetically might have caused death, if it were more severe.
c.
Requires hospitalization or prolongation of existing hospitalization
NOTE:

In general, hospitalization signifies that the subject has been detained (usually 
involving at least an overnight stay) at the hospital or emergency ward for 
observation and/or treatment that would not have been appropriate in the physician’s 
office or out-patient setting.  Complications that occur during hospitalization are 
AEs.  If a complication prolongs hospitalization or fulfills any other serious criteria, 
the event is serious.  When in doubt as to whether “hospitalization” occurred or was 
necessary, the AE should be considered serious.

Hospitalization for elective treatment of a pre-existing condition that did not worsen 
from baseline is not considered an AE.
 
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d.
Results in disability/incapacity
NOTE:

The term disability means a substantial disruption of a person’s ability to conduct 
normal life functions.

This definition is not intended to include experiences of relatively minor medical 
significance such as uncomplicated headache, nausea, vomiting, diarrhea, influenza, 
and accidental trauma (e.g. sprained ankle) which may interfere or prevent everyday 
life functions but do not constitute a substantial disruption
e.
Is a congenital anomaly/birth defect
f.
Other situations:

Medical or scientific judgment should be exercised in deciding whether reporting is 
appropriate in other situations, such as important medical events that may not be 
immediately life-threatening or result in death or hospitalization but may jeopardize 
the subject or may require medical or surgical intervention to prevent one of the 
other outcomes listed in the above definition.  These should also be considered 
serious.

Examples of such events are invasive or malignant cancers, intensive treatment in an 
emergency room or at home for allergic bronchospasm, blood dyscrasias or 
convulsions that do not result in hospitalization, or development of drug dependency 
or drug abuse
g.
Is associated with liver injury and impaired liver function defined as:

ALT 3xULN and total bilirubin* 2xULN (>35% direct), or

ALT 3xULN and INR** > 1.5.
* Serum bilirubin fractionation should be performed if testing is available; if unavailable, 
measure urinary bilirubin via dipstick.  If fractionation is unavailable and ALT 3xULN 
and total bilirubin 2xULN, then the event is still to be reported as an SAE.
** INR testing not required per protocol and the threshold value does not apply to 
subjects receiving anticoagulants.  If INR measurement is obtained, the value is to be 
recorded on the SAE form.

Refer to Appendix 2 for the required liver chemistry follow-up instructions
 
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12.4.3.
Definition of Cardiovascular Events
Cardiovascular Events (CV) Definition:
Investigators will be required to fill out the specific CV event page of the CRF for the 
following AEs and SAEs:

Myocardial infarction/unstable angina

Congestive heart failure

Arrhythmias

Valvulopathy

Pulmonary hypertension

Cerebrovascular events/stroke and transient ischemic attack

Peripheral arterial thromboembolism

Deep venous thrombosis/pulmonary embolism

Revascularization
12.4.4.
Recording of AEs and SAEs
AEs and SAE Recording:

When an AE/SAE occurs, it is the responsibility of the investigator to review all 
documentation (e.g., hospital progress notes, laboratory, and diagnostics reports) 
relative to the event.

The investigator will then record all relevant information regarding an AE/SAE in 
the CRF

It is not acceptable for the investigator to send photocopies of the subject’s medical 
records to GSK in lieu of completion of the GSK, AE/SAE CRF page.

There may be instances when copies of medical records for certain cases are 
requested by GSK.  In this instance, all subject identifiers, with the exception of the 
subject number, will be blinded on the copies of the medical records prior to 
submission of to GSK.

The investigator will attempt to establish a diagnosis of the event based on signs, 
symptoms, and/or other clinical information.  In such cases, the diagnosis will be 
documented as the AE/SAE and not the individual signs/symptoms.

Subject-completed Value Evidence and Outcomes questionnaires and the collection 
of AE data are independent components of the study.

Responses to each question in the Value Evidence and Outcomes questionnaire will 
be treated in accordance with standard scoring and statistical procedures detailed by 
the scale’s developer.
 
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
The use of a single question from a multidimensional health survey to designate a 
cause-effect relationship to an AE is inappropriate.
12.4.5.
Evaluating AEs and SAEs
Assessment of Intensity
The investigator will make an assessment of intensity for each AE and SAE reported 
during the study and will assign it to one of the following categories:

Mild:  An event that is easily tolerated by the subject, causing minimal discomfort 
and not interfering with everyday activities.

Moderate:  An event that is sufficiently discomforting to interfere with normal 
everyday activities

Severe:  An event that prevents normal everyday activities. - an AE that is assessed 
as severe will not be confused with an SAE. Severity is a category utilized for rating 
the intensity of an event; and both AEs and SAEs can be assessed as severe.

An event is defined as ‘serious’ when it meets at least one of the pre-defined 
outcomes as described in the definition of an SAE.
Assessment of Causality

The investigator is obligated to assess the relationship between study treatment and 
the occurrence of each AE/SAE.

A "reasonable possibility" is meant to convey that there are facts/evidence or 
arguments to suggest a causal relationship, rather than a relationship cannot be ruled 
out.

The investigator will use clinical judgment to determine the relationship.

Alternative causes, such as natural history of the underlying diseases, concomitant 
therapy, other risk factors, and the temporal relationship of the event to the study 
treatment will be considered and investigated.

The investigator will also consult the Investigator Brochure (IB) and/or Product 
Information, for marketed products, in the determination of his/her assessment.

For each AE/SAE the investigator must document in the medical notes that he/she 
has reviewed the AE/SAE and has provided an assessment of causality.

There may be situations when an SAE has occurred and the investigator has minimal 
information to include in the initial report to GSK.  However, it is very important 
that the investigator always make an assessment of causality for every event 
prior to the initial transmission of the SAE data to GSK.

The investigator may change his/her opinion of causality in light of follow-up 
 
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information, amending the SAE data collection tool accordingly.

The causality assessment is one of the criteria used when determining regulatory 
reporting requirements.
Follow-up of AEs and SAEs

The investigator is obligated to perform or arrange for the conduct of supplemental 
measurements and/or evaluations as may be indicated or as requested by GSK to 
elucidate as fully as possible the nature and/or causality of the AE or SAE.

The investigator is obligated to assist.  This may include additional laboratory tests 
or investigations, histopathological examinations or consultation with other health 
care professionals.

If a subject dies during participation in the study or during a recognized follow-up 
period, the investigator will provide GSK with a copy of any post-mortem findings, 
including histopathology.

New or updated information will be recorded in the originally completed CRF.

The investigator will submit any updated SAE data to GSK within the designated 
reporting time frames.
12.4.6.
Reporting of SAEs to GSK
SAE reporting to GSK via electronic data collection tool

Primary mechanism for reporting SAEs to GSK will be the electronic data collection 
tool

If the electronic system is unavailable for greater than 24 hours, the site will use the 
paper SAE data collection tool and fax it to the Medical Monitor Site will enter the 
serious adverse event data into the electronic system as soon as it becomes available.

The investigator will be required to confirm review of the SAE causality by ticking 
the ‘reviewed’ box at the bottom of the eCRF page within 72 hours of submission of 
the SAE.

After the study is completed at a given site, the electronic data collection tool (e.g., 
InForm system) will be taken off-line to prevent the entry of new data or changes to 
existing data

If a site receives a report of a new SAE from a study subject or receives updated data 
on a previously reported SAE after the electronic data collection tool has been taken 
off-line, the site can report this information on a paper SAE form or to the Medical 
Monitor telephone.

Contacts for SAE receipt can be found at the beginning of this protocol on the 
Sponsor/Medical Monitor Contact Information page.
 
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SAE reporting to GSK via paper CRF

Facsimile transmission of the SAE paper CRF is the preferred method to transmit 
this information to the Medical Monitor

In rare circumstances and in the absence of facsimile equipment, notification by 
telephone is acceptable, with a copy of the SAE data collection tool sent by 
overnight mail

Initial notification via the telephone does not replace the need for the investigator to 
complete and sign the SAE CRF pages within the designated reporting time frames.

Contacts for SAE receipt can be found at this beginning of the protocol on the 
Sponsor/Medical Monitor Contact Information page.
 
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12.5.
Appendix 5: Modified List of Highly Effective Methods for 
Avoiding Pregnancy and Collection of Pregnancy 
Information
12.5.1.
Modified List of Highly Effective Methods for Avoiding Pregnancy
The list does not apply to FRP with same sex partners or for subjects who are and will 
continue to be abstinent from penile-vaginal intercourse on a long term and persistent 
basis, when this is their preferred and usual lifestyle. Periodic abstinence (e.g. calendar, 
ovulation, symptothermal, post-ovulation methods) and withdrawal are not acceptable 
methods of contraception.
1.
Contraceptive subdermal implant
2.
Intrauterine device or intrauterine system
3.
Combined estrogen and progestogen oral contraceptive [Hatcher, 2011]
4.
Injectable progestogen [Hatcher, 2011]
5.
Contraceptive vaginal ring [Hatcher, 2011]
6.
Percutaneous contraceptive patches [Hatcher, 2011]
7.
Male partner sterilization with documentation of azoospermia prior to the female 
subject's entry into the study, and this male is the sole partner for that subject 
[Hatcher, 2011]. The documentation on male sterility can come from the site 
personnel’s: review of subject’s medical records, medical examination and/or semen 
analysis, or medical history interview provided by her or her partner.
These allowed methods of contraception are only effective when used consistently, 
correctly and in accordance with the product label. The investigator is responsible for 
ensuring that subjects understand how to properly use these methods of contraception.
Contraceptive requirements for male subjects with female partners of reproductive 
potential (when applicable).
Male subjects with female partners of child bearing potential must comply with the 
following contraception requirements from the time of first dose of study medication 
until [at least five half-lives of study medication OR for a cycle of spermatogenesis 
following five terminal half-lives] after the last dose of study medication.
1.
Vasectomy with documentation of azoospermia. The documentation on male sterility 
can come from the site personnel’s: review of subject’s medical records, medical 
examination and/or semen analysis, or medical history interview.
2.
Male condom plus partner use of one of the contraceptive options below that meets 
the Standard Operating Procedure (SOP) effectiveness criteria including a <1% rate 
of failure per year, as stated in the product label:

Contraceptive subdermal implant

Intrauterine device or intrauterine system
 
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
Combined estrogen and progestogen oral contraceptive [Hatcher, 2011] 

Injectable progestogen [Hatcher, 2011]

Contraceptive vaginal ring [Hatcher, 2011]

Percutaneous contraceptive patches [Hatcher, 2011]
These allowed methods of contraception are only effective when used consistently, 
correctly and in accordance with the product label. The investigator is responsible for 
ensuring that subjects understand how to properly use these methods of contraception.
12.5.2.
Collection of Pregnancy Information

Investigator will collect pregnancy information on any female subject, who becomes 
pregnant while participating in this study

Information will be recorded on the appropriate form and submitted to GSK within 2 
weeks of learning of a subject's pregnancy.

Subject will be followed to determine the outcome of the pregnancy. The 
investigator will collect follow up information on mother and infant, which will be 
forwarded to GSK.  Generally, follow-up will not be required for longer than 6 to 8 
weeks beyond the estimated delivery date. 

Any termination of pregnancy will be reported, regardless of fetal status (presence or 
absence of anomalies) or indication for procedure.

While pregnancy itself is not considered to be an AE or SAE, any pregnancy 
complication or elective termination of a pregnancy will be reported as an AE or 
SAE.

A spontaneous abortion is always considered to be an SAE and will be reported as 
such.  

Any SAE occurring as a result of a post-study pregnancy which is considered 
reasonably related to the study treatment by the investigator, will be reported to GSK 
as described in Appendix 5. While the investigator is not obligated to actively seek 
this information in former study participants, he or she may learn of an SAE through 
spontaneous reporting.
Any female subject who becomes pregnant while participating

will discontinue study medication or be withdrawn from the study

Investigator will attempt to collect pregnancy information on any female partner of a 
male study subject who becomes pregnant while participating in this study. This 
applies only to subjects who are randomised to receive study medication. 

After obtaining the necessary signed informed consent from the female partner 
directly, the investigator will record pregnancy information on the appropriate form 
and submit it to GSK within 2 weeks of learning of the partner’s pregnancy
 
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
Partner will also be followed to determine the outcome of the pregnancy.  
Information on the status of the mother and child will be forwarded to GSK. 

Generally, follow-up will be no longer than 6 to 8 weeks following the estimated 
delivery date.  Any termination of the pregnancy will be reported regardless of fetal 
status (presence or absence of anomalies) or indication for procedure.
12.5.3.
References
Hatcher R A, Trussell J, Nelson AL, Cates W Jr, Stewart F, Kowal D, Policar MS, 
editors. Contraceptive Technology. 20th edition. Atlanta, Georgia: Ardent Media, Inc., 
2011: 50. Table 3-2.
 
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12.6.
Appendix 6:  Protocol Changes
12.6.1.
Protocol Amendment 01 (24-Feb-2017) from Original Protocol 
(23-Sep-2016)
This is a global amendment.
12.6.1.1.
Summary of Changes and Rationale for Amendment
Additional Inclusion Criteria (Section 5.2) and Subject Stopping Criteria (Section 5.4) 
added in response to comments from BfArM.
12.6.1.2.
List of Specific Changes
Title Page, Author (s)
Rationale for change:  Addition and removal of author(s).
 
 
Sponsor Signatory
Rationale for change:  Change in sponsor signatory
Dr Richard Marshall Dr Aili Lazaar
Vice President, Fibrosis & Lung Injury Discovery Performance Unit (DPU) Head, 
Respiratory Therapy Area Unit Director, Discovery Medicine
Project Physician Leader, Respiratory Therapy Area
Section 5.2:  Exclusion Criteria
Rationale for change: Addition of exclusion criteria number 4 and 5.
CONCURRENT CONDITIONS/MEDICAL HISTORY (INCLUDES LIVER 
FUNCTION AND QTc INTERVAL) 
1. ALT >1.5x Upper limit of normal (ULN).
2. Bilirubin >1.5xULN (isolated bilirubin >1.5xULN is acceptable if bilirubin is 
fractionated and direct bilirubin <35%).
3. Current or chronic history of liver disease, or known hepatic or biliary abnormalities 
(with the exception of Gilbert's syndrome or asymptomatic gallstones).
4. Prior history of altitude sickness.
5. Recently been scuba diving (within 1 week before screening).
 
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6. QTc > 450 msec
NOTES:

The QTc is the QT interval corrected for heart rate according to Bazett’s 
formula (QTcB), Fridericia’s formula (QTcF), and/or another method, machine-
read or manually over-read.

The specific formula that will be used to determine eligibility and 
discontinuation for an individual subject should be determined prior to initiation 
of the study. In other words, several different formulae cannot be used to 
calculate the QTc for an individual subject and then the lowest QTc value used 
to include or discontinue the subject from the trial.

For purposes of data analysis, QTcB, QTcF, another QT correction formula, or a 
composite of available values of QTc will be used as specified in the Reporting 
and Analysis Plan (RAP).
Section 5.4:  Withdrawal/Stopping Criteria
Rationale for change: Addition of withdrawal criteria.
Subjects may be withdrawn from the study for any of the following reasons:

A subject may withdraw from study treatment at any time at his/her own request, 
or may be withdrawn at any time at the discretion of the investigator for safety, 
behavioural or administrative reasons. If a subject withdraws from the study, 
he/she may request destruction of any samples taken, and the investigator must 
document this in the site study records. 

If a subjects oxygen saturation falls below 65% at any point during the hypoxia 
challenge. 

If the subject experiences worsening shortness of breath or other symptoms, 
which in the opinion of the investigator are consistent with altitude sickness.

The Sponsor may request a subject withdraw for reasons such as significant 
protocol deviations (after discussion with the investigator).

Study is terminated by the Sponsor.
A subject will be considered to have prematurely withdrawn from the investigational 
product if they do not complete all doses in the treatment phase having received the first 
dose of investigational product, for any reason.
 
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GlaxoSmithKline group of companies
204987
1
TITLE PAGE
Division:  Worldwide Development
Information Type: Clinical Protocol
Title:
The effects of GSK2586881 on the responses to acute hypoxia 
and exercise
Compound Number:
GSK2586881
Development Phase
I
Effective Date:
23-SEP-2016
Author(s):
 
Copyright 2016 the GlaxoSmithKline group of companies.  All rights reserved.  
Unauthorised copying or use of this information is prohibited.
 
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MEDICAL MONITOR/SPONSOR INFORMATION PAGE
Medical Monitor/SAE Contact Information:
Role
Name
Day Time Phone 
Number and email 
address
After-hours 
Phone/Cell/
Pager Number
Fax 
Number
Site Address
Primary 
Medical 
Monitor
709 Swedeland 
Road
UW2531
King of Prussia, 
PA  19406 USA
Secondary 
Medical 
Monitor
Gunnels 
Wood Road, 
Stevenage, 
Hertfordshire, 
SG1 2NY, UK
SAE
contact
information
[Medical
monitor
as 
above]
Sponsor Legal Registered Address:
GlaxoSmithKline Research & Development Limited
980 Great West Road
Brentford
Middlesex, TW8 9GS
UK
In some countries, the clinical trial sponsor may be the local GlaxoSmithKline Affiliate 
Company (or designee). If applicable, the details of the alternative Sponsor and contact 
person in the territory will be provided to the relevant regulatory authority as part of the 
clinical trial application.   
Regulatory Agency Identifying Number(s): 2016-002465-55
 
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INVESTIGATOR PROTOCOL AGREEMENT PAGE

I confirm agreement to conduct the study in compliance with the protocol.

I acknowledge that I am responsible for overall study conduct. I agree to 
personally conduct or supervise the described study.

I agree to ensure that all associates, colleagues and employees assisting in the 
conduct of the study are informed about their obligations. Mechanisms are in 
place to ensure that site staff receives the appropriate information throughout the 
study.
Investigator Name: ______________________________
Investigator Signature
Date
 
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TABLE OF CONTENTS
PAGE
1.
PROTOCOL SYNOPSIS FOR STUDY 204987........................................................8
2.
INTRODUCTION....................................................................................................13
2.1.
Study Rationale ..........................................................................................14
3.
OBJECTIVE(S) AND ENDPOINT(S) ......................................................................16
4.
STUDY DESIGN ....................................................................................................18
4.1.
Overall Design ............................................................................................18
4.2.
Treatment Arms and Duration.....................................................................18
4.3.
Type and Number of Subjects.....................................................................19
4.4.
Design Justification.....................................................................................20
4.5.
Dose Justification........................................................................................20
4.6.
Benefit:Risk Assessment ............................................................................20
4.6.1.
Risk Assessment .........................................................................21
4.6.2.
Benefit Assessment.....................................................................23
4.6.3.
Overall Benefit:Risk Conclusion...................................................23
5.
SELECTION OF STUDY POPULATION AND WITHDRAWAL CRITERIA .............23
5.1.
Inclusion Criteria.........................................................................................23
5.2.
Exclusion Criteria........................................................................................26
5.3.
Screening/Baseline/Run-in Failures............................................................28
5.4.
Withdrawal/Stopping Criteria.......................................................................28
5.4.1.
Study Stopping Criteria................................................................29
5.4.2.
Liver Chemistry Stopping Criteria ................................................29
5.4.2.1.
Study Treatment Restart or Rechallenge....................30
5.5.
Subject and Study Completion....................................................................30
6.
STUDY TREATMENT ............................................................................................30
6.1.
Investigational Product and Other Study Treatment....................................30
6.2.
Planned Dose Adjustments.........................................................................31
6.3.
Blinding.......................................................................................................32
6.4.
Packaging and Labeling..............................................................................33
6.5.
Preparation/Handling/Storage/Accountability..............................................33
6.6.
Compliance with Study Treatment Administration.......................................33
6.7.
Treatment of Study Treatment Overdose....................................................34
6.8.
Treatment after the End of the Study ..........................................................34
6.8.1.
Meals and Dietary Restrictions ....................................................34
6.8.2.
Caffeine, Alcohol, and Tobacco ...................................................34
6.8.3.
Activity .........................................................................................35
6.9.
Concomitant Medications and Non-Drug Therapies....................................35
6.9.1.
Permitted Medications and Non-Drug Therapies..........................35
6.9.2.
Prohibited Medications and Non-Drug Therapies.........................35
7.
STUDY ASSESSMENTS AND PROCEDURES .....................................................36
7.1.
Time and Events Table...............................................................................37
7.1.1.
Screening and Follow up .............................................................37
7.1.2.
Treatment Period 1 and 2 ............................................................38
7.2.
Safety .........................................................................................................40
 
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7.2.1.
Adverse Events (AE) and Serious Adverse Events (SAEs)..........40
7.2.1.1.
Time period and Frequency for collecting AE 
and SAE information...................................................40
7.2.1.2.
Method of Detecting AEs and SAEs ...........................41
7.2.1.3.
Follow-up of AEs and SAEs........................................41
7.2.1.4.
Regulatory Reporting Requirements for SAEs............41
7.2.2.
Physical Exams ...........................................................................42
7.2.3.
Vital Signs....................................................................................42
7.2.4.
Electrocardiogram (ECG).............................................................42
7.2.5.
QTc Stopping Criteria ..................................................................42
7.2.6.
Clinical Safety Laboratory Assessments ......................................43
7.3.
Hypoxia Challenge......................................................................................44
7.3.1.
Exercise Challenge......................................................................45
7.4.
Echocardiogram..........................................................................................45
7.5.
Ventilatory parameters................................................................................45
7.6.
Pulse Oximetry ...........................................................................................46
7.7.
Pharmacokinetics .......................................................................................46
7.7.1.
Blood Sample Collection..............................................................46
7.7.2.
Sample Analysis ..........................................................................46
7.8.
Biomarker(s)/Pharmacodynamic Markers ...................................................46
7.8.1.
Renin-angiotensin system biomarkers .........................................46
7.8.2.
Other Biomarkers.........................................................................46
7.9.
Genetics .....................................................................................................47
7.9.1.
Blood sample collection ...............................................................47
7.10.
Immunogenicity...........................................................................................47
7.10.1.
Sample collection.........................................................................47
7.10.2.
Sample analysis...........................................................................47
8.
DATA MANAGEMENT ...........................................................................................48
9.
STATISTICAL CONSIDERATIONS AND DATA ANALYSES .................................48
9.1.
Hypotheses.................................................................................................48
9.2.
Sample Size Considerations.......................................................................48
9.2.1.
Sample Size Assumptions ...........................................................49
9.2.2.
Sample Size Re-estimation..........................................................50
9.3.
Data Analysis Considerations .....................................................................51
9.3.1.
Analysis Populations....................................................................51
9.3.2.
Interim Analysis ...........................................................................52
9.3.3.
Multiple Comparisons and Multiplicity ..........................................56
9.4.
Key Elements of Analysis Plan ...................................................................56
9.4.1.
Pharmacokinetic Analyses...........................................................57
10. STUDY GOVERNANCE CONSIDERATIONS........................................................57
10.1.
Posting of Information on Publicly Available Clinical Trial Registers............57
10.2.
Regulatory and Ethical Considerations, Including the Informed 
Consent Process ........................................................................................57
10.3.
Quality Control (Study Monitoring) ..............................................................58
10.4.
Quality Assurance.......................................................................................59
10.5.
Study and Site Closure ...............................................................................59
10.6.
Records Retention......................................................................................60
10.7.
Provision of Study Results to Investigators, Posting of Information 
on Publically Available Clinical Trials Registers and Publication .................61
 
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11. REFERENCES.......................................................................................................62
12. APPENDICES........................................................................................................65
12.1.
Appendix 1: Abbreviations and Trademarks................................................65
12.2.
Appendix 2: Liver Safety Required Actions and Follow up 
Assessments ..............................................................................................68
12.3.
Appendix 3: Genetic Research ...................................................................70
12.4.
Appendix 4: Definition of and Procedures for Recording, Evaluating, 
Follow-Up and Reporting of Adverse Events...............................................73
12.4.1.
Definition of Adverse Events........................................................73
12.4.2.
Definition of Serious Adverse Events...........................................74
12.4.3.
Definition of Cardiovascular Events .............................................76
12.4.4.
Recording of AEs and SAEs ........................................................76
12.4.5.
Evaluating AEs and SAEs............................................................77
12.4.6.
Reporting of SAEs to GSK...........................................................78
12.5.
Appendix 5: Modified List of Highly Effective Methods for Avoiding 
Pregnancy and Collection of Pregnancy Information...................................80
12.5.1.
Modified List of Highly Effective Methods for Avoiding 
Pregnancy ...................................................................................80
12.5.2.
Collection of Pregnancy Information ............................................81
12.5.3.
References ..................................................................................82
 
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1.
PROTOCOL SYNOPSIS FOR STUDY 204987
Rationale
The purpose of this study is to examine how GSK2586881, a recombinant human ACE2 
peptide, modulates the acute hypoxic pulmonary vasoconstriction (HPV) response in 
healthy volunteers.
HPV is an acute physiological response that plays a fundamental role in maintaining 
optimal arterial oxygen (PaO2) levels in health and in pathophysiological settings such as 
acute respiratory distress syndrome (ARDS) by facilitating re-distribution of pulmonary 
blood flow to areas of ventilated lung. The literature supports a role for the renin 
angiotensin system (RAS) in driving acute HPV and while there is a strong biological 
rationale for modulation of RAS in the treatment of ARDS patients, therapeutic 
strategies aimed at RAS may have unintended, negative consequences for ARDS patients 
if they blunt the normal HPV response and negatively impact on arterial oxygenation 
(PaO2). Thus, from a safety (and efficacy) perspective it is important to understand the 
impact of modulation of the RAS system by GSK2586881 on the acute HPV response.
 
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Objective(s)/Endpoint(s)
Objectives
Endpoints
Primary

To evaluate the effect of a single IV 
dose of GSK2586881 on the HPV 
response in healthy volunteers during 
exercise under hypoxic conditions.

Change from baseline of Pulmonary 
Artery Systolic Pressure (PASP) 
measured via Echocardiography.
Secondary

To evaluate the effect of a single IV 
dose GSK2586881 on RAS peptide 
responses.

To evaluate the safety of a single IV 
dose of GSK2586881 in healthy 
volunteers.

To evaluate the pharmacokinetics of a 
single IV dose of GSK2586881.

Effect of GSK2586881 on baseline 
levels and changes in response to 
hypoxia and exercise of RAS peptides 
(e.g. Ang II, Ang(1-7), Ang(1-5)).

Vital signs (heart rate, systolic and 
diastolic blood pressure), oxygen 
saturation, 12-lead ECGs, AEs, 
immunogenicity and clinical laboratory 
assessments and continuous pulse 
oximetry.

Plasma concentrations of GSK2586881 
and derived pharmacokinetic 
parameters.
 
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Objectives
Endpoints
Exploratory 

To evaluate the effect of a single IV 
dose of GSK2586881 on ventilatory 
parameters in healthy volunteers during 
exercise in hypoxic conditions.

To evaluate the effect of a single IV 
dose of GSK2586881 on peptide 
hormone responses to hypoxia and 
exercise.

To evaluate the pharmacodynamic 
activity of a single IV dose of 
GSK2586881 in healthy volunteers 
during exercise in hypoxic conditions.

To evaluate Pharmacogenetics

Change from baseline of oxygen 
consumption (VO2), carbon dioxide 
production (CO2) and other parameters
as data permit.

Baseline levels and changes in response
to hypoxia and exercise in kinins (e.g. 
des-Arg-bradykinin), apelins (e.g. 
Apelin 13, pyr1-Apelin, 13) and other 
systems (e.g. dynorphin A) as data 
permit.

Change from baseline in other  
biomarkers which may include Atrial 
Naturetic peptide (ANP), Brain 
Naturetic Peptide (NT-proBNP), 
Troponin I, Surfactant Protein D, IL-6 
and/or additional analytes to be 
determined.
Evaluate I/D polymorphisms in the 
Angiotensin Converting Enzyme 
(ACE) gene and analyse the impact on 
Ang II (and possibly other RAS 
peptides), hypoxic pulmonary 
vasoconstriction and responses to 
GSK2586881 administration.
Overall Design
The study will be single-centre , randomised, placebo-controlled and double blind
(sponsor open). Subjects will be randomised to receive a single IV dose of GSK2586881 
or saline in a crossover design.
A schematic of the study is shown below. Echocardiograms approximate timings are 
indicated by bold arrows.  
 
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APPROXIMATE TIMING OF SIMULATED ALTITUDE AND 
ECHOCARDIOGRAM MEASUREMENTS (BLACK ARROWS) 
DURING TREATMENT PERIODS 1 AND 2.
Treatment Groups, Randomisation Arms and Duration
The study is intended to follow a double blind (sponsor open) two-period cross-over 
design.
Treatment Group A: GSK2586881 0.8 mg/kg, administered as a single IV dose. . 
Treatment Group B: matching volume of placebo administered as a single IV dose.
Subjects will receive both treatments during the course of the study, and will be 
randomised to one of two sequences, each of which describes the order in which those 
treatments are received:
Sequence 1: AB: GSK2586881 in the first period followed by placebo in the second.
Sequence 2: BA: Placebo in the first period followed by GSK2586881 in the second.
The total study duration for each subject is expected to be a maximum of 56 days.
 
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Type and Number of Subjects
Approximately 35 subjects will be enrolled to ensure that a minimum of 30 subjects
complete all dosing and critical assessments (the target of 30 may be revised by the 
sample size re-estimation).
If subjects prematurely discontinue the study, additional replacement subjects will not be 
recruited in order to preserve randomisation integrity. 
Analysis
This study is designed to estimate the effect of GSK2586881 relative to placebo on 
change from baseline in PASP following exercise under hypoxic conditions. No formal 
hypothesis will be tested. Point estimates will be calculated together with corresponding 
95% confidence intervals (or credible intervals if utilising a Bayesian framework) for the 
difference between the mean of the test treatment and the mean of the reference 
treatment.
Analysis of PASP: Statistical modelling of changes from baseline (Ti-T0) will be done 
using a Bayesian mixed effects regression model, including covariates for period, 
treatment, period baseline and subject baseline (the mean of the two period baselines) as 
fixed effects and subject as a random effect. A compound symmetric covariance structure 
within each subject-period-treatment cell will be assumed to account for repeated 
measurements a) inherent in the two-period crossover design and b) due to the four post-
baseline timepoints within each treatment period. Non-informative priors will be used for 
the model parameters. Posterior distributions will be obtained for the GSK2586881 Vs 
Placebo comparisons at each of the post dosing timepoints (T1-T4). These distributions 
will be used to produce several posterior probability statements; the most important being 
the probability that the change from baseline in PASP is reduced by the GSK2586881at 
time T3. 
Oxygenation saturation will also be analysed in a similar way; although of interest is the 
posterior probability that the study drug causes (absolute) reductions in oxygenation 
saturation in excess of 5%.
An interim analysis is planned after 15 subjects have completed period 1 and 2 
assessments to i) evaluate safety and tolerability (SAE, AE and Oxygenation saturation), 
ii) determine whether the study should stop for futility based on expected PASP 
outcomes if the study were allowed to complete recruitment and iii) Re-estimate the 
sample size based using the observed variance parameters.
 
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2.
INTRODUCTION
GSK2586881 is a purified intravenous formulation of soluble recombinant human  
angiotensin converting enzyme type 2 (rhACE2) which is expressed in Chinese Hamster  
Ovary cells. Angiotensin converting enzyme type 2 (ACE2) is a zinc carboxypeptidase 
involved in the Renin-Angiotensin System  (RAS) that controls blood pressure, 
electrolytes, and intravascular fluid volume. A key function of ACE2 is believed to be the 
cleavage of Angiotensin II (Ang II) to Ang (1-7), which have opposing physiological 
roles. Elevated levels of Ang II are associated with vasoconstriction, inflammation, 
fibrosis, vascular leak, and sodium absorption. Ang (1-7) appears to be a counter-
regulatory protein in the RAS; associated with vasodilation, anti-proliferation, anti-
inflammation, and reduced vascular leak, as noted in Figure 1 below [Paul, 1992; Santos, 
2005; Suzuki, 2003].
Figure 1
Renin Angiotensin System
Angiotensinogen
Angiotensin I (1-10)
Angiotensin II(1-8)
Angiotensin (1-9)
Angiotensin (1-7)
Renin
ACE 1
Aldosterone
Vascular leak
Vasoconstriction
Pro-inflammatory
Pro-fibrotic/apoptotic
Sodium/water retention
ACE 1
ACE 2
ACE 2
Reduced vascular leak
Vasodilatation
Anti-inflammatory
Anti-proliferation/apoptotic
Ang II binds to two distinct receptors called AT-1 and AT-2, with the AT-1 receptor 
mediating the vasoconstrictive, proliferative and pro-inflammatory actions of Ang II. The
function of the AT-2 receptor has not been fully elucidated. Ang (1-7) initiates its effects
by binding to the Mas-receptor, and also acts by inhibiting the activity of the
carboxyterminal domain of angiotensin converting enzyme (ACE), which prevents ACE
from fully acting on its substrates Angiotensin I and bradykinin.
ACE and Angiotensin II has been implicated in the pathogenesis of the acute respiratory 
distress syndrome (ARDS, and pulmonary hypertension. It has been observed that 
circulating Ang II levels and lung ACE levels are increased in humans with ARDS and 
pulmonary hypertension. It has also been shown that the DD ACE polymorphism, which
is associated with higher ACE activity, is associated with susceptibility to development
of lung injury and worsened outcome (mortality) in patients with ARDS [Marshall, 2002]
and to the development of pulmonary hypertension [Abraham, 2003]
 
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It is expected that the reduction of Ang II and simultaneous formation of Ang (1-7)
should have positive impacts in ARDS and on pulmonary haemodynamics in patients 
with pulmonary hypertension. This dual action can be achieved by ACE2, and thus, an 
enhancement of the activity of this enzyme is seen as promising approach for the 
treatment of diseases and conditions with an imbalance of the RAS system, insufficient 
natural ACE2 activity, and pathologically elevated Ang II levels or decreased Ang (1-7) 
such as is observed in ALI/ARDS [Tom, 2001; Idell S, 1987; Santos, 2003; Wenz, 2000]
and pulmonary hypertension [Maron, 2014]
This study will demonstrate how GSK2586881 modulates the acute HPV response in 
healthy volunteers. 
2.1.
Study Rationale
Hypoxic pulmonary vasoconstriction (HPV) is an acute physiological response that plays 
a fundamental role in maintaining optimal arterial oxygen (PaO2) levels in health and in 
pathophysiological settings such as acute respiratory distress syndrome (ARDS) by 
facilitating re-distribution of pulmonary blood flow to areas of ventilated lung. However, 
in many ARDS patients with pulmonary microvascular injury and dystonia, the normal 
HPV reflex is compromised resulting in the mismatching of perfusion (Q) and ventilation 
(VA) and formation of areas of low perfusion to ventilated alveoli (high VA/Q; 
physiological deadspace), or perfusion of alveoli with minimal or no ventilation (low 
V/Q; physiological shunt).  
The literature is conflicting as to the role of the RAS in modulating the HPV response; 
however, the majority of reports support a role for the RAS in driving acute HPV (Cargil, 
1996; Kiely, 1996). While there is a strong biological rationale for modulation of the 
RAS in the treatment of ARDS patients, therapeutic strategies aimed at RAS may have 
unintended, negative consequences for ARDS patients if they impact on PaO2 and 
produce a blunted HPV response. Surprisingly, there are scant data regarding the effect of 
RAS modulation on HPV, V-Q matching or PaO2 in healthy human volunteers.
Inhibition of the acute HPV response would be expected to promote blood flow to areas 
of poorly-ventilated lung resulting in an increase in venous admixture and a reduction in 
PaO2 levels. In the context of acute lung injury, correction of any V/Q mismatch would 
be expected to be beneficial with respect to maintaining and improving PaO2 levels. 
Conversely, inhibition of HPV by pharmacological agents might be expected to worsen 
V/Q matching and compromise PaO2 levels. Thus, from a safety (and efficacy) 
perspective it is vital to understand the impact of modulation of the RAS system on the 
acute HPV response and subsequent PaO2.
Recombinant human ACE2 (rhACE2) delivered intravenously to pigs inhibits the HPV 
response to acute hypoxic challenge assessed by inhibition of mean pulmonary artery 
pressures and pulmonary vascular resistance. There was also a strong trend to increased 
shunt with administration of rhACE2; however PaO2 was not significantly affected. The 
authors concluded that the increased shunt may not have been sufficient to result in a 
reduction in PaO2 (Kleinsasser., 2012). 
 
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An elegant study by Wagner and colleagues demonstrated the importance of end arterial 
capillary diffusion limitations on PaO2 levels in healthy volunteers during hypoxia ± 
exercise (Torre-Bueno, 1985). Diffusion limitation made a significant contribution to 
PaO2 levels particularly under conditions where exercise and hypoxia were combined. In 
addition, V/Q mismatching was suggested to increase with the combined stresses of 
exercise and hypoxia resulting in significantly more arterial oxygen desaturation than 
observed with either stressor by itself.
The main goals of this study are to examine whether GSK2586881 modulates the acute 
HPV response in healthy volunteers with a subsequent impact on O2 saturation.  Should 
the application of GSK2586881 lead to accentuated arterial oxygen desaturation, further 
clinical studies to examine the therapeutic efficacy of GSK2586881 in acute lung injury 
should be approached with caution. Conversely, a reduction in HPV without augmented 
hypoxemia would provide supporting evidence that GSK2586881 could have a positive 
impact in patients with pulmonary hypertension.
 
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3.
OBJECTIVE(S) AND ENDPOINT(S)
Objectives
Endpoints
Primary

To evaluate the effect of a single IV 
dose of GSK2586881 on the HPV 
response in healthy volunteers during 
exercise under hypoxic conditions.

Change from baseline of Pulmonary 
Artery Systolic Pressure (PASP) 
measured via Echocardiography.
Secondary

To evaluate the effect of a single IV 
dose GSK2586881 on RAS peptide 
responses. 

To evaluate the safety of a single IV 
dose of GSK2586881 in healthy 
volunteers.

To evaluate the pharmacokinetics of a 
single IV dose of GSK2586881.

Effect of GSK2586881 on baseline 
levels and changes in response to 
hypoxia and exercise of RAS peptides 
(e.g. Ang II, Ang(1-7), Ang(1-5)).

Vital signs (heart rate, systolic and 
diastolic blood pressure), oxygen 
saturation, 12-lead ECGs, AEs, 
immunogenicity and clinical laboratory 
assessments and continuous pulse 
oximetry. 

Plasma concentrations of GSK2586881 
and derived pharmacokinetic 
parameters.
 
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Objectives
Endpoints
Exploratory 

To evaluate the effect of a single IV 
dose of GSK2586881 on ventilatory 
parameters in healthy volunteers during 
exercise in hypoxic conditions.

To evaluate the effect of a single IV 
dose of GSK2586881 on peptide 
hormone responses to hypoxia and 
exercise.

To evaluate the pharmacodynamic 
activity of a single IV dose of 
GSK2586881 in healthy volunteers 
during exercise in hypoxic conditions.

To evaluate Pharmacogenetics 

Change from baseline of oxygen 
consumption (VO2), carbon dioxide 
production (CO2) and other parameters
as data permit.

Baseline levels and changes in response
to hypoxia and exercise in kinins (e.g. 
des-Arg-bradykinin), apelins (e.g. 
Apelin 13, pyr1-Apelin, 13) and other 
systems (e.g. dynorphin A) as data 
permit.

Change from baseline in other  
biomarkers which may include Atrial 
Naturetic peptide (ANP), Brain 
Naturetic Peptide (NT-proBNP), 
Troponin I, Surfactant Protein D, IL-6 
and/or additional analytes to be 
determined.
Evaluate I/D polymorphisms in the 
Angiotensin Converting Enzyme 
(ACE) gene and analyse the impact on 
Ang II (and possibly other RAS 
peptides), hypoxic pulmonary 
vasoconstriction and responses to 
GSK2586881 administration.
 
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4.
STUDY DESIGN
4.1.
Overall Design
This is a single-centre, randomised, placebo-controlled  and double blind (sponsor open), 
two-period crossover study in healthy subjects. 
The subjects will be required to attend the unit for a screening visit, treatment period 1, 
treatment period 2 and a follow up visit.
4.2.
Treatment Arms and Duration
Figure 2
Subject participation flow
The subjects must participate in the procedures detailed in the Time and Events Table 
(Section 7.1) and the timings of the simulated altitude, exercise and echocardiograms is 
shown in Figure 3
. 
 
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Figure 3
Approximate timing of simulated altitude and echocardiogram 
measurements (black arrows) during  Treatment Periods 1 and 2
There will be a washout period of 3-14 days between treatments to ensure biomarkers 
return to pre-challenge baseline. Subjects then return to the site and repeat the same 
procedures as above, except that they will receive the treatment (GSK2586881 or Saline) 
that they did not receive in the first period.
Follow Up
This will occur up to 10 days after the end of the second treatment period. During the 
visit various safety tests will be conducted (see time and events table in Section 7.1). 
The total study duration for each subject is expected to be a maximum of 56 days.
4.3.
Type and Number of Subjects
Approximately 35 subjects healthy volunteers will be randomised such that 
approximately 30 evaluable subjects complete the study (the target of 30 may be revised 
following the sample size re-estimation) see Section 9.2.2).
If subjects prematurely discontinue the study, additional replacement subjects will not be 
recruited in order to preserve randomisation integrity.
 
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4.4.
Design Justification
The study design is based on a paper published by Ricart, 2005 and is considered to be 
feasible. The study will provide important information on whether GSK2586881
modulates the acute HPV response in healthy volunteers.  In addition, the study will 
include assessments of PK and PD effects of GSK2586881.  This will be achieved by 
assessing blood levels of GSK2586881 and RAS peptide responses throughout the 
duration of the hypoxia challenges.
The study will be placebo controlled (saline) so each subject can be used as their own 
control.
4.5.
Dose Justification
GSK2586881 has been studied in 21 healthy subjects as single, intravenous doses over 30 
minutes from 0.1 mg/kg to 1.2 mg/kg, and in repeated daily doses for up to six days of 
0.4 mg/kg once a day.  In addition, ARDS patients have received four doses of 
GSK2586881: 0.1 mg/kg, 0.2 mg.kg, 0.4 mg/kg and 0.8 mg/kg over a 24 hour period 
(n=5) or 0.4 mg/kg BID twice daily for 3 days (n=19). One subject with Pulmonary 
Arterial Hypertension (PAH) has received a single dose of 0.2 mg/kg.
A population PK model for GSK2586881 was derived from data obtained in healthy 
subjects and ARDS patients and showed that the systemic PK profile was adequately 
described by a two-compartment first order elimination model and that the PK profile 
was independent of population (health subjects or ARDS patients).  Furthermore the 
PKPD response (AngII) in healthy subjects and ARDS patients was consistent with a 
single direct Emax model after accounting for differences in baseline AngII 
concentrations between healthy subjects and ARDS patients.  
Based on the population PK/PD model described above, single intravenous doses of 0.4 -
1.2 mg/kg GSK2586881 are predicted to reduce elevated levels of AngII (baseline AngII 
consistent with an ARDS population) to levels consistent with that observed in healthy 
subjects for the duration of the hypoxic challenge (approx 2.25h). The dose of 0.8 mg/kg 
has been selected to ensure maximal reduction of AngII levels, whilst maintaining dosing 
volumes within acceptable limits, and will further aid the understanding of the PK/PD 
relationship for GSK2586881.
4.6.
Benefit:Risk Assessment
Summaries of findings from both clinical and non-clinical studies conducted with 
GSK2586881 can be found in the Investigator’s Brochure (GlaxoSmithKline Document 
Number 2010N108777_00 , 2015).  The following section outlines the risk assessment 
and mitigation strategy for this protocol:  
 
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4.6.1.
Risk Assessment
Potential Risk of Clinical Significance
Summary of Data/Rationale for Risk
Mitigation Strategy
Investigational Product (IP) [GSK2586881]
Cardiovascular risk
Potential Reproductive/embryofetal risks
Potential for Immunogenicity
Potential for rash
During preclinical testing a brief period of 
non-sustained ventricular tachycardia was 
observed in one monkey receiving a dose of 
20.8 mg/kg/day.
Preclinical studies have not been performed
There has been no induction of an immune 
response to rhACE2 in either of the clinical 
studies to date in healthy subjects or 
participants with ARDS.
In study ACE114622, rash was reported 
more frequently in subjects receiving 
GSK2586881, although only one event was 
considered drug-related.
The dose used in this study is much 
lower.and well below the No observed 
adverse effect level (NOAEL) for the 14 
day repeat dose cynomolgus monkeys of 8 
mg/kg/day.  
Women of childbearing potential will be 
excluded from the study.
Patients will have routine monitoring of any 
immunological response that may occur.  If 
an immunological response is seen the 
patient will be asked to return for further 
monitoring and assessment(s).
Patients will be monitored for rash in the 
clinical trials.
 
 
 
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Potential Risk of Clinical Significance
Summary of Data/Rationale for Risk
Mitigation Strategy
Study Procedures
Effects of hypoxia (light headiness, 
headaches, nausea)
The subjects will be exposed to hypoxic 
conditions for approximately 90 minutes 
with a simulated altitude of 4000m 
The subjects will be continuously observed 
and monitored with telemetry and pulse 
oximetry. Stopping criteria are included in 
the protocol.
 
 
 
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4.6.2.
Benefit Assessment
There will be no intended therapeutic clinical benefit to the subjects taking part in the 
study as it is a healthy volunteer study. However, subjects will undergo a medical 
evaluation during screening including physical exams, ECGs and laboratory assessments 
which may provide important health information.
By taking part in this study the subject will be contributing to the development of 
GSK2586881 for the treatment of pulmonary hypertension and ARDS. 
4.6.3.
Overall Benefit:Risk Conclusion
The design of the study is considered low risk to the subjects and justified based on the 
work carried out by other researchers, the safety information from the nonclinical studies
and the two previous clinical trials carried out on GSK2586881. 
5.
SELECTION OF STUDY POPULATION AND 
WITHDRAWAL CRITERIA
Specific information regarding warnings, precautions, contraindications, adverse events, 
and other pertinent information on the GSK investigational product or other study 
treatment that may impact subject eligibility is provided in the IB.
Deviations from inclusion and exclusion criteria are not allowed because they can 
potentially jeopardize the scientific integrity of the study, regulatory acceptability or 
subject safety. Therefore, adherence to the criteria as specified in the protocol is essential.
5.1.
Inclusion Criteria
A subject will be eligible for inclusion in this study only if all of the following criteria 
apply:
AGE
1. Between 18 and 40 years of age inclusive, at the time of signing the informed 
consent.
TYPE OF SUBJECT 
2. Healthy as determined by the investigator or medically qualified designee based on a 
medical evaluation including medical history, physical examination, laboratory tests 
and cardiac monitoring.
A subject with a clinical abnormality or laboratory parameter(s) which is/are not 
specifically listed in the inclusion or exclusion criteria, outside the reference range for 
the population being studied may be included only if the investigator [in consultation 
with the Medical Monitor if required] agree and document that the finding is unlikely 
to introduce additional risk factors and will not interfere with the study procedures. 
Note:  Screened subjects with laboratory values outside of the normal range may be 
 
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repeated once for inclusion into the study at the discretion of the Investigator.
3. Screening echocardiogram of good quality, without clinically significant 
abnormalities, and with mild-moderate tricuspid regurgitation sufficient for the 
reliable estimation of PASP, as determined by the echocardiography core laboratory 
or responsible cardiologist.
Screening PASP within the normal range according to site standards.
4. Subjects have not resided at an altitude >1500m for more than 7 days in the last  4 
month
5. Able to complete all study procedures.
6.
Any contraindication (orthopaedic, cardiac etc.) to perform exercise on a bicycle 
ergometer.
WEIGHT
7. Body weight 50-100 kg (inclusive).
SEX
8. Male or female (non CBP)
Male subjects with female partners of child bearing potential must comply with the 
following contraception requirements from the time of first dose of study medication 
until at least five half-lives of study medication OR for a cycle of spermatogenesis 
following five terminal half-lives after the last dose of study medication.
a. Vasectomy with documentation of azoospermia.  
b. Male condom plus partner use of one of the contraceptive options below:

Contraceptive subdermal implant 

Intrauterine device or intrauterine system 

Oral Contraceptive, either combined or progestogen alone [Hatcher, 2007a] 
Injectable progestogen [Hatcher, 2007a]

Contraceptive vaginal ring [Hatcher, 2007a]

Percutaneous contraceptive patches [Hatcher, 2007a]
This is an all-inclusive list of those methods that meet the following GSK definition of 
highly effective: having a failure rate of less than 1% per year when used consistently and 
correctly and, when applicable, in accordance with the product label. For non-product 
methods (e.g., male sterility), the investigator determines what is consistent and correct 
use. The GSK definition is based on the definition provided by the International 
Conference on Harmonization (ICH) [ICH, M3 (R2) 2009].”
 
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The investigator is responsible for ensuring that subjects understand how to properly use 
these methods of contraception.
This is an all inclusive list of those methods that meet the GSK definition of highly 
effective: having a failure rate of less than 1% per year when used consistently and, 
correctly and, when applicable, in accordance with the product label.  For non-product 
methods (e.g. male sterility), the investigator determines what is consistent and correct 
use. The GSK definition is based on the definition provided by ICH [ICH, M3 (R2) 
2009].
The investigator is responsible for ensuring that subjects understand how to properly use 
these methods of contraception.
Females: 
A female subject is eligible to participate if she is not pregnant (as confirmed by a 
negative urine human chorionic gonadotrophin (hCG) test), not lactating, and the 
following condition applies:
Non-reproductive potential defined as:
Pre-menopausal females with one of the following:
Documented tubal ligation
Documented hysteroscopic tubal occlusion procedure with follow-up 
confirmation of bilateral tubal occlusion 
Hysterectomy
Documented Bilateral Oophorectomy
Postmenopausal defined as 12 months of spontaneous amenorrhea [in 
questionable cases a blood sample with simultaneous follicle stimulating 
hormone (FSH) and estradiol levels consistent with menopause (refer to 
laboratory reference ranges for confirmatory levels)].  Females on hormone 
replacement therapy (HRT) and whose menopausal status is in doubt will be 
required to use one of the highly effective contraception methods if they wish to 
continue their HRT during the study.  Otherwise, they must discontinue HRT to 
allow confirmation of post-menopausal status prior to study enrolment.
The investigator is responsible for ensuring that subjects understand how to properly use 
these methods of contraception.
INFORMED CONSENT
9. Capable of giving signed informed consent as described in Section 7.2 which includes 
compliance with the requirements and restrictions listed in the consent form and in 
this protocol.
 
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5.2.
Exclusion Criteria
A subject will not be eligible for inclusion in this study if any of the following criteria 
apply:
CONCURRENT CONDITIONS/MEDICAL HISTORY (INCLUDES LIVER 
FUNCTION AND QTc INTERVAL) 
1. ALT >1.5x Upper limit of normal (ULN).
2. Bilirubin >1.5xULN (isolated bilirubin >1.5xULN is acceptable if bilirubin is 
fractionated and direct bilirubin <35%).
3. Current or chronic history of liver disease, or known hepatic or biliary abnormalities 
(with the exception of Gilbert's syndrome or asymptomatic gallstones).
4. QTc > 450 msec
NOTES:

The QTc is the QT interval corrected for heart rate according to Bazett’s 
formula (QTcB), Fridericia’s formula (QTcF), and/or another method, machine-
read or manually over-read.

The specific formula that will be used to determine eligibility and 
discontinuation for an individual subject should be determined prior to initiation 
of the study. In other words, several different formulae cannot be used to 
calculate the QTc for an individual subject and then the lowest QTc value used 
to include or discontinue the subject from the trial.

For purposes of data analysis, QTcB, QTcF, another QT correction formula, or a 
composite of available values of QTc will be used as specified in the Reporting 
and Analysis Plan (RAP).
CONCOMITANT MEDICATIONS
5.
Unable to refrain from prescription or non-prescription drugs, including agents active 
in the central nervous system, vitamins, herbal and dietary supplements (including St 
John’s Wort) within 7 days (or 14 days if the drug is a potential enzyme inducer) or 5 
half-lives (whichever is longer) prior to the first dose of study medication and 
throughout the study, unless in the opinion of the Investigator and/or GSK Medical 
Monitor (if needed) the medication will not interfere with the study procedures or 
compromise subject safety.
 
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RELEVANT HABITS
6. History of regular alcohol consumption within 6 months of the study defined as:

An average weekly intake of >21 units for males or >14 units for females. 
One unit is equivalent to 8 g of alcohol: a half-pint (~240 ml) of beer, 1 glass 
(125 ml) of wine or 1 (25 ml) measure of spirits
7. Urinary cotinine levels indicative of smoking or history or regular use of tobacco- or 
nicotine-containing products within 6 months prior to screening
CONTRAINDICATIONS 
8. History of sensitivity to any of the study medications, or components thereof or a 
history of drug or other allergy that, in the opinion of the investigator or Medical 
Monitor, contraindicates their participation.
DIAGNOSTIC ASSESSMENTS AND OTHER CRITERIA
9. Presence of hepatitis B surface antigen (HBsAg), positive hepatitis C antibody test
result at screening or within 3 months prior to first dose of study treatment. For potent
immunosuppressive agents, subjects with presence of hepatitis B core antibody
(HBcAb) should also be excluded.
10. A positive pre-study drug/alcohol screen.
11. A positive test for HIV antibody.
12. Where participation in the study would result in donation of blood or blood products
in excess of 500 ml within 56 days.
13. The subject has participated in a clinical trial and has received an investigational
product within the following time period prior to the first dosing day in the current
study: 30 days, 5 half-lives or twice the duration of the biological effect of the
investigational product (whichever is longer).
14. Exposure to more than four new chemical entities within 12 months prior to the first 
dosing day.
 
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5.3.
Screening/Baseline/Run-in Failures
Screen failures are defined as subjects who consent to participate in the clinical trial but 
are never subsequently randomised. In order to ensure transparent reporting of screen 
failure subjects, meet the Consolidated Standards of Reporting Trials (CONSORT) 
publishing requirements, and respond to queries from Regulatory authorities, a minimal 
set of screen failure information is required including Demography, Screen Failure 
details, Eligibility Criteria, and Serious Adverse Events (Section 7.2.1.4).
Subjects that are not enrolled into the study within the allotted screening window may be 
re-screened once. If re-screening is performed, subjects are assigned a different unique 
subject Identification (ID) number for the re-screening, and all screening procedures must 
be repeated.
See the SRM for specific details.
5.4.
Withdrawal/Stopping Criteria

Subjects may be withdrawn from the study for any of the following reasons:A 
subject may withdraw from study treatment at any time at his/her own request, or 
may be withdrawn at any time at the discretion of the investigator for safety, 
behavioural or administrative reasons. If a subject withdraws from the study, 
he/she may request destruction of any samples taken, and the investigator must 
document this in the site study records. 

If a subjects oxygen saturation falls below 65% at any point during the hypoxia 
challenge. 

The Sponsor may request a subject withdraw for reasons such as significant 
protocol deviations (after discussion with the investigator).

Study is terminated by the Sponsor.
A subject will be considered to have prematurely withdrawn from the investigational
product if they do not complete all doses in the treatment phase having received the first
dose of investigational product, for any reason.
Once a subject has discontinued investigational product the subject may not re-enter the
study. Dosing of the subjects with the investigational product may be stopped at any time, 
at the request of the subject or at the discretion of the Investigator (i.e. if clinically
significant adverse events should occur). Withdrawal due to adverse events will be 
distinguished from withdrawal for other reasons.
If a subject decides to withdraw or is withdrawn by the Investigator, the reasons for
withdrawal and the results of any relevant tests will be recorded in the Case Report Form 
(CRF) and the planned follow-up procedures will be performed, where possible.
The following actions must be taken in relation to a subject who fails to attend the clinic 
for a required study visit:
 
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
The site must attempt to contact the subject and re-schedule the missed visit as 
soon as possible. 

The site must counsel the subject on the importance of maintaining the assigned 
visit schedule and ascertain whether or not the subject wishes to and/or should 
continue in the study. 

In cases where the subject is deemed ‘lost to follow up’, the investigator or 
designee must make every effort to regain contact with the subject (where 
possible, 3 telephone calls and if necessary a certified letter to the subject’s last 
known mailing address or local equivalent methods). These contact attempts 
should be documented in the subject’s medical record. 

Should the subject continue to be unreachable, only then will he/she be considered 
to have withdrawn from the study with a primary reason of “Lost to Follow-up”.
5.4.1.
Study Stopping Criteria
An interim analysis is planned after approximately 15 subjects have completed treatment 
periods 1 and 2 and the study may be stopped if a reasonable change in PASP is not 
observed after dosing with GSK 2586881 or if review of the safety data suggests a 
change in the benefit-risk profile. The decision to stop the study will be made by the core 
members of the GSK study team.
Safety data that is collected on a continuous basis (oxygen saturation and telemetry) will 
be monitored live on site to determine whether a subject tolerates the hypoxia/exercise 
challenge; study procedures may be aborted on safety grounds if, in the Investigator's 
opinion, any of these measurements reach unsafe levels. The simulated altitude within the 
chamber may be reduced if too many participants fail to tolerate the challenge, and the 
study may be stopped if participants fail to tolerate the challenge at the minimum altitude. 
The full criteria for this procedure (which may lead to the study being stopped) are 
described in Section 7.3.
In addition, the study may be stopped at the interim analysis for a safety signal in oxygen 
saturation under hypoxia and exercise, combined with a lack of evidence of mechanistic 
effect on Angiotensin biomarkers (Ang II, Ang 1-7 and Ang 1-5). Full details on stopping 
criteria are described together with the full procedure for the interim analysis in Section 
9.3.2.
5.4.2.
Liver Chemistry Stopping Criteria
Liver chemistry stopping and increased monitoring criteria have been designed to 
assure subject safety and evaluate liver event etiology (in alignment with the Food and 
Drug Administration (FDA) premarketing clinical liver safety guidance). 
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guid
ances/UCM174090.pdf
Study treatment will be discontinued for a subject if liver chemistry stopping criteria are
met.
 
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Phase I Liver Chemistry Stopping Criteria – Liver Stopping Event Algorithm
Continue Study Treatment 
Discontinue Study Treatment 
*INR value not applicable to subjects on anticoagulants 
ALT ≥3xULN 
No
Yes
Must refer to Liver Safety Required Actions and Follow up Assessments  section in the Appendix
Report as an SAE if possible Hy’s Law case: ALT≥3xULN and  Bilirubin≥2xULN (>35% direct)  or 
INR>1.5, if measured*
Liver Safety Required Actions and Follow up Assessments Section can be found in
Appendix 2.
5.4.2.1.
Study Treatment Restart or Rechallenge
Study treatment restart or rechallenge after liver chemistry stopping criteria are met by 
any subject participating in this study is not allowed.
5.5.
Subject and Study Completion
A completed subject is one who has completed all phases of the study including the 
follow-up visit.
The end of the study is defined as the last subjects last visit.
6.
STUDY TREATMENT
6.1.
Investigational Product and Other Study Treatment
The term ‘study treatment’ is used throughout the protocol to describe any combination 
of products received by the subject as per the protocol design. Study treatment may 
therefore refer to the individual study treatments or the combination of those study 
treatments.
 
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Study Treatment
Product name:
(Generic name and trade)
GSK2586881
Placebo
[Formulation description:]
rhACE2
Normal Saline (0.9%)
Dosage form:
IV
IV
Unit dose strength(s)/Dosage 
level(s):
0.8 mg/kg
Saline Placebo
Route of Administration E.g. oral, 
for IV infusion, for IV injection, 
intravitreal use etc
Intravenous
Intravenous
Dosing instructions:
Infuse over 3-5 minutes
Infuse over 3-5 minutes
[Physical description:]
Clear colourless liquid 
Clear colourless liquid
At Screening a unique Subject Number (CRF number) will be assigned to any subject 
who has at least one Screening procedure performed, other than informed consent. The 
unique Subject Number will be used to identify individual subjects during the course of 
the study.
Subjects who meet screening eligibility criteria will be assigned to one of the sequences 
listed in Table 1 below, in accordance with the randomisation schedule generated by 
Clinical Statistics, prior to the start of the study, using validated internal software. Once 
assigned, this number must not be reassigned to any other subject in the study.
Table 1
Description of sequences
Sequence
Period 1
Period 2
AB
GSK2586881
Saline Placebo
BA
Saline Placebo
GSK2586881
The subjects will be randomised using a central randomisation procedure created by 
GSK. 
Further details on how and when a subject is allocated a randomisation number and the 
subject numbering convention is in the SRM
6.2.
Planned Dose Adjustments
No dose adjustments are allowed.
 
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6.3.
Blinding
This will be double blind (sponsor open) study. All study staff involved in clinical 
assessments (which includes the investigator, sub-investigators, other site staff), and the 
subject will be blinded to the treatment allocated to individual subjects. An unblinded 
qualified staff member will be required at site to prepare the study treatment for dosing. 
The unblindedstaff member is not permitted to communicate the subject’s treatment 
allocation to blinded site staff. Selected study team members working for the sponsor 
(and delegates if programming activities are outsourced) will be unblinded to perform the 
interim analysis. This will include the medical monitor, study statistician, study 
programmer (and delegates) and study pharmacokineticist. Access to unblinded data will 
be kept to the minimum set of individuals required to implement any interim analyses but 
may include GSK management/review committees if alterations to the study conduct are 
required. Details of who were unblinded to what data and when will be included in the 
clinical study report.
The following will apply: 

The investigator or treating physician may unblind a subject’s treatment 
assignment only in the case of an emergency OR in the event of a serious 
medical condition when knowledge of the study treatment is essential for the 
appropriate clinical management or welfare of the subject as judged by the 
investigator. 

Investigators have direct access to the subject’s individual study treatment. 

It is preferred (but not required) that the investigator first contacts the Medical 
Monitor or appropriate GSK study personnel to discuss options before unblinding 
the subject’s treatment assignment. 

If GSK personnel are not contacted before the unblinding, the investigator must 
notify GSK as soon as possible after unblinding, but without revealing the 
treatment assignment of the unblinded subject, unless that information is 
important for the safety of subjects currently in the study. 

The date and reason for the unblinding must be fully documented in the  CRF
A subject whose treatment sequence assignment is unblinded for emergency reasons (as 
described above) will not be permitted to continue in the study (due to the emergency 
requiring unblinding rather than the unblinding itself). The event or condition that led to 
the unblinding will be recorded in the CRF as the primary reason for discontinuation.
A subject whose treatment sequence assignment is inadvertently unblinded (either to 
investigative staff or the subject themselves) will be permitted to remain in the study, 
although the accidental unblinding will be recorded as a protocol deviation and hence the 
subject will be subject to review as to their inclusion in analyses as per the procedures set 
out in Section 9.3.1.
 
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6.4.
Packaging and Labeling
The contents of the label will be in accordance with all applicable regulatory 
requirements.
6.5.
Preparation/Handling/Storage/Accountability
A description of the methods and materials required for GSK2586881 will be detailed in 
a Study Specific Technical Agreement/Memo (TTS) or Pharmacy Manual which will be 
accompanied by a Quality Agreement.

The investigator or designee must confirm appropriate temperature conditions 
have been maintained during transit for all study treatment received and any 
discrepancies are reported and resolved before use of the study treatment.

Only subjects enrolled in the study may receive study treatment and only 
authorized site staff may supply or administer study treatment.  All study 
treatments must be stored in a secure environmentally controlled and monitored 
(manual or automated) area in accordance with the labelled storage conditions 
with access limited to the investigator and authorized site staff. 

The investigator, institution, or the head of the medical institution (where 
applicable) is responsible for study treatment accountability, reconciliation, and 
record maintenance (i.e. receipt, reconciliation and final disposition records).  

Further guidance and information for final disposition of unused study treatment 
are provided in the Study Reference Manual (SRM).

Under normal conditions of handling and administration, study treatment is not 
expected to pose significant safety risks to site staff.  Take adequate precautions to 
avoid direct eye or skin contact and the generation of aerosols or mists. In the case 
of unintentional occupational exposure notify the monitor, Medical Monitor 
and/or GSK study contact.

A Material Safety Data Sheet (MSDS)/equivalent document describing 
occupational hazards and recommended handling precautions either will be 
provided to the investigator, where this is required by local laws, or is available 
upon request from GSK.
6.6.
Compliance with Study Treatment Administration
When the individual dose for a subject is prepared from a bulk supply, the preparation of 
the dose will be confirmed by a second member of the study site staff. 
When subjects are dosed at the site, they will receive study treatment directly from the 
investigator or designee, under medical supervision.  The date and time of each dose 
administered in the clinic will be recorded in the source documents.  The dose of study 
treatment and study subject identification will be confirmed at the time of dosing by a 
member of the study site staff other than the person administering the study treatment.  
 
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GSK2586881 and the saline placebo will be intravenously administered to subjects at the 
site.  Administration will be documented in the source documents and reported in the 
CRF.
6.7.
Treatment of Study Treatment Overdose
For this study, any dose of GSK2586881 > 1.5 mg/kg within a 24 hour time period 
will be considered an overdose.
GSK does not recommend specific treatment for an overdose. The investigator will use 
clinical judgment to treat any overdose.
In the event of an overdose the investigator or treating physician should:
1.
contact the Medical Monitor immediately
2.
closely monitor the subject for adverse events (AEs)/serious adverse events (SAEs) 
and laboratory abnormalities until GSK2586881can no longer be detected 
systemically (at least 3 days for GSK2586881).
3.
obtain a plasma sample for pharmacokinetic (PK) analysis within 1 day from the date 
of the last dose of study treatment if requested by the Medical Monitor (determined 
on a case-by-case basis)
4.
document the quantity of the excess dose as well as the duration of the overdosing in 
the CRF.
Decisions regarding dose interruptions or modifications will be made by the investigator 
in consultation with the Medical Monitor based on the clinical evaluation of the subject.
6.8.
Treatment after the End of the Study
Subjects will not receive any additional treatment from GSK after completion of the 
study because only healthy volunteers are eligible for study participation.
6.8.1.
Meals and Dietary Restrictions

No dietary restrictions prior to first treatment.
6.8.2.
Caffeine, Alcohol, and Tobacco

During each dosing session, subjects will abstain from caffeine for 12 hours prior to 
the start of dosing until collection of the final pharmacokinetic and or 
pharmacodynamic sample during each session. 

During each dosing session, subjects will abstain from alcohol for 12 hours prior to 
the start of dosing until collection of the final pharmacokinetic and or 
pharmacodynamic sample during each session. 

Use of tobacco products is not allowed as outlined in the exclusion criteria. 
 
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6.8.3.
Activity
Subjects will abstain from strenuous exercise for 24 hours prior to screening and each 
treatment period  Subjects may participate in light recreational activities between the 
planned study procedures (e.g., watch television, read).
6.9.
Concomitant Medications and Non-Drug Therapies
6.9.1.
Permitted Medications and Non-Drug Therapies
Paracetamol, at doses of 2 grams/day is permitted for use any time during the study. 
Other concomitant medication may be considered on a case by case basis by the 
investigator in consultation with the Medical Monitor if required.
6.9.2.
Prohibited Medications and Non-Drug Therapies
Subjects must abstain from taking prescription or non-prescription drugs (including 
vitamins and dietary or herbal supplements), within 7 days (or 14 days if the drug is a 
potential enzyme inducer) or 5 half-lives (whichever is longer) prior to the first dose of 
study medication until completion of the follow-up visit, unless in the opinion of the 
Investigator and sponsor the medication will not interfere with the study.
 
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7.
STUDY ASSESSMENTS AND PROCEDURES
Protocol waivers or exemptions are not allowed with the exception of immediate safety 
concerns. Therefore, adherence to the study design requirements, including those 
specified in the Time and Events Table, are essential and required for study conduct.
This section lists the procedures and parameters of each planned study assessment.  The 
exact timing of each assessment is listed in the Time and Events Table Section 7.1
The following points must be noted: 

If assessments are scheduled for the same nominal time, THEN the assessments 
should occur in the following order:
1. Echocardiograms
2. 12-lead ECG
3. vital signs
4. blood draws  
Note: The timing of the assessments should allow the blood draw to occur at the 
exact nominal time.

The timing and number of planned study assessments, including: safety,
echocardiogram, pharmacokinetic, pharmacodynamic/biomarker or other 
assessments may be altered during the course of the study based on newly 
available data (e.g., to obtain data closer to the time of peak plasma 
concentrations) to ensure appropriate monitoring. 

The change in timing or addition of time points for any planned study 
assessments must be documented in a Note to File which is approved by the
relevant GSK study team member and then archived in the study sponsor and 
site study files, but this will not constitute a protocol amendment. 

The Institutional Review Board (IRB)/IEC will be informed of any safety issues 
that require alteration of the safety monitoring scheme or amendment of the 
Informed Consent Form. 

No more than 500 mL of blood will be collected over the duration of the study, 
including any extra assessments that may be required.
 
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7.1.
Time and Events Table
7.1.1.
Screening and Follow up
Procedure 
Screening1
(up to 28 days prior to 
Treatment Period 1, Day 
1)
Follow up
(7- 10 days 
post lastdose)
Notes
Informed consent
X
Inclusion and exclusion criteria
X
Demography
X
Full physical exam including height and 
weight
X
X
Weight at screening will be used for dosing calculation.
Alcohol, DoA , Smoking test
X
Medical history (includes substance usage  
[and family history of premature CV disease])
X
Substances: [Drugs, Alcohol, tobacco]
Past and current medical conditions  
[including cardiovascular medical history]
X
[Serum OR urine] pregnancy test ( WCBP)
X
HIV, Hep B and Hep C screen
X
Laboratory assessments (include liver 
chemistries 
X
X
Non Fasting 
Immunogenicity
X
X
12-lead ECG)
X
X
Triplicate ECG required at screening.
Vital signs)
X
X
Triplicate vital signs required at screening. 
Echocardiogram
X
Concomitant Medication review 
X
X
Hypoxia chamber plus exercise 
X
Tolerance to 4000m for 10 mins followed by followed by incremental exercise 
testing to determine  maximum oxygen uptake (VO2max) and calculate 70% of 
VO2max for the exercise challenge d 
Pharmacogenetic sample (PGx)
X
Can be taken any time after consent has been signed. Only required once and is 
optional. 
AE/SAE review
X
X
As per timings detailed in Section 7.2.1.1
1.
Screening assessments are allowed to be conducted on more than one day
 
 
 
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7.1.2.
Treatment Period 1 and 2
Procedure
Treatment Period 1 and 2 (Washout 3-14 days)
Notes
Times relative to 
dosing
Hypoxia (Times relative to 
entry to Chamber)
Predose
0h
15 m 
15-45m
0-60m
60m
60-70m
Immediately after 
exercise
30m rest on exit 
from chamber
After 30 mins 
rest
60 minutes after 
exit from 
Chamber 
Randomisation
X
Randomisation can occur up to the day before 
the first treatment period
Brief physical exam 
X
Vital signs
X
X
X
X
Immunogenicity
X
Treatment period 2 only 
12-lead ECG
X
X
X
Echocardiogram
X
X
X
X
X
Echo duration approx 5 mins
Subject enters chamber
X
Subject enters chamber approximately 30 
minutes after study treatment
Study Treatment (Dosing) 
X
Subject leaves chamber
X
Subject leaves chamber after the fourth 
echocardiogram and vital signs have been taken.
Exercise challenge
X
For approx 5-10 minutes
Ventilatory parameters
X
X
X
X1
X
Measurements to be taken at the same time as 
the Echocardiograms. During the exercise 
challenge, an ECG integrated with the ventilatory 
assessment will be carried out. 
Pulse Oximetry
(O2 saturation)
------------------------------------------------------------------------------------------------
Will be continuously monitored for safety.
Measurement should be recorded at time of each 
echocardiogram post-treatment and databased.
RAS Biomarkers
X
X2
X3
X4
X3
X3
X5
X3
Other Biomarkers
X
X2
X3
X4
X3
X3
X5
X3
PK sampling
X
X2
X3
X4
X3
X3
X5
X3
 
 
 
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Procedure
Treatment Period 1 and 2 (Washout 3-14 days)
Notes
Times relative to 
dosing
Hypoxia (Times relative to 
entry to Chamber)
Predose
0h
15 m 
15-45m
0-60m
60m
60-70m
Immediately after 
exercise
30m rest on exit 
from chamber
After 30 mins 
rest
60 minutes after 
exit from 
Chamber 
AE/SAE review
============================================================
Concomitant medication review
X
1.
To be taken at the end of exercise 
2.
Take at the end of the infusion
3.
Taken immediately after echocardiogram 
4.
Immediately before entering the chamber
5.
To be taken as soon as possible after leaving chamber
 
 
 
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After written informed consent, screening assessments will be performed as outlined in 
the Time and Events Table (Section 7.1).
The following demographic parameters will be captured: year of birth, sex, race and 
ethnicity.
Medical/medication/family history will be assessed as related to the inclusion/exclusion 
criteria listed in Section 5.
Cardiovascular medical history/risk factors (as detailed in the CRF) will be assessed at 
screening.
Cardiorespiratory fitness during bicycle exercise and hypoxia tolerance will be assessed.
Procedures conducted as part of the subject’s routine clinical management (e.g. blood 
count) and obtained prior to signing of informed consent may be utilized for Screening or 
baseline purposes provided the procedure meets the protocol-defined criteria and has 
been performed in the timeframe of the study.
7.2.
Safety
Planned time points for all safety assessments are listed in the Time and Events Table 
(Section 7.1).  Additional time points for safety tests such as vital signs, physical exams 
and laboratory safety tests may be added during the course of the study based on newly 
available data to ensure appropriate safety monitoring.
7.2.1.
Adverse Events (AE) and Serious Adverse Events (SAEs)
The definitions of an AE or SAE can be found in Appendix 4.
The investigator and their designees are responsible for detecting, documenting and 
reporting events that meet the definition of an AE or SAE. 
7.2.1.1.
Time period and Frequency for collecting AE and SAE information

Any SAEs assessed as related to study participation (e.g., protocol-mandated 
procedures, invasive tests, or change in existing therapy) or related to a GSK 
product will be recorded from the time a subject consents to participate in the 
study up to and including any follow-up contact. 

AEs will be collected from the start of Study Treatment until the follow-up 
contact (see Section 7.2.1.3), at the timepoints specified in the Time and Events 
Table (Section 7.1).

Medical occurrences that begin prior to the start of study treatment but after 
obtaining informed consent may be recorded on the Medical History/Current 
Medical Conditions section of the CRF.

All SAEs will be recorded and reported to GSK within 24 hours, as indicated in 
Appendix 4.
 
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
Investigators are not obligated to actively seek AEs or SAEs in former study 
subjects. However, if the investigator learns of any SAE, including a death, at any 
time after a subject has been discharged from the study, and he/she considers the 
event reasonably related to the study treatment or study participation, the 
investigator must promptly notify GSK.
NOTE: The method of recording, evaluating and assessing causality of AEs and SAEs 
plus procedures for completing and transmitting SAE reports to GSK are provided in 
Appendix 4
7.2.1.2.
Method of Detecting AEs and SAEs
Care will be taken not to introduce bias when detecting AEs and/or SAEs. Open-ended 
and non-leading verbal questioning of the subject is the preferred method to inquire about 
AE occurrence.  Appropriate questions include:

“How are you feeling?” 

“Have you had any (other) medical problems since your last visit/contact?” 

“Have you taken any new medicines, other than those provided in this study, since 
your last visit/contact?” 
7.2.1.3.
Follow-up of AEs and SAEs
After the initial AE/SAE report, the investigator is required to proactively follow each 
subject at subsequent visits/contacts.  All SAEs, and non-serious AEs of special interest 
(as defined in Section 4.6.1) will be followed until resolution, until the condition 
stabilizes, until the event is otherwise explained, or until the subject is lost to follow-up 
(as defined in Section 5.4). Further information on follow-up procedures is given in 
Appendix 4.
7.2.1.4.
Regulatory Reporting Requirements for SAEs
Prompt notification by the investigator to GSK of SAEs related to study treatment (even 
for non- interventional post-marketing studies) is essential so that legal obligations and 
ethical responsibilities towards the safety of subjects and the safety of a product under 
clinical investigation are met. 
GSK has a legal responsibility to notify both the local regulatory authority and other 
regulatory agencies about the safety of a product under clinical investigation.  GSK will 
comply with country specific regulatory requirements relating to safety reporting to the 
regulatory authority, Institutional Review Board (IRB)/Independent Ethics Committee 
(IEC) and investigators.
Investigator safety reports are prepared for suspected unexpected serious adverse 
reactions according to local regulatory requirements and GSK policy and are forwarded 
to investigators as necessary.
 
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An investigator who receives an investigator safety report describing a SAE(s) or other 
specific safety information (e.g., summary or listing of SAEs) from GSK will file it with 
the IB and will notify the IRB/IEC, if appropriate according to local requirements.
7.2.2.
Physical Exams

A complete physical examination will include, at a minimum, assessment of the 
Cardiovascular, Respiratory, Gastrointestinal and Neurological systems. Height 
and weight will also be measured and recorded. This will be carried out at 
screening and follow up. 

A brief physical examination will include, at a minimum assessments of the skin,
lungs, cardiovascular system, and abdomen (liver and spleen). To be carried out at 
the start of each period. 

Investigators should pay special attention to clinical signs related to previous 
serious illnesses.
7.2.3.
Vital Signs

Vital signs will be measured in semi-supine position after 5 minutes rest and will 
include temperature, systolic and diastolic blood pressure and pulse rate. Three 
readings of blood pressure and pulse rate will be taken.

First reading should be rejected.

Second and third readings should be averaged to give the measurement to be 
recorded in the CRF. (Triplicate measurements will only be taken at screening and 
single measurements to be taken after that).
7.2.4.
Electrocardiogram (ECG)

Triplicate 12-lead ECGs will be obtained at screening. At all other time-points a 
single 12-lead ECGs will be obtained at each time point during the study using an 
ECG machine that automatically calculates the heart rate and measures PR, QRS, 
QT, and QTc intervals.  Refer to Section 7.2.5 for QTc withdrawal criteria and 
additional QTc readings that may be necessary.

ECG to be measured in a semi-supine position after 5 minutes rest.
7.2.5.
QTc Stopping Criteria

The same QT correction formula must be used for each individual subject to 
determine eligibility for and discontinuation from the study.  This formula may 
not be changed or substituted once the subject has been enrolled.

For example, if a subject is eligible for the protocol based on QTcB, then QTcB 
must be used for discontinuation of this individual subject as well.

Once the QT correction formula has been chosen for a subject’s eligibility, the 
same formula must continue to be used for that subject for all QTc data being 
collected for data analysis.  Safety ECGs and other non-protocol specified 
ECGs are an exception.  
 
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
The QTc should be based on single or averaged QTc values of triplicate 
electrocardiograms obtained over a brief (e.g., 5-10 minute) recording period
A subject that meets either bulleted criterion below will be withdrawn from the study.

QTcB or QTcF > 500 msec,

Change from baseline: QTc >60 msec
7.2.6.
Clinical Safety Laboratory Assessments
All protocol required laboratory assessments, as defined in Table 2, must be conducted in 
accordance with the Protocol Time and Events Schedule. Laboratory requisition forms 
must be completed and samples must be clearly labelled with the subject number, 
protocol number, site/centre number, and visit date. Details for the preparation and 
shipment of samples will be provided by the laboratory and are detailed in the laboratory 
manual. Reference ranges for all safety parameters will be provided to the site by the 
laboratory responsible for the assessments.
If additional non-protocol specified laboratory assessments are performed at the 
institution’s local laboratory and result in a change in subject management or are 
considered clinically significant by the investigator (e.g., SAE or AE or dose 
modification) the results must be recorded in the CRF.
Refer to the SRM for appropriate processing and handling of samples to avoid duplicate 
and/or additional blood draws.
Haematology, clinical chemistry, urinalysis and additional parameters to be tested are 
listed in Table 2.
 
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Table 2
Protocol Required Safety Laboratory Assessments
Laboratory 
Assessments
Parameters
Haematology
Platelet Count
RBC Indices:
WBC count with Differential:
RBC Count
MCV
Neutrophils
Hemoglobin
MCH
Lymphocytes
Hematocrit
Monocytes
Eosinophils
Basophils
Clinical 
Chemistry 1
BUN
Potassium
AST (SGOT)
Total and direct 
bilirubin
Creatinine
Sodium
ALT (SGPT)
Total Protein
Glucose 
Calcium
Alkaline phosphatise
Albumin
Routine 
Urinalysis

Specific gravity

pH, glucose, protein, blood and ketones by dipstick

Microscopic examination (if blood or protein is abnormal)
Other 
Screening 
Tests

HIV

Hepatitis B (HBsAg)

Hepatitis C (Hep C antibody)

Alcohol, smoking and drug screen (to include at minimum: 
amphetamines, barbiturates, cocaine, opiates, cannabinoids, 
benzodiazepines and cotinine) performed at site

Urine hCG Pregnancy test (as needed) 2
NOTES :
1.
Details of Liver Chemistry Stopping Criteria and Required Actions and Follow-Up 
Assessments after liver stopping or monitoring event are given in Section 5.4.2 and 
Appendix 2.
2.
Local urine testing will be standard for the protocol unless serum testing is required 
by local regulation or ethics committee.
All laboratory tests with values that are considered clinically significantly abnormal 
during participation in the study or within 3 days after the last dose of study treatment 
should be repeated until the values return to normal or baseline.  If such values do not 
return to normal within a period judged reasonable by the investigator, the etiology
should be identified and the sponsor notified.
7.3.
Hypoxia Challenge
Each subject will be inside the hypoxia chamber for approximately 80 minutes per 
period, during which time they will be under the full 4000m ± 10%. hypoxic conditions 
 
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If three or more subjects do not tolerate the hypoxic challenge, either due to symptoms or 
O2 saturation of <65%, then the simulated altitude will be adjusted in decrements of 
500m (i.e. from 4000m to 3500m) for all remaining subjects to a minimum of 3000m.
Further details about the hypoxia challenge is detailed in the SRM. 
7.3.1.
Exercise Challenge
Subjects will perform an exercise challenge at 70% of maximum VO2 uptake on a cycle 
ergometer within the hypoxia chamber for 10 minutes as detailed in the SRM.
Subjects must complete a minimum of 5 minutes exercises at 70% of maximummax 
maxVO2 uptake.
Further details about the exercise challenge is detailed in the SRM. 
7.4.
Echocardiogram
Echocardiograms will be taken as detailed in the Time and Events table (Section 7.1). 
Echocardiograms will be obtained with the subject resting supine or lying on their left 
side.
PASP will be measured and recorded.
PASP will be determined by measuring maximal tricuspid regurgitation velocity and 
applying the modified Bernoulli equation to convert this value into pressure values. 
Estimated right atrial pressure (RAP) must be added to this obtained value.
Further details about the PASP measurement is detailed in the SRM. 
Additional echocardiograms may be obtained for each subject as needed (in the 
judgement of the Investigator and GSK Medical Monitor if required.
Further details can be found in the SRM.  
7.5.
Ventilatory parameters 
Ventilatory parameters will be measured as detailed in the Time and Events table 
(Section 7.1). 
Measurements may include change from baseline of oxygen consumption (VO2), carbon 
dioxide production (CO2) and other parameters as data permit
Further details can be found in the SRM.  
 
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7.6.
Pulse Oximetry
Oxygen saturation will be monitored continuously via pulse oximetry as detailed in the 
SRM. Measurements to be taken at the same time as the echocardiograms and recorded in 
the eCRF. 
7.7.
  Pharmacokinetics
7.7.1.
Blood Sample Collection
Blood samples for pharmacokinetic (PK) analysis of GSK2586881 will be collected at 
the time points indicated in the Time and Events Table (Section 7.1).  The actual date and 
time of each blood sample collection will be recorded.  
The timing of PK samples may be altered and/or PK samples may be obtained at 
additional time points to ensure thorough PK monitoring.  
Details of PK blood sample collection (including volume to be collected), processing,
storage and shipping procedures are provided in the SRM.
7.7.2.
Sample Analysis
Plasma analysis will be performed under the control of PTS, In Vitro/In Vivo 
Translations (IVIVT) Department and Third Party Resourcing (TPR), GlaxoSmithKline. 
The details of the Bioanalytical Laboratory will be included in the Study Reference 
Manual (SRM). Concentrations of GSK2586881 will be determined in plasma samples 
using the currently approved bioanalytical methodology. Raw data will archived at the 
Bioanalytical Site (to be detailed in the SRM).
7.8.
Biomarker(s)/Pharmacodynamic Markers
Blood samples for biomarker/PD analysis will be collected at the time points indicated in,
the Time and Events Table (Section 7.1).  The actual date and time of each blood sample 
collection will be recorded.  The timing of biomarker/PD samples may be altered and/or 
samples may be obtained at additional time points to ensure thorough monitoring.  
Details of biomarker/PD blood sample collection (including volume to be collected), 
processing, storage and shipping procedures are provided in the SRM.
7.8.1.
Renin-angiotensin system biomarkers
RAS peptides including but not limited to AngII, Ang(1-7) and Ang(1-5) may be 
analysed as data permit.
7.8.2.
Other Biomarkers
Peptide hormones such as Kinins (e.g. des-Arg-bradykinin), apelins (e.g. Apelin 13, 
pyr1-Apelin, 13) and other systems (e.g. dynorphin A) may be analysed as data permit.
 
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Atrial Naturetic peptide (ANP), Brain Naturetic Peptide (NT-proBNP), Troponin I, 
Surfactant Protein D, IL-6 and/or additional analytes to be determined may also be 
analysed as data permit.
7.9.
Genetics
Information regarding genetic research is included in Appendix 3.
Genetic sampling is optional. Subjects can refuse PGx sampling but will still be allowed 
to participate in the study. 
7.9.1.
Blood sample collection
Blood samples to investigate the association between the loss of function polymorphism 
rs1799752, representing the I/D polymorphism, in intron 16 of the Angiotensin 
Converting Enzyme (ACE) gene and Ang II (and possibly other RAS peptides) and 
hypoxic pulmonary vasoconstriction will be collected as specified in the Time and Events 
Table (Section 7.1). 
Further information for blood sample collection, processing, storage and shipping 
procedures are provided in the SRM. 
Information regarding genetic research is included in Appendix 3.
7.10.
Immunogenicity 
7.10.1.
Sample collection
Blood samples for immunogenicity analysis will be collected at the time points indicated
in Section 7.1, Time and Events Table. Additional visits to obtain immunogenicity
samples may be required in the unlikely event that subjects develop a clinically relevant
immunoglobulin response to the drug as described in the SRM.
Details of immunogenicity blood sample collection (including volume to be collected),
processing, storage and shipping procedures are provided in the SRM.
7.10.2.
Sample analysis
Immunogenicity analysis will be performed under the management of Clinical
Immunology, Biopharm R&D, GlaxoSmithKline. All pre-dose and post-dose samples
will be first tested for Anti-ACE2 binding antibodies by screening and confirmation assay
steps. The post-dose samples tested positive for anti-ACE2 binding antibodies will be
further characterized for anti-ACE2 neutralizing antibodies. Both positive incidences for
anti-ACE2 binding and neutralizing antibodies will be reported.
 
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8.
DATA MANAGEMENT

For this study subject data will be entered into GSK defined CRFs, transmitted 
electronically to GSK or designee and combined with data provided from other 
sources in a validated data system.  

Management of clinical data will be performed in accordance with applicable 
GSK standards and data cleaning procedures to ensure the integrity of the data, 
e.g., removing errors and inconsistencies in the data.

Adverse events and concomitant medications terms will be coded using MedDRA 
(Medical Dictionary for Regulatory Activities) and an internal validated 
medication dictionary, GSKDrug.  

CRFs (including queries and audit trails) will be retained by GSK, and copies will 
be sent to the investigator to maintain as the investigator copy.  Subject initials 
and day/month of birth will not be collected or transmitted to GSK according to 
GSK policy.
9.
STATISTICAL CONSIDERATIONS AND DATA 
ANALYSES
9.1.
Hypotheses
The focus of this study is on the exploration the effect of GSK2586881 on a range of 
echocardiography, pulse oximetry, biomarker, safety and PK endpoints, when subjecting 
healthy volunteers to an exercise challenge under hypoxic conditions. No formal 
statistical hypotheses are being tested. A Bayesian statistical analysis framework with 
non-informative priors for model parameters (unless otherwise specified) will be used to 
obtain posterior distributions for effects of interest. These posterior distributions will be 
used to obtain a number of probability statements about the magnitude of treatment 
effects (e.g. Probability of any treatment related reduction in PASP, or Probability that 
the treatment related reduction in PASP 5 mmHg).
A rule of thumb for end of “study success” is if the probability of any treatment related 
reduction in PASP (T3-T0) exceeds 0.95 (success is also conditional on the probability of 
(absolute) treatment related reductions in oxygen saturation exceeding 5% being small).
9.2.
Sample Size Considerations
The sample size of 30 patients is based on logistical considerations and is not based on 
formal sample size calculations. However, estimates of precision for the treatment 
difference in the primary endpoint are presented for context. (Note: precision in this 
context is defined as one half of the width of the 95% confidence interval.) A sample size 
re-estimation is planned after 15 subjects. 
 
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9.2.1.
Sample Size Assumptions
The precision of the primary treatment comparison (change from baseline PASP to 
hypoxic/exercise PASP) was estimated using simulation. PASP data points were 
simulated for each subject: normoxic at rest, and hypoxic after exercise, each for two 
study periods, giving a total of four PASP measurements for each subject. The four PASP 
measurements were drawn from a multivariate normal distribution to allow for different 
levels of within-subject correlation. One simulated study with a given sample size (N) 
was created by repeating this process of generating individual subject data N times, 
randomly allocating each subject to a treatment sequence in a 1:1 ratio, and calculating 
the half-width of the confidence interval of the treatment difference in change from 
baseline in PASP from that simulated dataset (using a linear mixed effects model 
including period baseline, subject baseline, treatment and period as fixed effects, and 
subject as a random effect). A full simulation run consisted of 1000 iterations of 
simulated studies, and a final estimate for precision was calculated as the mean precision 
across the 1000 iterations.
The following assumptions were made regarding the mean and Standard Deviation (SD)
of PASP based on data from Antoni Ricart, 2005

Mean PASP was 30 mmHg at baseline (i.e. normoxic and at rest) and 45 mmHg 
under hypoxia and exercise

SD of PASP was 2.81 mmHg at baseline and 4.30 mmHg under hypoxia and exercise

As the purpose of this simulation was to estimate precision by evaluating the SD of 
the treatment difference rather than the mean, there was no treatment effect assumed 
in the simulations

The within-subject correlation of PASP was unknown, therefore four different 
scenarios of within-subject correlation were evaluated: zero correlation, low 
correlation (0.3), high correlation (0.6) and very high correlation (0.9).

A range of sample sizes was considered: from 5 to 10 in increments of 1, and then up 
to 40 in increments of 5. The table below shows a subset of these; the figure includes 
them all.
Based on these assumptions, the estimated precisions for these sample sizes and under 
these scenarios of within-subject correlation were as follows (smaller number for 
precision denotes more precise estimates):
 
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Table 3
Estimated precision of treatment comparisons of change from 
baseline in PASP (mmHg) for a range of sample sizes and within-
subject correlation scenarios
Within-subject correlation
Sample size (N)
0
0.3
0.6
0.9
10
4.35
3.83
2.92
1.48
20
2.76
2.40
1.83
0.91
30
2.22
1.91
1.46
0.72
40
1.91
1.63
1.23
0.62
Figure 4 illustrates precision estimates under the full range of sample sizes considered 
(from 5 to 40), and for all within-subject correlation scenarios. The red line at 5 mmHg is 
superimposed to indicate a rough guide to the magnitude of a clinically meaningful 
difference.
Figure 4
Sensitivity of study precision to sample size and within subject 
correlation of PASP
9.2.2.
Sample Size Re-estimation
A sample size re-estimation will be conducted at the interim analysis (see Section 9.3.2). 
The purpose of the sample size re-estimation is to determine whether the total number of 
subjects can be reduced below the anticipated 30, based on treatment comparison 
between GSK2586881 and Placebo in change from pre-dose PASP to hypoxic/exercised 
 
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PASP (i.e. T3-T0). The sample size re-estimation is to be considered advisory, and taken 
into account together with other considerations. These will include:

ensuring sufficient data is collected on secondary endpoints,

non-conclusive safety data at the time of interim analysis (e.g. a weak signal of a 
reduction in oxygen saturation data that would require the full set of remaining 
subjects to be able to reach a conclusion),

speed of recruitment.
9.3.
Data Analysis Considerations
Data will be listed and summarised according to GSK integrated data standards library 
(IDSL) reporting standards where applicable.  Complete details will be provided in the 
Reporting and Analysis Plan (RAP).
The key endpoints referred to in the text below comprise PASP measured by 
echocardiography, oxygen saturation measured by continuous pulse oximetry, RAS 
peptides and safety data.
9.3.1.
Analysis Populations
All Subjects Screened Population: This population contains all subjects that complete at 
least one Visit 1 (Screening) procedure. This population will be used for the summary of 
subject disposition (including reasons for screening failures, run-in failures, and 
stabilization failures) and for the listing of AEs and SAEs for non-randomised subjects.
Intent-to-Treat (ITT) Population: This population will comprise all randomised subjects, 
excluding those who were randomised in error. A subject who is recorded as a screen 
failure, run-in failure, or stabilisation failure, but is randomised and does not receive a 
dose of study treatment, is considered to be randomised in error. Any other subject who 
receives a randomisation number will be considered to have been randomised. This will 
constitute the primary population for all efficacy and safety analyses.
Pharmacokinetic (PK) population: This population will comprise all subject in the ITT 
Population for whom a PK sample was obtained and analysed and on active treatment.
In addition to the above populations, the effect of important protocol violations, including 
any subjects who failed the inclusion/exclusion criteria, may be assessed by means of 
sensitivity analyses. A blind review of all protocol violations will be performed prior to 
DBF in order to identify any important deviations and consequently identify any subjects 
who will be excluded from such sensitivity analyses.
 
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9.3.2.
Interim Analysis
An interim analysis is planned after 15 subjects have completed the following critical 
assessments:

PASP at T0 and T3 for both study periods

Oxygen saturation at T0 and T3 for both study periods

Adverse events 
The interim analysis will use the following study data:

PASP at time T0 and T3 for both periods, for the first 15 subjects

Oxygen saturation at T0 and T3 for both periods, for the first 15 subjects

Adverse events for the first 15 subjects

Angiotensin biomarker concentrations for the first 5 subjects (to allow time for 
the samples to be analysed by the external lab).
The interim analysis will use a data snapshot that has been cleaned to the best extent 
allowed by the timeframes (i.e. the interim data will not be fully cleaned or fully QC’d 
data and there will not be a locked database).
The aims of the interim analysis, and the endpoints to be used to address them, are as 
follows:

Using the primary endpoint (treatment differences between GSK2586881 and 
Placebo in change from pre-dose PASP to hypoxic/exercised PASP [T3-T0]):
o
To decide whether to continue the study or stop based on futility, and
o
to conduct an advisory sample-size re-estimation with the view to 
potentially reduce the number of subjects participating in the study below 
30.

Using secondary endpoints:
o
to estimate treatment differences between GSK2586881 and Placebo in 
change from pre-dose oxygen saturation to hypoxic/exercised oxygen 
saturation [T3-T0], with a view to stopping the study if there is evidence 
that GSK2586881 causes a reduction in oxygen saturation in healthy 
volunteers. As a non-binding guide high posterior probability of observing 
5% absolute differences in mean oxygenation saturation values between 
placebo and active arms would be of concern; but clinical judgement 
 
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would override any statistical methods if, for example, the majority of 
subjects displayed consistent patterns of reductions e.g. between 2-3%).
o
to compare adverse events within the two treatment groups and explore 
any potential safety signals that may emerge
To assess the operating characteristics of the interim analysis decisions to be made based 
on the primary endpoint, a simulation was carried out to estimate the relative proportion 
of studies reaching conclusions to stop for futility, continue with no change to the sample 
size, and to continue with a reduced sample size, under various different scenarios of the 
true treatment effect. Broadly speaking, the aim of the simulation was to confirm that (in 
an overwhelming majority of cases) a decision to stop for futility would be reached in the 
case of no true treatment effect and a decision to continue (perhaps with reduced sample 
size) would be reached in the case of a true treatment effect.
Simulated datasets of PASP at baseline (i.e. normoxic and at rest) and under hypoxia and 
exercise for 15 subjects, each receiving both treatments in sequence, were generated 
using the following assumptions:

15 simulated subjects were randomised to one of the two available treatment 
sequences (see Section 6.2) using block randomisation with block size of 4 records

PASP at baseline and under hypoxia and exercise for both treatment groups (a total of 
four PASP measurements per subject) were sampled from a multivariate normal 
distribution, using values for mean PASP, standard deviation of PASP and within-
subject correlation of PASP as described below.

Mean PASP was 30 mmHg at baseline (i.e. normoxic and at rest) for both treatments, 
and 45 mmHg under hypoxia and exercise for Placebo (as in Section 9.2.1). For 
GSK2586881, mean PASP under hypoxia and exercise was (45 - Δ) mmHg, where Δ 
(the mean treatment difference) was varied according to four different scenarios:
o
no treatment difference (Δ = 0 mmHg)
o
weak treatment difference of a magnitude of half the clinically meaningful 
difference (Δ = 2.5 mmHg)
o
minimum clinically meaningful difference (Δ = 5 mmHg)
o
overwhelming treatment difference one-and-a-half times the clinically 
meaningful difference (Δ = 7.5 mmHg)

SD of PASP was 2.81 mmHg at baseline and 4.30 mmHg under hypoxia and 
exercise, for both treatment groups (as in Section 9.2.1) 

The within-subject correlation of PASP was unknown, therefore four different 
scenarios of within-subject correlation were evaluated: zero correlation, low 
correlation (0.3), high correlation (0.6) and very high correlation (0.9) (as in Section 
9.2.1). Within-subject correlation of PASP was assumed to be compound symmetric 
 
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(i.e. the same correlation was used for each of the six possible pairs of the four PASP 
measurements within each subject).

It was assumed that there would be no effect of period in the simulation, i.e. it was 
assumed that it would make no difference if the measurement was taken from the first 
or second chronological period in the treatment sequence.
Modelling took on a three-step process, with decisions after each. Firstly, the treatment 
difference and its associated standard error was then estimated for the dataset of 15 
simulated subjects using a mixed effects linear regression model, including covariates for 
period, treatment, period baseline and subject baseline (the mean of the two period 
baselines) as fixed effects and subject as a random effect. If the sign of treatment 
difference arising from the simulated data was in the wrong direction (i.e. the simulated 
outcome for GSK2586881 was worse than for Placebo), then the simulated study was 
stopped for futility.
Secondly, in the alternative case that the simulated treatment difference was in favour of 
GSK2586881 over Placebo, a posterior probability of success (where success was defined 
as a 97.5% posterior probability of the treatment difference being in favour of 
GSK2586881 over Placebo) was evaluated for 30 subjects. This was evaluated using a t-
distribution, with the mean and standard deviation taken as the treatment difference and 
standard error (multiplied by a factor of the square root of 15 to estimate the standard 
deviation) from step one respectively, and . If this posterior probability was less than 0.2, 
then the study was stopped for futility as being unlikely to show any benefit of 
GSK2586881 over Placebo.
Thirdly, provided that the simulated study hadn't been stopped for futility in either of the 
first two steps, posterior probabilities of success were calculated for N ranging from 15 to 
29 subjects. If any of these posterior probabilities of success were greater than or equal to 
0.9, then the study was continued with a reduced sample size equal to the lowest N at 
which that threshold was reached. Otherwise, the conclusion from the simulated interim 
analysis would be to continue the study with unchanged sample size.
This whole process (simulating data for 15 subjects, modelling the treatment difference, 
evaluating posterior probabilities of success and simulating the decision-making process) 
was replicated 1000 times for each scenario, with the decision ("futile", "no change to N" 
or "reduce N") recorded for each iteration. Each combination of the four treatment 
difference scenarios and the four correlation scenarios was evaluated for a total of 16 
scenarios in all.
The estimated proportions of each decision being reached under each of the 16 scenarios 
are presented in Table 4.
 
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Table 4
Operating characteristics of interim analysis under four scenarios of 
treatment effect and four scenarios of within-subject correlation
Frequency of decisions (%)
Treatment 
effect 
Scenario
Within-subject 
correlation of PASP
Futile
Continue with 30 
subjects
Continue with 
reduced sample 
size
Δ=0 mmHg (no treatment difference)
0.0
87%
13%
0%
0.3
87%
13%
1%
0.6
85%
15%
0%
0.9
86%
14%
0%
Δ=2.5 mmHg (weak treatment effect, less than clinically meaningful difference)
0.0
31%
60%
9%
0.3
24%
65%
11%
0.6
10%
66%
25%
0.9
0%
9%
91%
Δ=5 mmHg (good treatment effect, at threshold of clinical meaningful difference)
0.0
2%
46%
52%
0.3
1%
35%
64%
0.6
0%
11%
89%
0.9
0%
0%
100%
Δ=7.5 mmHg (very strong treatment effect)
0.0
0%
10%
90%
0.3
0%
2%
98%
0.6
0%
0%
100%
0.9
0%
0%
100%
These results suggest primarily that if there is no true treatment difference between 
GSK2586881 and Placebo, the study would be stopped for futility 85-87% of the time 
(irrespective of within-subject correlation of PASP). A drug with a weak treatment effect 
would most likely result in the study being continued without change or stopped for 
futility (except in the case where within-subject correlation is 0.9, which is presented here 
as an extreme case, unlikely to occur in practice). If the true treatment effect is at the 
clinically relevant threshold of 5 mmHg, then the study is highly unlikely to be stopped 
for futility and may indicate being reduced in sample size.
Secondarily, it should be noted that the higher the within-subject correlation, then the 
higher the probability of success. This is because the more correlation there is in 
measurements within the same individual, the less variability there will be in change from 
baseline. Results for correlations of 0.0 and 0.9 are presented as extreme cases unlikely to 
occur in practice, though the exact strength of within-subject correlation of PASP 
(particularly under different stressed conditions) is not known.
Full details of the interim analysis will be supplied in the RAP.
 
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9.3.3.
Multiple Comparisons and Multiplicity
As this is an early-phase exploratory study, no adjustment for multiple comparisons will 
be made. Treatment comparisons will be presented as effect sizes with 95% confidence 
intervals.
9.4.
Key Elements of Analysis Plan
Each subject will undergo two treatment periods in this crossover study, each one of 
which being subdivided into five sub-epochs (labelled T0-T4) as follows:

T0: Pre-dose (period baseline)

T1: Post-dose, normoxic, at rest, pre-challenge

T2: Hypoxic, at rest

T3: Hypoxic, immediately after exercise

T4: Post-challenge, normoxic, at rest
This follows the principle illustrated in the diagram of echocardiograph measurements 
(Figure 2).
Pharmacodynamic endpoints will be assigned to T0 thru T4 timepoints based on when 
they happened relative to the sequence of events that the subject undertakes during the 
course of the study day.
Pharmacokinetic endpoints will be timed based on elapsed time since dose 
administration.
In addition to T0 being defined as the period baseline, an overall subject baseline will be 
defined as the mean of the two T0 measurements (one from each period).
Change from baseline at time points T1 - T4 will be calculated as the difference between 
the measurement at the time point in question and the period baseline.In general, 
statistical modelling of changes from baseline will be done using a Bayesian mixed 
effects regression model, including covariates for period, treatment, period baseline and 
subject baseline (the mean of the two period baselines) as fixed effects and subject as a 
random effect (non-informative priors for model parameters). A compound symmetric 
covariance structure within each subject-period-treatment cell will be assumed to account 
for repeated measurements a) inherent in the two-period crossover design and b) due to 
the four post-baseline timepoints within each treatment period.
PASP data will be summarized by treatment and time-point in tabular and graphical 
format. A Bayesian mixed effects regression model (as described above) will be fitted 
(using non-informative priors for the model parameters), and an estimate of the mean 
change from baseline in PASP for each treatment group and post-baseline timepoint, 
 
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together with its 95% credible interval, will be obtained.  Estimates for treatment 
differences will also be presented. Data may be log-transformed if necessary.
Details of the analysis of other endpoints will be described in the RAP.
9.4.1.
Pharmacokinetic Analyses
Pharmacokinetic analysis will be performed by, or under the auspices, of Clinical 
Pharmacology Modelling and Simulation Depertment with GlasxoSmithKline.  Plasma 
GSK2586881 concnetration-time data will be analysed by non-compartmental methods 
with WinNonLin V6.3 or greater.  Calculations will be based on the actual sampling 
times recorded during the study.
From the plasma concentration-time data, the following pharmacokinetic parameters will 
be determined, as data permit: maximum observed plasma concentration (Cmax), time to 
Cmax (tmax), area under the plasma concentration-time curve over the study period 
[nominally AUC(0-2.5h) post-dose], AUC over the hypoxia challenge (nominally 
AUC(0.5-2.0h post-dose), plasma clearance (CL), volume of distribution (V) and 
apparent terminal phase half-life (t1/2), if data permit.  Other PK parameters may also be 
determined.
Pharmacokinetic data will be presented in graphical and/or tabular form and will be
summarized descriptively. All pharmacokinetic data will be stored in the Archives, 
GlaxoSmithKline Pharmaceuticals, R&D. 
The relationship between the RAS biomarkers and other pharmacodynamic endpoints 
(echocardiography and pulse oximetry) and GSK2586881 concentrations and/or PK 
parameters may also be explored, if appropriate.
If appropriate, a population PK analysis may also be conducted, in addition the plasma 
concentration-time data may be merged with historical data and analysed as part of a 
population PK meta-analysis.
10.
STUDY GOVERNANCE CONSIDERATIONS
10.1.
Posting of Information on Publicly Available Clinical Trial 
Registers
Study information from this protocol will be posted on publicly available clinical trial 
registers before enrollment of subjects begins.
10.2.
Regulatory and Ethical Considerations, Including the 
Informed Consent Process
Prior to initiation of a site, GSK will obtain favourable opinion/approval from the 
appropriate regulatory agency to conduct the study in accordance with ICH Good Clinical 
Practice (GCP) and applicable country-specific regulatory requirements.
 
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The study will be conducted in accordance with all applicable regulatory requirements, 
and with GSK policy.
The study will also be conducted in accordance with ICH Good Clinical Practice (GCP), 
all applicable subject privacy requirements, and the guiding principles of the current 
version of the Declaration of Helsinki.  This includes, but is not limited to, the following:

IRB/IEC review and favorable opinion/approval of the study protocol and 
amendments as applicable

Obtaining signed informed consent

Investigator reporting requirements (e.g. reporting of AEs/SAEs/protocol 
deviations to IRB/IEC)

GSK will provide full details of the above procedures, either verbally, in writing, 
or both.

Signed informed consent must be obtained for each subject prior to participation 
in the study

The IEC/IRB, and where applicable the regulatory authority, approve the clinical 
protocol and all optional assessments, including genetic research.  

Optional assessments (including those in a separate protocol and/or under separate 
informed consent) and the clinical protocol should be concurrently submitted for 
approval unless regulation requires separate submission.  

Approval of the optional assessments may occur after approval is granted for the 
clinical protocol where required by regulatory authorities.  In this situation, 
written approval of the clinical protocol should state that approval of optional 
assessments is being deferred and the study, with the exception of the optional 
assessments, can be initiated.
10.3.
Quality Control (Study Monitoring)

In accordance with applicable regulations including GCP, and GSK procedures, 
GSK monitors will contact the site prior to the start of the study to review with the 
site staff the protocol, study requirements, and their responsibilities to satisfy 
regulatory, ethical, and GSK requirements.  

When reviewing data collection procedures, the discussion will also include 
identification, agreement and documentation of data items for which the CRF will 
serve as the source document.

Source documents provide evidence for the existence of the participant and 
substantiate the integrity of the data collected. Source documents are filed at the 
investigator’s site.

Data entered in the eCRFs that are transcribed from source documents must be 
consistent with the source documents or the discrepancies must be explained. The 
investigator may need to request previous medical records or transfer records, 
depending on the study; also current medical records must be available.
 
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GSK will monitor the study and site activity to verify that the:

Data are authentic, accurate, and complete.

Safety and rights of subjects are being protected.

Study is conducted in accordance with the currently approved protocol and any 
other study agreements, GCP, and all applicable regulatory requirements.
The investigator and the head of the medical institution (where applicable) agrees to 
allow the monitor direct access to all relevant documents
10.4.
Quality Assurance

To ensure compliance with GCP and all applicable regulatory requirements, GSK 
may conduct a quality assurance assessment and/or audit of the site records, and 
the regulatory agencies may conduct a regulatory inspection at any time during or 
after completion of the study. 

In the event of an assessment, audit or inspection, the investigator (and institution) 
must agree to grant the advisor(s), auditor(s) and inspector(s) direct access to all 
relevant documents and to allocate their time and the time of their staff to discuss 
the conduct of the study, any findings/relevant issues and to implement any 
corrective and/or preventative actions to address any findings/issues identified.
10.5.
Study and Site Closure

Upon completion or premature discontinuation of the study, the GSK monitor will 
conduct site closure activities with the investigator or site staff, as appropriate, in 
accordance with applicable regulations including GCP, and GSK Standard 
Operating Procedures.

GSK reserves the right to temporarily suspend or prematurely discontinue this 
study at any time for reasons including, but not limited to, safety or ethical issues 
or severe non-compliance. For multicenter studies, this can occur at one or more 
or at all sites.  

If GSK determines such action is needed, GSK will discuss the reasons for taking 
such action with the investigator or the head of the medical institution (where 
applicable).  When feasible, GSK will provide advance notification to the 
investigator or the head of the medical institution, where applicable, of the 
impending action.

If the study is suspended or prematurely discontinued for safety reasons, GSK will
promptly inform all investigators, heads of the medical institutions (where 
applicable) and/or institution(s) conducting the study. GSK will also promptly 
inform the relevant regulatory authorities of the suspension or premature 
discontinuation of the study and the reason(s) for the action.  

If required by applicable regulations, the investigator or the head of the medical 
institution (where applicable) must inform the IRB/IEC promptly and provide the 
reason for the suspension or premature discontinuation.
 
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10.6.
Records Retention

Following closure of the study, the investigator or the head of the medical 
institution (where applicable) must maintain all site study records (except for 
those required by local regulations to be maintained elsewhere), in a safe and 
secure location.  

The records must be maintained to allow easy and timely retrieval, when needed 
(e.g., for a GSK audit or regulatory inspection) and must be available for review 
in conjunction with assessment of the facility, supporting systems, and relevant 
site staff.  

Where permitted by local laws/regulations or institutional policy, some or all of 
these records can be maintained in a format other than hard copy (e.g., microfiche, 
scanned, electronic); however, caution needs to be exercised before such action is 
taken.  

The investigator must ensure that all reproductions are legible and are a true and 
accurate copy of the original and meet accessibility and retrieval standards, 
including re-generating a hard copy, if required.  Furthermore, the investigator 
must ensure there is an acceptable back-up of these reproductions and that an 
acceptable quality control process exists for making these reproductions.

GSK will inform the investigator of the time period for retaining these records to 
comply with all applicable regulatory requirements.  The minimum retention time 
will meet the strictest standard applicable to that site for the study, as dictated by 
any institutional requirements or local laws or regulations, GSK 
standards/procedures, and/or institutional requirements. 

The investigator must notify GSK of any changes in the archival arrangements, 
including, but not limited to, archival at an off-site facility or transfer of 
ownership of the records in the event the investigator is no longer associated with
the site.
 
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10.7.
Provision of Study Results to Investigators, Posting of 
Information on Publically Available Clinical Trials Registers 
and Publication
Where required by applicable regulatory requirements, an investigator signatory will be 
identified for the approval of the clinical study report.  The investigator will be provided 
reasonable access to statistical tables, figures, and relevant reports and will have the 
opportunity to review the complete study results at a GSK site or other mutually-
agreeable location.
GSK will also provide the investigator with the full summary of the study results.  The 
investigator is encouraged to share the summary results with the study subjects, as 
appropriate.
GSK will provide the investigator with the randomisation codes for their site only after 
completion of the full statistical analysis.
The procedures and timing for public disclosure of the results summary and for 
development of a manuscript for publication will be in accordance with GSK Policy.
A manuscript will be progressed for publication in the scientific literature if the results 
provide important scientific or medical knowledge.
 
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11.
REFERENCES
Abraham WT, Raynolds MV, Badesch DB, Wynne KM, Groves BM, Roden RL,et al..
Angiotensin-converting enzyme DD genotype in patients with primary pulmonary 
hypertension: increased frequency and association with preserved haemodynamics.  J 
Renin Angiotensin Aldosterone Syst. 2003 Mar;4(1):27-30.
Antoni Ricart, Jaume Maristany, Núria Fort, Conxita Leal, Teresa Pagés, and Ginés 
Viscor. High Altitude Medicine & Biology. March 2005, 6(1): 43-49. 
doi:10.1089/ham.2005.6.43
Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, et al. The American-
European consensus conference on ARDS: definitions, mechanisms, relevant outcomes, 
and clinical trial coordination. Am J Respir Crit Care Med. 1994;49:818-822. 
Cargil RI, Lipworth BJ. Lisinopril attenuates acute hypoxic pulmonary vasoconstriction 
in humans. Chest. 1996 Feb;109(2):424-9/
GlaxoSmithKline Document Number 2010N108777_00 Study ID GSK2586881. 
Investigator's Brochure for GSK2586881 (formerly known as APN01)– A Soluble 
Recombinant Human Angiotensin Converting Enzyme 2 (rhACE2). Report Date 16-
FEB-2011. 
Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F, Kowal D, editors. 
Contraceptive Technology. 19th edition. New York: Ardent Media, 2007(a): 24. Table 3-
2.
Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F, Kowal D, editors. 
Contraceptive Technology. 19th edition. New York: Ardent Media, 2007(b): 28.
ICH Topic M3 (R2)  Non-clinical safety studies for the conduct of human clinical trials 
and marketing authorisation for pharmaceuticals, 2009
Idell S, Kueppers, F, Lippmann, M, Rosen, H, Niederman, M, Fein, A. ACE elevated in 
ARDS BAL. Angiotensin converting enzyme in bronchoalveolar lavage in ARDS. Chest. 
1987;91:52-56.
Kiely DG, Cargill RI, Lipworth BJ (1996) Effects of hypercapnia on hemodynamic, 
inotropic, lusitropic, and electrophysiologic indices in humans. Chest 109:1215–1221
Kiely DG1, Cargill RI, Wheeldon NM, Coutie WJ, Lipworth BJ. Haemodynamic and 
endocrine effects of type 1 angiotensin II receptor blockade in patients with hypoxaemic 
cor pulmonale. Cardiovasc Res. 1997 Jan;33(1):201-8.
Kleinsasser A1, Pircher I, Treml B, Schwienbacher M, Schuster M, Janzek E, Loibner H, 
Penninger JM, Loeckinger A. Recombinant angiotensin-converting enzyme 2 suppresses 
pulmonary vasoconstriction in acute hypoxia. Wilderness Environ Med. 2012 
Mar;23(1):24-30
 
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Maron BA, Leopold JA. The role of the renin-angiotensin-aldosterone system in the 
pathobiology of pulmonary arterial hypertension (2013 Grover Conference series. Pulm 
Circ. 2014 Jun;4(2):200-10. doi: 10.1086/675984  
Marshall RP, Webb S, Bellingan GJ, Montgomery HE, Chaudhari B, Chambers RJ, , GJ
et al. Angiotensin converting enzyme insertion/deletion polymorphism is associated with 
susceptibility and outcome in acute respiratory distress syndrome. Am. J. Resp. Crit. Care 
Med. 2002;166:646-650. 
Paul M, Bachmann J, Ganten D. Angiotensin II-induced vasoconstriction and sodium 
resorption. The Tissue Renin-Angiotensin System in Cardiovascular Disease. Trends 
Cardiovasc. Med. 1992;2:94-99. 
Ricart A1, Maristany J, Fort N, Leal C, Pagés T, Viscor G. Effects of sildenafil on the 
human response to acute hypoxia and exercise. High Alt Med Biol. 2005 Spring;6(1):43-
9.
Rubenfeld GD, Caldwell E, Peabody E. Incidence and Outcomes of Acute Lung Injury. N 
Engl J Med. 2005;353:1685-1693. 
Santos RAS, Ferreira AJ, Pinheiro SVB, Sampaio WO, Touyz R, Campangole-Santos 
MJ. Counter-regulatory effects of ANG (1-7) in ANG II. Angiotensin(1-7) and its 
receptor as potential targets for cardiovascular drugs’ Expert Op. Investig. Drugs. 
2005;1019:1031. 
Santos RAS, Simoes e Silva, AC, Maric C, Silva DMR, Machado RP, de Buhr I, et al. 
ANG (1-7) as the agonist of mas. ‘Angiotensin (1-7) is an endogenous ligand for the G-
protein coupled receptor Mas’ Proc. Natl. Acad. Sci. USA. 2003;100:8258-8263. 
Suzuki Y, Ruiz-Ortega, M., Lorenzo, O., Ruperez, M., Esteban, V., Egido, J. 
Inflammatory and pro-fibrotic activity of ANG II. ) Inflammation and Angiotensin II. Int. 
J. Biochem. Cell Biol. 2003;35:881-900. 
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes 
as compared with traditional tidal volumes for acute lung injury and the acute respiratory 
distress syndrome. N Engl J Med. 2000;342:1301-1308. 
The ARDS Network Authors for the ARDS network. Ketoconzaole for Early Treatment 
of Acute Lung Injury and Acute Respiratory Distress Syndrome. JAMA. 2000;283:1995-
2002. 
Tom B, deVries R, Saxena PR, Danser J. ANG (1-7) inhibiting ACE and modifying 
Bradykinin responses. Bradykinin potentiation by angiotensin (1-7) and ACE inhibitors 
correlates with C- and N-terminal blockade’ Hypertension. 2001;38:95-99.
Torre-Bueno JR, Wagner PD, Saltzman HA, Gale GE, Moon RE. Diffusion limitation in 
normal humans during exercise at sea level and simulated altitude. J Appl Physiol (1985). 
1985 Mar;58(3):989-95
 
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Wenz M, Hoffmann B, Bohlender J, Kaczmarczyk G. ANG II elevated in ARDS. 
Anfgiotensin II formation and endothelin clearance in ARDS patients in supine and prone 
positions. Intensive Care Med. 2000;26:292-298. 
Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP, deBoisblanc 
B,et al.. Pulmonary-Artery versus Central Venous Catheter to Guide Treatment of Acute 
Lung Injury. N Engl J Med. 2006;25:354(21):2213-24. Epub 2006 May 21.
Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B,et 
al. Comparison of Two Fluid-Management Strategies in Acute Lung Injury. N Engl J 
Med. 2006;354(24):2564-75. Epub 2006 May 21.
 
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12.
APPENDICES
12.1.
Appendix 1: Abbreviations and Trademarks
Abbreviations
ACE2
Angiotensin converting enzyme type 2
AE
Adverse Event
ALI
Acute Lung Injury
ALT
Alanine aminotransferase (SGPT)
Ang II
Angiotensin II
ANP
Atrial Naturetic peptide
ARDS
Acute respiratory distress syndrome
AST
Aspartate aminotransferase (SGOT)
AUC
Area under concentration-time curve
BID
Bi-Daily
BUN
Blood urea nitrogen
CBP
Child Bearing Potential
CL
Clearance
CO2
Carbon dioxide
CONSORT
Consolidated Standards of Reporting Trials
CRF
Case Report Form
CV
Cardiovascular
DNA
Deoxyribonucleic acid
ECG
Electrocardiogram
eCRF
Electronic case report form
FDA
Food and Drug Administration
FRP
Females of Reproductive Potential
GCP
Good Clinical Practice
GLP
Good Laboratory Practice
GSK
GlaxoSmithKline
HBcAb
Hepatitis B core antibody
HBsAg
Hepatitis B surface antigen
hCG
Human chorionic gonadotropin
HIV
Human Immunodeficiency Virus
HPLC
High performance liquid chromatography
HPV
Hypoxic pulmonary vasoconstriction
IB
Investigator’s Brochure
ICH
International Conference on Harmonization of Technical 
Requirements for Registration of Pharmaceuticals for 
Human Use
ID
Identification
IEC
Independent Ethics Committee
IgG
Immunoglobulin G
IND
Investigational New Drug
IP
Investigational Product
 
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IRB
Institutional Review Board
ITT
Intent-to-Treat
IV
Intravenous
IVIVT
In Vitro/In Vivo Translations
Kg
Kilogram
LDH
Lactate dehydrogenase
LFTs
Liver function tests
m
Meters
MCH
Mean corpuscular hemogloin
MCV
Mean corpuscular volume
MedDRA
Medical Dictionary for Regulatory Activities
mg
Milligrams
mL
Milliliter
MSDS
Material Safety Data Sheet
msec
Milliseconds
NOAEL
No observed adverse effect level
NT-proBNP
Brain Naturetic Peptide
O2
Oxygen
PaO2
Partial Pressure of Oxygen in arterial blood
PAH
Pulmonary Arterial Hypertension
PASP
Pulmonary Artery Systolic Pressure
PD
Pharmacodynamic
PGx
Pharmacogenetics
PK
Pharmacokinetic
Q
Perfusion
QC
Quality control
QTcB
QT duration corrected for heart rate by Bazett’s formula
QTcF
QT duration corrected for heart rate by Fridericia’s formula
RAP
Reporting and Analysis Plan
RAS
Renin-Angiotensin System
RBC
Red blood cells
rhACE2
Recombinant human angiotensin converting enzyme type 2
RNA
Ribonucleic acid
SAE
Serious adverse event(s)
SD
Standard deviation
SRM
Study Reference Manual
TPR
Third Party Resourcing
TTS
Technical Terms of Supply
t½
Terminal phase half-life
tmax
Time of occurrence of Cmax
V
Volume of Distribution
VA
Ventilation
VO2
Oxygen Consumption
 
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Trademark Information
Trademarks of the GlaxoSmithKline 
group of companies
Trademarks not owned by the 
GlaxoSmithKline group of companies
NONE
MedDRA
WinNonlin
 
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12.2.
Appendix 2: Liver Safety Required Actions and Follow up 
Assessments
Phase I Liver chemistry stopping criteria have been designed to assure subject safety and 
to evaluate liver event etiology (in alignment with the FDA premarketing clinical liver 
safety guidance).
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guid
ances/UCM174090.pdf.
Phase I liver chemistry stopping criteria and required follow up assessments
Liver Chemistry Stopping Criteria – Liver Stopping Event
ALT-absolute
ALT≥3xULN
If  ALT≥3xULN AND bilirubin1,2 2xULN (>35% direct bilirubin) or  INR >1.5, 
Report as an SAE.
See additional Actions and Follow Up Assessments listed below
Required Actions and Follow up Assessments following Liver Stopping Event
Actions
Follow Up Assessments

Immediately discontinue study treatment

Report the event to GSK within 24 hours

Complete the liver event CRF, and complete 
an SAE data collection tool if the event also 
meets the criteria for an SAE2

Perform liver event follow up assessments 

Monitor the subject until liver chemistries 
resolve, stabilise, or return to within baseline
(see MONITORING below)
MONITORING:
If ALT≥3xULN AND bilirubin 2xULN  or INR 
>1.5

Repeat liver chemistries (include ALT, AST, 
alkaline phosphatase, bilirubin) and perform 
liver event follow up assessments within  24 
hrs

Monitor subjects twice weekly until liver 
chemistries resolve, stabilise or return to 
within baseline

A specialist or hepatology consultation is 

Viral hepatitis serology3

Obtain INR and recheck with each liver 
chemistry assessment until the 
transaminases values show downward 
trend.

Blood sample for pharmacokinetic (PK) 
analysis, obtained 24 hours after last dose

Serum creatine phosphokinase (CPK) and 
lactate dehydrogenase (LDH).

Fractionate bilirubin, if total 
bilirubin2xULN

Obtain complete blood count with 
differential to assess eosinophilia

Record the appearance or worsening of 
clinical symptoms of liver injury, or 
hypersensitivity, on the AE report form

Record use of concomitant medications on 
the concomitant medications report form
including acetaminophen, herbal remedies, 
other over the counter medications.
 
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Liver Chemistry Stopping Criteria – Liver Stopping Event
recommended
If ALT≥3xULN AND bilirubin < 2xULN  and 
INR ≤1.5:

Repeat liver chemistries (include ALT, AST, 
alkaline phosphatase, bilirubin) and perform
liver event follow up assessments within 24-
72 hrs

Monitor subjects weekly until liver 
chemistries resolve, stabilize or return to 
within baseline

Record alcohol use on the liver event 
alcohol intake case report form
If ALT≥3xULN AND bilirubin 2xULN  or 
INR >1.5:

Anti-nuclear antibody, anti-smooth muscle 
antibody, Type 1 anti-liver kidney 
microsomal antibodies, and quantitative 
total immunoglobulin G (IgG or gamma 
globulins).

Serum acetaminophen adduct HPLC assay 
(quantifies potential acetaminophen 
contribution to liver injury in subjects with 
definite or likely acetaminophen use in the 
preceding week [James, 2009]. NOTE: not 
required in China.

Liver imaging (ultrasound, magnetic 
resonance, or computerised tomography) 
and /or liver biopsy to evaluate liver 
disease; complete Liver Imaging and/or 
Liver Biopsy CRF forms.
1.
Serum bilirubin fractionation should be performed if testing is available. If serum bilirubin fractionation is not 
immediately available, discontinue study treatment for that subject if ALT 3xULN and bilirubin 2xULN. 
Additionally, if serum bilirubin fractionation testing is unavailable, record presence of detectable urinary bilirubin on 
dipstick, indicating direct bilirubin elevations and suggesting liver injury. 
2.
All events of ALT 3xULN and bilirubin 2xULN (>35% direct bilirubin) or ALT 3xULN and INR>1.5, if INR 
measured, which may indicate severe liver injury (possible ‘Hy’s Law’), must be reported as an SAE (excluding 
studies of hepatic impairment or cirrhosis); INR measurement is not required and the threshold value stated will 
not apply to subjects receiving anticoagulants
3.
Includes: Hepatitis A IgM antibody; Hepatitis B surface antigen and Hepatitis B Core Antibody (IgM); Hepatitis C 
RNA; Cytomegalovirus IgM antibody;  Epstein-Barr viral capsid antigen IgM antibody (or if unavailable, obtain 
heterophile antibody or monospot testing);  Hepatitis E IgM antibody 
4.
PK sample may not be required for subjects known to be receiving placebo or non-GSK comparator treatments.  
Record the date/time of the PK blood sample draw and the date/time of the last dose of study treatment prior to 
blood sample draw on the CRF. If the date or time of the last dose is unclear, provide the subject’s best 
approximation. If the date/time of the last dose cannot be approximated OR a PK sample cannot be collected in 
the time period indicated above, do not obtain a PK sample. Instructions for sample handling and shipping are in 
the SRM.
References
James LP, Letzig L, Simpson PM, Capparelli E, Roberts DW, Hinson JA,et al.. 
Pharmacokinetics of Acetaminophen-Adduct in Adults with Acetaminophen Overdose 
and Acute Liver Failure. Drug Metab Dispos 2009; 37:1779-1784.
 
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12.3.
Appendix 3: Genetic Research
Genetics – Background
Naturally occurring genetic variation may contribute to inter-individual variability in 
response to medicines, as well as an individual's risk of developing specific diseases. 
Genetic factors associated with disease characteristics may also be associated with 
response to therapy, and could help to explain some clinical study outcomes. For 
example, genetic variants associated with age-related macular degeneration (AMD) are 
reported to account for much of the risk for the condition [Gorin, 2012] with certain 
variants reported to influence treatment response [Chen, 2012]. Thus, knowledge of the 
genetic etiology of disease may better inform understanding of disease and the 
development of medicines. Additionally, genetic variability may impact the 
pharmacokinetics (absorption, distribution, metabolism, and elimination), or 
pharmacodynamics (relationship between concentration and pharmacologic effects or the 
time course of pharmacologic effects) of a specific medicine and/or clinical outcomes 
(efficacy and/or safety) observed in a clinical study.
Genetic Research Objectives and Analyses
The objectives of the genetic research are to investigate the relationship between genetic 
variants and: 

Response to medicine, including [any treatment regimens under investigation in 
this study] or any concomitant medicines;
Genetic data may be generated while the study is underway or following completion of 
the study.  Genetic evaluations may include focused candidate gene approaches and/or 
examination of a large number of genetic variants throughout the genome (whole genome 
analyses). Genetic analyses will utilize data collected in the study and will be limited to 
understanding the objectives highlighted above.  Analyses may be performed using data 
from multiple clinical studies to investigate these research objectives.
Appropriate descriptive and/or statistical analysis methods will be used. A detailed 
description of any planned analyses will be documented in a Reporting and Analysis Plan 
(RAP) prior to initiation of the analysis. Planned analyses and results of genetic 
investigations will be reported either as part of the clinical RAP and study report, or in a 
separate genetics RAP and report, as appropriate.
Study Population
Any subject who is enrolled in the study can participate in genetic research.  Any subject 
who has received an allogeneic bone marrow transplant must be excluded from the 
genetic research.
Study Assessments and Procedures
A key component of successful genetic research is the collection of samples during 
clinical studies. Collection of samples, even when no a priori hypothesis has been 
 
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identified, may enable future genetic analyses to be conducted to help understand 
variability in disease and medicine response.  

A 6 ml blood sample will be taken for Deoxyribonucleic acid (DNA) extraction. 
A blood sample is collected at the baseline visit, after the subject has been 
randomised and provided informed consent for genetic research. Instructions for 
collection and shipping of the genetic sample are described in the laboratory
manual. The DNA from the blood sample may undergo quality control analyses to 
confirm the integrity of the sample. If there are concerns regarding the quality of 
the sample, then the sample may be destroyed. The blood sample is taken on a 
single occasion unless a duplicate sample is required due to an inability to utilize 
the original sample.  
The genetic sample is labelled (or “coded”) with the same study specific number used to 
label other samples and data in the study.   This number can be traced or linked back to 
the subject by the investigator or site staff. Coded samples do not carry personal 
identifiers (such as name or social security number). 
Samples will be stored securely and may be kept for up to 15 years after the last subject 
completes the study, or GSK may destroy the samples sooner.  GSK or those working 
with GSK (for example, other researchers) will only use samples collected from the study 
for the purpose stated in this protocol and in the informed consent form.  Samples may be 
used as part of the development of a companion diagnostic to support the GSK medicinal 
product.
Subjects can request their sample to be destroyed at any time.
Informed Consent
Subjects who do not wish to participate in the genetic research may still participate in the 
study.  Genetic informed consent must be obtained prior to any blood being taken.
Subject Withdrawal from Study
If a subject who has consented to participate in genetic research withdraws from the 
clinical study for any reason other than being lost to follow-up, the subject will be given a 
choice of one of the following options concerning the genetic sample, if already 
collected:

Continue to participate in the genetic research in which case the genetic DNA 
sample is retained

Discontinue participation in the genetic research and destroy the genetic DNA 
sample 
If a subject withdraws consent for genetic research or requests sample destruction for any 
reason, the investigator must complete the appropriate documentation to request sample 
destruction within the timeframe specified by GSK and maintain the documentation in 
the site study records. 
 
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Genotype data may be generated during the study or after completion of the study and 
may be analyzed during the study or stored for future analysis. 

If a subject withdraws consent for genetic research and genotype data has not been 
analyzed, it will not be analyzed or used for future research.  

Genetic data that has been analyzed at the time of withdrawn consent will 
continue to be stored and used, as appropriate. 
Screen and Baseline Failures
If a sample for genetic research has been collected and it is determined that the subject 
does not meet the entry criteria for participation in the study, then the investigator should 
instruct the subject that their genetic sample will be destroyed. No forms are required to 
complete this process as it will be completed as part of the consent and sample 
reconciliation process.  In this instance a sample destruction form will not be available to 
include in the site files.
Provision of Study Results and Confidentiality of Subject’s Genetic Data
GSK may summarize the genetic research results in the clinical study report, or 
separately and may publish the results in scientific journals. 
GSK may share genetic research data with other scientists to further scientific 
understanding in alignment with the informed consent. GSK does not inform the subject, 
family members, insurers, or employers of individual genotyping results that are not 
known to be relevant to the subject’s medical care at the time of the study, unless 
required by law. This is due to the fact that the information generated from genetic 
studies is generally preliminary in nature, and therefore the significance and scientific 
validity of the results are undetermined.  Further, data generated in a research laboratory 
may not meet regulatory requirements for inclusion in clinical care.
Chen H, Yu KD, Xu GZ. Association between Variant Y402H in Age-Related Macular 
Degeneration (AMD) Susceptibility Gene CFH and Treatment Response of AMD: A 
Meta-Analysis. PloS ONE 2012; 7: e42464
Gorin MB. Genetic insights into age-related macular degeneration: Controversies 
addressing risk, causality, and therapeutics. Mol. Asp. Med. 2012; 33: 467-486.
 
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12.4.
Appendix 4: Definition of and Procedures for Recording, 
Evaluating, Follow-Up and Reporting of Adverse Events
12.4.1.
Definition of Adverse Events
Adverse Event Definition:

An AE is any untoward medical occurrence in a patient or clinical investigation 
subject, temporally associated with the use of a medicinal product, whether or not 
considered related to the medicinal product.

NOTE: An AE can therefore be any unfavorable and unintended sign (including an 
abnormal laboratory finding), symptom, or disease (new or exacerbated) temporally 
associated with the use of a medicinal product.
Events meeting AE definition include:

Any abnormal laboratory test results (hematology, clinical chemistry, or urinalysis) 
or other safety assessments (e.g., ECGs, radiological scans, vital signs 
measurements), including those that worsen from baseline, and felt to be clinically 
significant in the medical and scientific judgement of the investigator.

Exacerbation of a chronic or intermittent pre-existing condition including either an 
increase in frequency and/or intensity of the condition.

New conditions detected or diagnosed after study treatment administration even 
though it may have been present prior to the start of the study.

Signs, symptoms, or the clinical sequelae of a suspected interaction.

Signs, symptoms, or the clinical sequelae of a suspected overdose of either study 
treatment or a concomitant medication (overdose per se will not be reported as an 
AE/SAE unless this is an intentional overdose taken with possible suicidal/self-
harming intent.  This should be reported regardless of sequelae).

"Lack of efficacy" or "failure of expected pharmacological action" per se will not be 
reported as an AE or SAE.  However, the signs and symptoms and/or clinical 
sequelae resulting from lack of efficacy will be reported if they fulfil the definition 
of an AE or SAE.

The signs and symptoms and/or clinical sequelae resulting from lack of efficacy will 
be reported if they fulfil the definition of an AE or SAE.  Also, "lack of efficacy" or 
"failure of expected pharmacological action" also constitutes an AE or SAE.
Events NOT meeting definition of an AE include:

Any clinically significant abnormal laboratory findings or other abnormal safety 
assessments which are associated with the underlying disease, unless judged by the 
 
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investigator to be more severe than expected for the subject’s condition.

The disease/disorder being studied or expected progression, signs, or symptoms of 
the disease/disorder being studied, unless more severe than expected for the subject’s 
condition.

Medical or surgical procedure (e.g., endoscopy, appendectomy): the condition that 
leads to the procedure is an AE.

Situations where an untoward medical occurrence did not occur (social and/or 
convenience admission to a hospital).

Anticipated day-to-day fluctuations of pre-existing disease(s) or condition(s) present 
or detected at the start of the study that do not worsen.
12.4.2.
Definition of Serious Adverse Events
If an event is not an AE per definition above, then it cannot be an SAE even if serious 
conditions are met (e.g., hospitalization for signs/symptoms of the disease under study, 
death due to progression of disease, etc).
Serious Adverse Event (SAE) is defined as any untoward medical occurrence that, 
at any dose:
a.
Results in death
b.
Is life-threatening
NOTE:
The term 'life-threatening' in the definition of 'serious' refers to an event in which the 
subject was at risk of death at the time of the event.  It does not refer to an event, which 
hypothetically might have caused death, if it were more severe.
c.
Requires hospitalization or prolongation of existing hospitalization
NOTE:

In general, hospitalization signifies that the subject has been detained (usually 
involving at least an overnight stay) at the hospital or emergency ward for 
observation and/or treatment that would not have been appropriate in the physician’s 
office or out-patient setting.  Complications that occur during hospitalization are 
AEs.  If a complication prolongs hospitalization or fulfills any other serious criteria, 
the event is serious.  When in doubt as to whether “hospitalization” occurred or was 
necessary, the AE should be considered serious.

Hospitalization for elective treatment of a pre-existing condition that did not worsen 
from baseline is not considered an AE.
 
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d.
Results in disability/incapacity
NOTE:

The term disability means a substantial disruption of a person’s ability to conduct 
normal life functions.

This definition is not intended to include experiences of relatively minor medical 
significance such as uncomplicated headache, nausea, vomiting, diarrhea, influenza, 
and accidental trauma (e.g. sprained ankle) which may interfere or prevent everyday 
life functions but do not constitute a substantial disruption
e.
Is a congenital anomaly/birth defect
f.
Other situations:

Medical or scientific judgment should be exercised in deciding whether reporting is 
appropriate in other situations, such as important medical events that may not be 
immediately life-threatening or result in death or hospitalization but may jeopardize 
the subject or may require medical or surgical intervention to prevent one of the 
other outcomes listed in the above definition.  These should also be considered 
serious.

Examples of such events are invasive or malignant cancers, intensive treatment in an 
emergency room or at home for allergic bronchospasm, blood dyscrasias or 
convulsions that do not result in hospitalization, or development of drug dependency 
or drug abuse
g.
Is associated with liver injury and impaired liver function defined as:

ALT 3xULN and total bilirubin* 2xULN (>35% direct), or

ALT 3xULN and INR** > 1.5.
* Serum bilirubin fractionation should be performed if testing is available; if unavailable, 
measure urinary bilirubin via dipstick.  If fractionation is unavailable and ALT 3xULN 
and total bilirubin 2xULN, then the event is still to be reported as an SAE.
** INR testing not required per protocol and the threshold value does not apply to 
subjects receiving anticoagulants.  If INR measurement is obtained, the value is to be 
recorded on the SAE form.

Refer to Appendix 2 for the required liver chemistry follow-up instructions
 
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12.4.3.
Definition of Cardiovascular Events
Cardiovascular Events (CV) Definition:
Investigators will be required to fill out the specific CV event page of the CRF for the 
following AEs and SAEs:

Myocardial infarction/unstable angina

Congestive heart failure

Arrhythmias

Valvulopathy

Pulmonary hypertension

Cerebrovascular events/stroke and transient ischemic attack

Peripheral arterial thromboembolism

Deep venous thrombosis/pulmonary embolism

Revascularization
12.4.4.
Recording of AEs and SAEs
AEs and SAE Recording:

When an AE/SAE occurs, it is the responsibility of the investigator to review all 
documentation (e.g., hospital progress notes, laboratory, and diagnostics reports) 
relative to the event.

The investigator will then record all relevant information regarding an AE/SAE in 
the CRF

It is not acceptable for the investigator to send photocopies of the subject’s medical 
records to GSK in lieu of completion of the GSK, AE/SAE CRF page.

There may be instances when copies of medical records for certain cases are 
requested by GSK.  In this instance, all subject identifiers, with the exception of the 
subject number, will be blinded on the copies of the medical records prior to 
submission of to GSK.

The investigator will attempt to establish a diagnosis of the event based on signs, 
symptoms, and/or other clinical information.  In such cases, the diagnosis will be 
documented as the AE/SAE and not the individual signs/symptoms.

Subject-completed Value Evidence and Outcomes questionnaires and the collection 
of AE data are independent components of the study.

Responses to each question in the Value Evidence and Outcomes questionnaire will 
be treated in accordance with standard scoring and statistical procedures detailed by 
the scale’s developer.
 
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
The use of a single question from a multidimensional health survey to designate a 
cause-effect relationship to an AE is inappropriate.
12.4.5.
Evaluating AEs and SAEs
Assessment of Intensity
The investigator will make an assessment of intensity for each AE and SAE reported 
during the study and will assign it to one of the following categories:

Mild:  An event that is easily tolerated by the subject, causing minimal discomfort 
and not interfering with everyday activities.

Moderate:  An event that is sufficiently discomforting to interfere with normal 
everyday activities

Severe:  An event that prevents normal everyday activities. - an AE that is assessed 
as severe will not be confused with an SAE. Severity is a category utilized for rating 
the intensity of an event; and both AEs and SAEs can be assessed as severe.

An event is defined as ‘serious’ when it meets at least one of the pre-defined 
outcomes as described in the definition of an SAE.
Assessment of Causality

The investigator is obligated to assess the relationship between study treatment and 
the occurrence of each AE/SAE.

A "reasonable possibility" is meant to convey that there are facts/evidence or 
arguments to suggest a causal relationship, rather than a relationship cannot be ruled 
out.

The investigator will use clinical judgment to determine the relationship.

Alternative causes, such as natural history of the underlying diseases, concomitant 
therapy, other risk factors, and the temporal relationship of the event to the study 
treatment will be considered and investigated.

The investigator will also consult the Investigator Brochure (IB) and/or Product 
Information, for marketed products, in the determination of his/her assessment.

For each AE/SAE the investigator must document in the medical notes that he/she 
has reviewed the AE/SAE and has provided an assessment of causality.

There may be situations when an SAE has occurred and the investigator has minimal 
information to include in the initial report to GSK.  However, it is very important 
that the investigator always make an assessment of causality for every event 
prior to the initial transmission of the SAE data to GSK.

The investigator may change his/her opinion of causality in light of follow-up 
 
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information, amending the SAE data collection tool accordingly.

The causality assessment is one of the criteria used when determining regulatory 
reporting requirements.
Follow-up of AEs and SAEs

The investigator is obligated to perform or arrange for the conduct of supplemental 
measurements and/or evaluations as may be indicated or as requested by GSK to 
elucidate as fully as possible the nature and/or causality of the AE or SAE.

The investigator is obligated to assist.  This may include additional laboratory tests 
or investigations, histopathological examinations or consultation with other health 
care professionals.

If a subject dies during participation in the study or during a recognized follow-up 
period, the investigator will provide GSK with a copy of any post-mortem findings, 
including histopathology.

New or updated information will be recorded in the originally completed CRF.

The investigator will submit any updated SAE data to GSK within the designated 
reporting time frames.
12.4.6.
Reporting of SAEs to GSK
SAE reporting to GSK via electronic data collection tool

Primary mechanism for reporting SAEs to GSK will be the electronic data collection 
tool

If the electronic system is unavailable for greater than 24 hours, the site will use the 
paper SAE data collection tool and fax it to the Medical Monitor Site will enter the 
serious adverse event data into the electronic system as soon as it becomes available.

The investigator will be required to confirm review of the SAE causality by ticking 
the ‘reviewed’ box at the bottom of the eCRF page within 72 hours of submission of 
the SAE.

After the study is completed at a given site, the electronic data collection tool (e.g., 
InForm system) will be taken off-line to prevent the entry of new data or changes to 
existing data

If a site receives a report of a new SAE from a study subject or receives updated data 
on a previously reported SAE after the electronic data collection tool has been taken 
off-line, the site can report this information on a paper SAE form or to the Medical 
Monitor telephone.

Contacts for SAE receipt can be found at the beginning of this protocol on the 
Sponsor/Medical Monitor Contact Information page.
 
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SAE reporting to GSK via paper CRF

Facsimile transmission of the SAE paper CRF is the preferred method to transmit 
this information to the Medical Monitor

In rare circumstances and in the absence of facsimile equipment, notification by 
telephone is acceptable, with a copy of the SAE data collection tool sent by 
overnight mail

Initial notification via the telephone does not replace the need for the investigator to 
complete and sign the SAE CRF pages within the designated reporting time frames.

Contacts for SAE receipt can be found at this beginning of the protocol on the 
Sponsor/Medical Monitor Contact Information page.
 
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12.5.
Appendix 5: Modified List of Highly Effective Methods for 
Avoiding Pregnancy and Collection of Pregnancy 
Information
12.5.1.
Modified List of Highly Effective Methods for Avoiding Pregnancy
The list does not apply to FRP with same sex partners or for subjects who are and will 
continue to be abstinent from penile-vaginal intercourse on a long term and persistent 
basis, when this is their preferred and usual lifestyle. Periodic abstinence (e.g. calendar, 
ovulation, symptothermal, post-ovulation methods) and withdrawal are not acceptable 
methods of contraception.
1.
Contraceptive subdermal implant
2.
Intrauterine device or intrauterine system
3.
Combined estrogen and progestogen oral contraceptive [Hatcher RA, 2011]
4.
Injectable progestogen [Hatcher RA, 2011]
5.
Contraceptive vaginal ring [Hatcher RA, 2011]
6.
Percutaneous contraceptive patches [Hatcher RA, 2011]
7.
Male partner sterilization with documentation of azoospermia prior to the female 
subject's entry into the study, and this male is the sole partner for that subject 
[Hatcher RA, 2011]. The documentation on male sterility can come from the site 
personnel’s: review of subject’s medical records, medical examination and/or semen 
analysis, or medical history interview provided by her or her partner.
These allowed methods of contraception are only effective when used consistently, 
correctly and in accordance with the product label. The investigator is responsible for 
ensuring that subjects understand how to properly use these methods of contraception.
Contraceptive requirements for male subjects with female partners of reproductive 
potential (when applicable).
Male subjects with female partners of child bearing potential must comply with the 
following contraception requirements from the time of first dose of study medication 
until [at least five half-lives of study medication OR for a cycle of spermatogenesis 
following five terminal half-lives] after the last dose of study medication.
1.
Vasectomy with documentation of azoospermia. The documentation on male sterility 
can come from the site personnel’s: review of subject’s medical records, medical 
examination and/or semen analysis, or medical history interview.
2.
Male condom plus partner use of one of the contraceptive options below that meets 
the Standard Operating Procedure (SOP) effectiveness criteria including a <1% rate 
of failure per year, as stated in the product label:

Contraceptive subdermal implant

Intrauterine device or intrauterine system
 
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
Combined estrogen and progestogen oral contraceptive [Hatcher RA, 2011] 

Injectable progestogen [Hatcher RA, 2011]

Contraceptive vaginal ring [Hatcher RA, 2011]

Percutaneous contraceptive patches [Hatcher RA, 2011]
These allowed methods of contraception are only effective when used consistently, 
correctly and in accordance with the product label. The investigator is responsible for 
ensuring that subjects understand how to properly use these methods of contraception.
12.5.2.
Collection of Pregnancy Information

Investigator will collect pregnancy information on any female subject, who becomes 
pregnant while participating in this study

Information will be recorded on the appropriate form and submitted to GSK within 2 
weeks of learning of a subject's pregnancy.

Subject will be followed to determine the outcome of the pregnancy. The 
investigator will collect follow up information on mother and infant, which will be 
forwarded to GSK.  Generally, follow-up will not be required for longer than 6 to 8 
weeks beyond the estimated delivery date. 

Any termination of pregnancy will be reported, regardless of fetal status (presence or 
absence of anomalies) or indication for procedure.

While pregnancy itself is not considered to be an AE or SAE, any pregnancy 
complication or elective termination of a pregnancy will be reported as an AE or 
SAE.

A spontaneous abortion is always considered to be an SAE and will be reported as 
such.  

Any SAE occurring as a result of a post-study pregnancy which is considered 
reasonably related to the study treatment by the investigator, will be reported to GSK 
as described in Appendix 5. While the investigator is not obligated to actively seek 
this information in former study participants, he or she may learn of an SAE through 
spontaneous reporting.
Any female subject who becomes pregnant while participating

will discontinue study medication or be withdrawn from the study

Investigator will attempt to collect pregnancy information on any female partner of a 
male study subject who becomes pregnant while participating in this study. This 
applies only to subjects who are randomised to receive study medication. 

After obtaining the necessary signed informed consent from the female partner 
directly, the investigator will record pregnancy information on the appropriate form 
and submit it to GSK within 2 weeks of learning of the partner’s pregnancy
 
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
Partner will also be followed to determine the outcome of the pregnancy.  
Information on the status of the mother and child will be forwarded to GSK. 

Generally, follow-up will be no longer than 6 to 8 weeks following the estimated 
delivery date.  Any termination of the pregnancy will be reported regardless of fetal 
status (presence or absence of anomalies) or indication for procedure.
12.5.3.
References
Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F, Kowal D, Policar MS, 
editors. Contraceptive Technology. 20th edition. Atlanta, Georgia: Ardent Media, Inc., 
2011: 50. Table 3-2.
 
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