Velusetrag for the Treatment of Chronic Intestinal Pseudo-Obstruction (CIPO). A Multicenter, Double-blind, Placebo-controlled, Cross-over, Multiple (n=1) Trial.
Phase: PHASE2
Conditions: Chronic Intestinal Pseudo-obstruction
Sponsor: Alfasigma S.p.A.

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STUDY PROTOCOL
Velusetrag for the treatment of Chronic Intestinal Pseudo-Obstruction (CIPO). A multicenter,
double-blind, placebo-controlled, cross-over, multiple (n=1) trial
Study code:
VE-CIP2001/2021
EudraCT number:
2021-000854-24
Phase:
II
Name of the investigational 
product:
Velusetrag 
Coordinating Investigator 
Prof.
Sponsor:
Alfasigma S.p.A.
Via Ragazzi del ’99, n. 5
40133 Bologna, Italy.
CRO:
Status/Date:
Final version 1.0-24 May 2021
The information in this document is confidential and provided to you as 
investigator/consultant (if relevant), to your staff, and relevant institutional ethics committee. 
By accepting this document, you agree that the information contained herein will not be 
disclosed to others without the authorization of Alfasigma S.p.A.
 

Study code: VE-CIP2001/2021                                                                    
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SIGNATURE PAGE (4/4)
Declaration of the Investigator
Title: Velusetrag for the treatment of Chronic Intestinal Pseudo-Obstruction (CIPO). A multicenter,
double-blind, placebo-controlled, cross-over, multiple (n=1) trial
All documentation for this study supplied to me, which has not been previously published, will be 
kept in the strictest confidence. This documentation includes this study protocol, Investigator’s 
Brochure, Case Report Forms, and other scientific data.
The study will not be commenced without the prior written approval of a properly constituted 
Institutional Review Board (IRB) or Independent Ethics Committee (IEC).
No changes will be made to the study protocol without the prior written approval of the Sponsor and 
the IRB or IEC, except where necessary to eliminate an immediate hazard to the subjects.
I have read and understood and agree to abide by all the conditions and instructions contained in 
this protocol.
Responsible Investigator of the local study center:
XXXXXXXXX, MD
Director of Department of 
XXXXXXXXX
Address
Telephone
Date 
(dd/mm/yyyy)
Signature
 
 

Study code: VE-CIP2001/2021                                                                    
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In case, during a treatment period or during a washout period, a 
subject should experience an exacerbation of the CIPO related 
gastrointestinal symptoms that is not controlled by permitted 
medications and is not judged as an adverse event, he/she will attend 
an early switch visit (ESV) at the clinical site. After being reassessed,
he/she will start the next scheduled treatment period (SOT-2 or SOT-
3 or SOT-4) without completing the ongoing treatment or washout 
period. Only one early switch is possible during the study.
Number of Subjects: 16 (4 subjects per treatment sequence).
Study Population: Subjects with a diagnosis of idiopathic CIPO or CIPO secondary to 
primary neurodegenerative or demyelinating conditions (e.g.,
Parkinsonian Syndromes, multiple sclerosis, etc.).
Inclusion Criteria:
Men or women aged 18-80 years.
Subjects with history of chronic idiopathic intestinal pseudo-
obstruction or CIPO
secondary to neurodegenerative or 
demyelinating disease. 
Subjects with estimated oral caloric intake of at least 30% of the 
daily age- and sex-recommended caloric intake (stage 0, 1 or 2 of 
the “
, see 21.3 Appendix 3: 
 
 for CIPO patients).
Subjects with at least 2 out of 4 CIPO gastrointestinal symptoms 
(i.e., abdominal pain, bloating, nausea and vomiting), each of the 
2 with a score  RQ D  WR  VFDOH FROOHFWHG RQ WKH
gastrointestinal symptom questionnaire at Day -1
Subjects accepting to provide and legally capable of providing free 
and informed consent to all procedures included in the protocol.
All sexually active male participants who are partner of women of 
childbearing potential must use condom during intercourse until 
the 90th day after the end of the entire study.
All female participants must be: 
x
of non-childbearing potential, i.e.: i) post-menopausal (at 
least 2 years without spontaneous menses), or ii) surgically 
sterile (bilateral tubal occlusion, or hysterectomy), or iii) 
ablation of both ovaries 
or
x
of childbearing potential with a negative pregnancy test result 
at screening and randomization AND agreeing to use a 
highly effective method of contraception (i.e., with failure rate 
of less than 1% per year) until the end of the entire study. 
 
 
 
 
 
 
 
 
 

Study code: VE-CIP2001/2021                                                                    
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Note 1. Based on the EU Clinical Trial Facilitation Group
recommendations, a highly effective method of contraception is one 
of the following: 
x
Intrauterine device (IUD).
x
Intrauterine hormone-releasing systems (IUS).
x
Combined hormonal contraceptives (i.e., estrogen and 
progestogen) in oral, intravaginal or transdermal form, with 
inhibition of ovulation as primary mode of action.
x
Progestogen-only hormonal contraceptives in oral, injectable 
or implantable form, with inhibition of ovulation as primary 
mode of action.
x
True and absolute abstinence: when this is in line with the 
preferred and usual lifestyle of the subject. 
Note 2. Periodic abstinence, such as calendar, ovulation, symptom 
thermal, post ovulation methods, and withdrawal are not acceptable 
methods of contraception.
Note 3. In each case of delayed menstrual period (over one month 
between menstruations), female participants of child-bearing potential 
will be strongly recommended to provide a confirmation of absence of 
pregnancy. This recommendation applies also to women of child-
bearing potential with infrequent or irregular menstrual cycles.
Exclusion Criteria: 
Subjects with primary CIPO or CIPO secondary to other known 
endocrine/metabolic, autoimmune diseases and neurologic 
conditions other than neurodegenerative or demyelinating 
diseases.
Subjects with conditions characterized by mechanical intestinal 
obstruction.
Nasogastric tube, gastrostomy tube, or jejunostomy feeding tube 
in place at randomization or planned throughout the duration of 
the study, or 
 stage 3 (“total non-oral 
nutrition”, see 21.3 Appendix 3: Artificial Food Need" (AFN) Scale 
for CIPO patients).
Presence of untreated clinically relevant thyroid dysfunction or 
known thyroid dysfunction not well controlled by treatment (e.g., 
subjects with abnormal thyroid stimulating hormone [TSH], and, if 
available, triiodothyronine [T3] and thyroxin [T4] levels) deemed 
clinically significant by the Investigator.
Subjects with history of diabetes at screening.
Clinically significant ECG abnormalities (e.g., ST segment 
elevation or depression suggestive of ischemia, partial or 
complete left bundle branch block [LBBB]) at Screening and 
randomization.
Screening ECG with a QTcF >450 msec in males or >470 msec 
in females or family history of sudden cardiac death.
Subjects requiring a low galactose diet.
 
 
 
 
 
 
 
 
 
 

Study code: VE-CIP2001/2021                                                                    
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Hypersensitivity or documented intolerance to lactulose, lactose
or any excipient of the lactulose preparation to be used for 
.
History of sensitivity to velusetrag, or any of the velusetrag or 
placebo excipients.
Use of scopolamine or erythromycin within 2 weeks prior to 
Screening and/or planned throughout the duration of the study.
Use of 
within 5 days prior to randomization 
and/or planned throughout the duration of the study
Use of opioids within 8 weeks from screening and/or planned 
throughout the duration of the study.
Received strong cytochrome P450-isozyme 3A4 (CYP3A4)
inhibitors 
(e.g.,
clarithromycin, 
indinavir, 
itraconazole, 
ketoconazole, nefazodone, nelfinavir, ritonavir, saquinavir, 
telithromycin, grapefruit juice) or strong CYP3A4 inducers (e.g., 
rifampin, phenytoin, carbamazepine, phenobarbital, St. John's 
wort) within 2 weeks prior to screening and/or planned throughout 
the duration of the study.
Received strong P-glycoprotein (P-gp) transporter inhibitors (e.g., 
captopril, carvedilol, diltiazem) within 2 weeks prior to Screening 
and/or planned throughout the duration of the study.
Received strong breast cancer resistance protein (BCRP) 
transporter 
inhibitors 
(e.g., 
curcumin, 
cyclosporine 
A, 
eltrombopag) within 2 weeks prior to Screening and/or planned 
throughout the duration of the study.
Current swab-positive or suspected (under investigation) COVID-
19 infection.
Cancer (excluding non-melanoma skin cancer) and/or need of any 
anti-cancer treatment (also including radiotherapy) within the last 
5 years.
Severe kidney impairment (i.e., estimated glomerular filtration rate 
<30 ml/min). 
Aspartate aminotransferase (AST) or alanine transaminase (ALT) 
levels >2.5 times the upper limit of normal (ULN); bilirubin (unless 
deemed to be due to Gilbert’s Syndrome) or alkaline phosphatase 
(ALP) >1.5 times ULN.
Severe hepatic impairment defined as Child-Pugh C.
History of any of the following cardiac disorders:
x
Torsade de pointes, ventricular tachycardia, ventricular 
fibrillation.
x
Previous myocardial infarction, unstable angina pectoris, 
acute coronary syndrome, coronary artery or cerebral
revascularization procedure or stroke within the previous 18 
months.
x
Angina pectoris class 2-4 during the last 12 months prior to 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Study code: VE-CIP2001/2021                                                                    
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screening.
x
Congestive heart failure NYHA class III-IV during the last 18 
months prior to screening.
History of any alcohol or drug abuse or dependence within the last 
year (Investigator’s judgement).
Any current significant health condition (e.g., cardiovascular, 
respiratory, renal, hepatic, neurologic, psychiatric, hematologic, 
oncologic, immune, muscle and joint, etc.) that in the 
Investigator’s judgement may:
x
jeopardize the subject’s safe participation in the trial; or
x
make unlikely the subject’s completion of the study; or 
x
make unlikely the subject’s compliance with the study 
procedures (e.g., highly anticipated need of non-permitted 
treatments, significant disability, terminal illness, etc.).
Pregnant or breastfeeding woman.
Use of any experimental drug within 12 weeks prior to screening.
Test product, dose and 
mode of administration:
Velusetrag 15 mg (
 mg 
 once a day to be taken orally 
approximately at the same time in the morning, on an empty stomach, 
with water.
Reference therapy, dose 
and mode of 
administration:
Placebo 
 (
) once a day to be taken orally 
approximately at the same time in the morning, on an empty stomach, 
with water.
Study duration: A maximum of 4 weeks of velusetrag (or placebo) followed by a 
maximum of 2-week wash-out period, 4 weeks of placebo (or 
velusetrag) and 2 weeks of wash-out. This cycle will be repeated 
twice. A follow up visit will be performed after 2 weeks from the end 
of the last treatment period. Overall, each subject will be involved in 
the study for a maximum of a 7-day screening period and 
approximately a 24 -week period after randomization.
Criteria for evaluation: EFFICACY
Rating of symptoms (i.e., abdominal pain, bloating, nausea and 
vomiting) is using a recall period of 7 days and a Likert scale with the 
following categories:
0 - Absent
1 - Mild (not influencing usual activities)
2 - Moderate (diverting from, but not urging modification of, 
usual activities)
3 - Severe (influencing usual activities markedly enough to 
urge modifications)
4 - Extremely severe (precluding daily activities)
Primary Efficacy Endpoint
Change in weekly global gastrointestinal symptoms average index 
score from start to the end of each treatment period.
 
 
 
 
 
 

Study code: VE-CIP2001/2021                                                                    
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The weekly global gastrointestinal symptoms average index score is 
obtained by averaging the scores for each of the 4 symptoms
assessed weekly: abdominal pain, bloating, nausea and vomiting.
 
 

Study code: VE-CIP2001/2021                                                                    
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Concomitant treatments:
Prohibited treatment:
Use of the following medications is not allowed within 2 weeks prior 
to Screening and throughout the duration of the study:
x
Strong CYP3A4 inhibitors or strong CYP3A4 inducers.
x
Strong P-gp transporter inhibitors.
x
Strong BCRP transporter inhibitors.
x
Scopolamine. 
x
Erythromycin.
 
 

Study code: VE-CIP2001/2021                                                                    
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x
Per Protocol Set (PPS), defined as the set of all subjects in 
the mFAS1 with no major deviations that may affect the 
analysis of the primary endpoint.
Analysis of the efficacy endpoints will be performed on the mFAS1
(primary analysis),
 PPS and FAS. Analysis of the safety and 
tolerability endpoints will be performed on the SS.
STATISTICAL ANALYSIS
Descriptive statistics per sequence, visit/period, and stratification 
factor will be presented as number of observations, number of missing 
observations, mean, standard deviation, median, minimum and 
maximum and 25th and 75th percentiles for continuous variables; 
frequency distribution (n, %) for categorical variables.
Graphical visualization for each subject overtime, including all 
assessments, will be used for the evaluation of efficacy and safety. 
All statistical analysis will be two-sided at a nominal level of 5%. 
Confidence intervals will be set at the 95% level.
SAS software (V. 9.3 or subsequent) will be used for all statistical 
analyses.
Primary efficacy endpoint
The primary endpoint is the change in weekly global gastrointestinal 
symptoms average index score from pre -treatment to the end of each 
treatment period.
The primary analysis is performed on the mFAS1.
The average weekly global gastrointestinal symptoms index score is 
obtained by averaging the scores for each of the 4 symptoms 
assessed weekly: abdominal pain, bloating, nausea and vomiting.
Descriptive statistics will be provided for each treatment sequence 
along with summaries of the paired differences (velusetrag minus 
placebo within paired treatment cycle – 2 cycles per subjects). Plots 
will be made by subjects, by cycle and by treatment. A stratified t-test 
will be used to analyze the treatment effect 
Other efficacy endpoints
Continuous efficacy endpoints will be summarized and analyzed in 
the same way as the primary endpoint.
 
 

Study code: VE-CIP2001/2021                                                                    
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Binary outcome will be compared between treatments with an odds 
ratio and confidence interval using logistic model and Cochran-
Mantel-Haenszel test. Poisson model will be used for count data.
Analysis of safety
 
 

Study code: VE-CIP2001/2021                                                                    
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STUDY SCHEDULE OF ASSESSMENTS
Screening Period
1st Treatment
Perioda
2nd Treatment
Perioda
3rd Treatment
Perioda
4th Treatment
Perioda
EFUn
ETV
ESVo
Randomiz.
SOT-1
EOT-1
SOT-2
EOT-2
SOT-3
EOT-3
SOT-4
EOT-4
End of 
Follow-up
Early 
Termination 
Visit
Early switch 
Visit
Visit
V1
V2
V3
V4
V5
V6
V7
V8
V9 
V10
ETV
ESV
Day
-7 to 
-1
1
28(±1)
43(±1)
70(±1)
85 (±1)
112(±1)
127(±1)
154(±1)
169(±1)
Any 
time 
betwe
en
Day 1
and
126
Informed 
Consent
X
On Site Visit
X
X
X
X
X
X
X
On Site Visit 
or home visitb
X
X
X
X
X
Medical, 
surgical 
history and
previous 
medications
X
Assessment 
of responder 
status to 
X
Demographics
X
 
 

Study code: VE-CIP2001/2021                                                                    
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TABLE OF CONTENTS
1
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS..................................................25
2
ETHICS................................................................................................................................27
2.1
INDEPENDENT ETHICS COMMITTEE (IEC) OR INSTITUTIONAL REVIEW BOARD (IRB) .............27
2.2
ETHICAL CONDUCT OF THE STUDY....................................................................................27
2.3
SUBJECT INFORMATION AND CONSENT..............................................................................27
3
GENERAL INFORMATION ..................................................................................................29
4
BACKGROUND AND RATIONALE ......................................................................................31
5
STUDY OBJECTIVES AND ENDPOINTS ............................................................................33
5.1
PRIMARY STUDY OBJECTIVE AND ENDPOINT.......................................................................33
6
OVERALL STUDY DESIGN AND PLAN...............................................................................36
7
DISCUSSION OF STUDY DESIGN, INCLUDING THE CHOICE OF CONTROL GROUPS .38
8
BENEFIT-RISK EVALUATION .............................................................................................38
9
SELECTION OF STUDY POPULATION ..............................................................................40
9.1
NUMBER OF PARTICIPANTS...............................................................................................40
9.2
INCLUSION CRITERIA........................................................................................................40
9.3
EXCLUSION CRITERIA.......................................................................................................41
9.4
PREMATURE DISCONTINUATION FROM THE STUDY PER SUBJECT........................................42
10 TREATMENTS.....................................................................................................................43
10.1 TREATMENTS TO BE ADMINISTERED ..................................................................................43
10.2 INVESTIGATIONAL PRODUCTS ...........................................................................................44
10.2.1
Test preparation ......................................................................................................44
10.2.2
Labelling and Packaging..........................................................................................44
10.2.3
Storage, Dispensing, Use and Disposal of the compound during and at the end of 
the study...............................................................................................................................45
10.3 METHOD OF ASSIGNING SUBJECTS TO TREATMENT GROUPS/RANDOMIZATION ....................45
10.4 SELECTION OF DOSES IN THE STUDY ................................................................................46
10.5 SELECTION AND TIMING OF DOSE FOR EACH SUBJECT .......................................................47
10.6 BLINDING.........................................................................................................................47
10.7 TREATMENT COMPLIANCE ................................................................................................47
10.8 PRIOR AND CONCOMITANT THERAPY.................................................................................47
11 STUDY PROCEDURES .......................................................................................................49
11.1 VISIT SCHEDULE..............................................................................................................49
11.2 STUDY EVALUATIONS/PROCEDURES .................................................................................49
11.2.1
Screening Period – Collectively named Visit 1 – from Day -7 to Day -1 ...................49
11.2.2
Visit 2 (Randomization Visit- V2)..............................................................................51
11.2.3
Visit 3 (V3; Day 28±1)..............................................................................................51
11.2.4
Start of Treatment (SOT) Visits: Visit 4 (V4, Day 43 ± 1), Visit 6 (V6, Day 85 ± 1) 
and Visit 8 (V8, Day 127 ± 1)................................................................................................52
11.2.5
End of Treatment (EOT) Visits: Visit 5 (V5, Day 70 ± 1), Visit 7 (V7, Day 112 ± 1) 
and Visit 9 (V9, Day 154 ± 1)................................................................................................53
11.2.6
End of Follow-up (EFU; Day 169 ±1) .......................................................................54
11.2.7
Early Termination Visit (ETV)...................................................................................55
11.2.8
Early Switch Visit (ESV; anytime between Day 1 and Day 126)...............................56
11.2.9
Contingency activities in case of travel restrictions due to SArS-COV2 pandemic ...57
11.3 LABORATORY TESTS........................................................................................................57
11.4 SUBJECT DIARY...............................................................................................................59
11.5 UNBLINDING OF RANDOMIZATION IN CASE OF EMERGENCY..................................................59
12 EFFICACY AND SAFETY ASSESSMENT ...........................................................................60
 
 

Study code: VE-CIP2001/2021                                                                    
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17.10 DATABASE PROCESSING ..................................................................................................79
17.11 ARCHIVING REQUIREMENTS FOR SPONSOR AND INVESTIGATOR..........................................80
18 PROJECT MANAGEMENT ..................................................................................................80
18.1 INVESTIGATOR INFORMATION AND TRAINING......................................................................80
18.2 QUALITY ASSURANCE AND QUALITY CONTROL...................................................................80
18.2.1
Audit and Supervision of the Study..........................................................................80
18.2.2
Monitoring................................................................................................................80
18.3 TRIAL STEERING COMMITTEE ............................................................................................81
18.4 DATA MONITORING COMMITTEE.........................................................................................81
18.5 AMENDMENTS TO THE PROTOCOL.....................................................................................81
18.6 CLOSURE OR DISCONTINUATION OF STUDY AND SITE.........................................................82
18.7 PREMATURE DISCONTINUATION OF THE STUDY IN A TRIAL SITE ..........................................82
18.8 PREMATURE DISCONTINUATION OF THE WHOLE STUDY......................................................82
18.9 INSURANCE FOR SUBJECTS ..............................................................................................83
18.10 DISCLOSURE OF ALL INFORMATION AND RESULTS..............................................................83
18.11 PUBLICATION POLICY........................................................................................................83
18.12 OWNERSHIP ....................................................................................................................83
18.13 CONTRACTS, FINANCES ...................................................................................................83
19 REPORTING........................................................................................................................84
20 REFERENCE LIST...............................................................................................................85
21 APPENDICES ......................................................................................................................87
 
 

Study code: VE-CIP2001/2021                                                                    
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1
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS
Abbreviation
Description
5-HT4
5-hydroxytryptamine receptor 4
AE
Adverse event
ALP
Alkaline phosphatase
ALT
Alanine transaminase
API
Active pharmaceutical ingredient
AST
Aspartate aminotransferase
BCRP
Breast cancer resistance protein
BMI
Body mass index
BP
Blood pressure
bpm
Beats per minute 
CH4
Methane
CIC
Chronic idiopathic constipation
CIPO
Chronic intestinal pseudo-obstruction
Cmax
Maximum concentration
CRF
Case report form
CYP(3A4)
Cytochrome P450 (isozyme 3A4)
ECG
Electrocardiogram
eCRF
Electronic-case report form
EFU
End of follow up 
EOT
End of treatment 
ES
Effect size
ESV
Early switch visit
ETV
Early termination visit
FAS
Full analysis set
GCP
Good clinical practice
GE t1/2
Gastric emptying half time
GI
Gastrointestinal
GMP
Good manufacturing practice 
GP
Gastroparesis
H2
Hydrogen
HDPE
High-density polyethylene
IB
Investigator's brochure
ICC
Interstitial cells of Cajal
 
 

Study code: VE-CIP2001/2021                                                                    
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Abbreviation
Description
ICF
Informed consent form
ICH
International Conference on Harmonization of Technical Requirements for 
Registration of Pharmaceuticals for Human Use
IEC
Independent ethics committee
IMP
Investigational medicinal product
IRB
Institutional review board
IWRS
Interactive web response system
LOCF
Last observation carried forward
MAA
Marketing approval authorization
MedDRA
Medical Dictionary for Regulatory Activities (MEDDRA®)
mFAS
Modified full analysis set
NYHA
New York Heart Association
P-gp
P-glycoprotein
PI
Principal investigator
PK
Pharmacokinetic(s)
PPS
Per protocol set 
PT
Preferred term
QP 
Qualified person 
SAE
Serious adverse event
SAP
Statistical analysis plan
SBM
Spontaneous bowel movement
SOC
System organ class 
SOT
Start of treatment
SS
Safety set
SS
Safety set
T3
Triiodothyronine
T4
Thyroxine
TEAE
Treatment emergent adverse event
Tmax
Time of maximum concentration
TSC
Trial steering committee
TSH
Thyroid stimulating hormone
ULN
Upper Limit of Normal 
 
 

Study code: VE-CIP2001/2021                                                                    
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2
ETHICS
2.1
INDEPENDENT ETHICS COMMITTEE (IEC) OR INSTITUTIONAL REVIEW BOARD (IRB)
Before initiating the trial, Alfasigma S.p.A. (AL) and the investigator(s)/institution(s) must obtain 
written and dated approval/favorable opinion from the IRB(s)/IEC(s) for the trial protocol, written 
informed consent form (ICF), subject recruitment procedures (e.g., adverts), and any other written 
information to be provided to subjects. As part of the investigator(s)’/institution(s)’ written application 
to the IRB/IEC, Alfasigma will provide the IRB(s)/IEC(s) with a current copy of the Investigator's 
Brochure (IB). If the IB is updated during the trial, AL will supply a copy of the updated IB to the 
IRB(s)/IEC(s).
Alfasigma S.p.A and the investigator(s)/institution(s) must obtain approval/favorable opinion from the 
IRB(s)/IEC(s) for change(s) to any aspect of the trial, such as modification(s) of the protocol, written 
ICF, written information to be provided to subjects, and/or other procedures.
Alfasigma S.p.A must promptly report any new information that may affect the safety of the subjects 
or the conduct of the trial to the IRB(s)/IEC(s).
Alfasigma S.p.A will submit safety update reports to the IRB(s)/IEC(s) and to the Competent 
Authorities periodically, in accordance with the applicable laws. Upon completion of the trial, 
Alfasigma S.p.A will provide the IRB(s)/IEC(s) and the Competent Authorities with a brief report of 
its outcome (synopsis).
(See also section: "Emergency Instructions")
2.2
ETHICAL CONDUCT OF THE STUDY
The Guidelines of the World Medical Association’s Declaration of Helsinki in its revised edition (64th
WMA General Assembly, Fortaleza, Brazil, October 2013), the Guidelines for Good Clinical Practice 
E6 (R2) (EMA/CHMP/ICH/135/1995, 1 December 2016) and the Directives 2001/20/EC and 
2005/28/EC as well as demands of the national drug and data protection laws will be strictly followed.
(See also sections: "18.9 Insurance for Subjects, "17.4 Data Protection" and "17.3 Documentation 
of Subjects’ Participation").
2.3
SUBJECT INFORMATION AND CONSENT
The investigator is responsible for not admitting subjects to the trial before informed consent has 
been given. Consent means that the person involved has the legal capacity to give consent and is 
able to exercise free power of choice. Consent should be given as written informed consent after 
receiving detailed information. The subjects who refuse to give informed consent must not be 
included in this trial.  
Subjects will be given a written "Subject information and consent form”.
Before signing the ICF the subject will be informed in detail by a physician about the following items:
A.
the aim and rationale of the trial
B.
the nature of the treatment and the allocation of subjects to the different treatment groups
C.
other therapeutic alternatives
D.
expected therapeutic effects of the medication
E.
known adverse drug reactions and other risks or inconvenience during the clinical trial
F.
the trial procedures to be followed, including all invasive procedures
G.
compensation and/or treatment available to the subject in the event of trial-related injury
 
 

Study code: VE-CIP2001/2021                                                                    
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H.
anticipated prorated payment and expenses to the subjects for participating in the trial (if 
applicable)
I.
subject's right to withdraw at any time without justification and without penalty or loss of 
benefits to which the subject is otherwise entitled
J.
the subject's responsibilities
K.
availability of more detailed information before and during the trial
L.
information about data protection
M.
person(s) to contact in the event of trial-related injury
N.
foreseeable circumstances and/or reasons under which the subject’s participation in the 
trial may be terminated
O.
the expected duration of the subject’s participation in the trial
P.
the approximate number of subjects involved in the trial
The subject must be given ample time to inquire about the details of the trial. The consent form is 
signed by the informing physician and by the subject. Persons who withdraw their informed consent 
must not continue the trial.
The filled-in and signed ICFs will be kept and archived in original by the investigator in the 
“Investigator’s Site File”. (See section 17.1 Documentation of Essential Documents/Supplements at 
Study Centre during the Trial). The subject will be provided with a copy. 
 
 

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3
GENERAL INFORMATION
Sponsor
Alfasigma S.p.A., Via Ragazzi del ‘99, 5, I-40133 Bologna, Italy
Sponsor Personnel:
Tel.: 
 
e-mail: 
Tel.: 
e-mail: 
 
 
Tel.: 
e-mail: 
 
Tel.: 
e-mail: 
Tel.: 
e-mail: 
CRO: 
Investigators
A list of all Investigators involved in the Study will be provided as a separate document.
 
 

Study code: VE-CIP2001/2021                                                                    
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Central Laboratory
Home nursing and travel agency
Central 
 reading laboratory
Tel.: 
Bioanalytical Laboratory
 
 

Study code: VE-CIP2001/2021                                                                    
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4
BACKGROUND AND RATIONALE
Chronic intestinal pseudo-obstruction (CIPO) is a rare, severe condition characterized by an 
impairment of coordinated propulsive activity in the intestinal tract resulting in a clinical picture similar 
to that of mechanical intestinal obstruction, although in the absence of any lesion occluding the gut 
(Antonucci 2008). It may be due to an underlying neuropathic, myopathic disorder, or abnormality in 
the interstitial cells of Cajal (ICC), either alone or in combination (Antonucci 2008).
CIPO is a rare condition and most estimates of the incidence and prevalence are from tertiary referral 
centers. In a national survey in Japan, the estimated prevalence of CIPO was 0.80 to 1.00 per 
100,000, with an incidence of 0.21 to 0.24 per 100,000 (Lida, 2013). The mean age at diagnosis is 
63.1 years for males and 59.2 for females (Camilleri 2021).
Neuropathic, myopathic, or ICC abnormalities may be idiopathic or secondary to another disease. 
Approximately half of the cases of CIPO are secondary to neurologic (e.g., Parkinson disease and 
Shy-Drager) syndromes, paraneoplastic, autoimmune, metabolic/endocrine, and infectious 
diseases. (Camilleri 2021). The clinical picture, characterized by disabling digestive symptoms (i.e.,
abdominal pain, bloating, nausea and vomiting, constipation, heartburn, fullness, early satiety) 
associated with “sub-occlusive episodes”, contributes a significant deterioration of quality of life of 
the patients. CIPO is one of the most important causes of chronic intestinal failure. Patients with 
CIPO are often unable to maintain normal body weight and/or normal oral nutrition (Antonucci 2008).
The diagnosis of CIPO is based on the presence of longstanding symptoms of mechanical 
obstruction in the absence of an anatomic cause on radiologic examination and endoscopy, and 
evidence of impaired motility. Confirmation of the diagnosis requires exclusion of mechanical 
obstruction and other causes of dysmotility by performing imaging studies, endoscopy, and 
scintigraphy to assess motility. (Camilleri 2021).
Prokinetic drugs (e.g.,
, erythromycin, etc.) are often used in CIPO patients to 
improve gastrointestinal motility. 
, accelerates transit through the stomach, small bowel, and 
colon. In a randomized, double-blind, crossover study, 
 appeared to provide symptom 
relief in 4 out of 7 patients with CIPO. In 3 patients with visceral myopathy and 1 with visceral 
neuropathy, 2 to 4 mg 
 (relative to placebo) significantly improved pain in 3 out of 4
patients, nausea in 2, vomiting in 1, and bloating in 4, whereas bowel function was not changed 
substantially. In contrast to 
 appears to have much lower risk of cardiac 
arrhythmia (Emmanuel 2012).
. In randomized trials, oral 
 at a dose of 20 mg 
three times a day was effective in improving gastric emptying but did not provide symptomatic relief 
in patients with CIPO (Abell 1991). 
 has been associated with a number of drug interactions 
and fatal cardiac arrhythmias, prompting the manufacturer to severely limit its availability in many 
countries.
Intravenous erythromycin is effective during acute exacerbations of CIPO, acting at least in part by 
stimulation of the motilin receptors (Catnach 1992, Emmanuel 2004). Such patients are typically 
hospitalized and require intravenous fluids. Intravenous erythromycin lactobionate at a dose of 3 
mg/kg every eight hours should be continued for at least five to seven days. Erythromycin has not 
been very effective for chronic therapy and has only been tried in a small number of patients (Chami 
1991).
Along with pharmacokinetics agents, symptomatic drugs (e.g., antisecretory drugs, antispasmodics, 
 
 

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laxatives, analgesics, etc.), antibiotics (to treat small intestinal bacterial overgrowth, SIBO) as well 
as invasive procedures such as surgery or small bowel transplant are used to treat patients with 
CIPO (Camilleri 2021) but no pharmacological treatment is currently licensed for this indication.
Velusetrag is a selective 5-hydroxytryptamine receptor 4 (5-HTR4) agonist. 5-HTR4 agonists are able 
to stimulate the release of acetylcholine from enteric motor neurons and calcitonin gene-related 
peptide from sensory neurons. Velusetrag has been shown to enhance the peristaltic reflex, 
stimulate intestinal secretion, and inhibit gastrointestinal visceral sensitivity.
Velusetrag contracts the guinea pig colonic longitudinal muscle–myenteric plexus and relaxes 
human colonic circular muscle in vitro. Data from in vivo nonclinical studies have shown that 
velusetrag increases colonic transit in guinea pigs, relaxes the esophagus in rats, and increases 
contractility in various portions of the GI tract of dogs.
A description of the clinical profile of velusetrag can be found in the current version of the velusetrag 
IB. Velusetrag has been evaluated in ten Phase 1 studies in healthy subjects, one Phase 2 study in 
subjects with chronic idiopathic constipation (CIC), and two Phase 2 studies in subjects with 
gastroparesis. 
Dosages studied in clinical trials range from 0.1 to 90 mg as single doses, from 15 to 50 mg 
administered once daily for up to 28 days, and from 5 to 30 mg administered once daily for 12 weeks. 
Overall, more than 800 subjects have received one or more velusetrag doses of 5 mg or higher.
In a Phase 1 study in healthy subjects assessing GI transit using scintigraphy, single and multiple 
doses of velusetrag were associated with acceleration of colonic transit and multiple doses with 
acceleration of gastric emptying (Manini, 2010]). Velusetrag also achieved statistically and clinically 
significant increases in stool frequency, including weekly frequency of spontaneous bowel 
movements (SBM) and weekly frequency of SBM resulting in a sensation of complete evacuation 
(complete spontaneous bowel movement, CSBM), relative to subjects receiving placebo, in a Phase 
2 study of 401 subjects with CIC of 1 month duration (Golberg, 2010).
In addition, a Phase 2 study of velusetrag in 34 subjects with diabetic or idiopathic gastroparesis 
(GP) exhibited clinically significant relevant improvements in gastric emptying half times (GE t1/2) at 
doses of 5 mg (-35 minutes), 15 mg (-34 minutes), and 30 mg (52 minutes) compared to placebo (-
13 minutes) (Ahn, 2015). Similar treatment effects were observed in both diabetic and idiopathic 
gastroparesis subjects treated with velusetrag. 
A Phase 2b study was conducted in 233 subjects with diabetic or idiopathic GP (~50%/~50% 
allocation) to assess GP symptom improvement with velusetrag up to 12 weeks of dosing. A reverse 
dose-response pattern was noted with the most robust improvements in symptoms observed at 5 
mg. Velusetrag at 5 mg was observed to reduce all symptoms of GP including nausea, vomiting, 
upper abdominal pain, fullness, bloating, and epigastric burning. In addition, after 4-week treatment 
a statistically significant reduction in gastric emptying time was observed in all 3 velusetrag dose 
groups. Gastric emptying normalization, defined as a 4-hour retention percentage < 10%, was 
observed in 44%, 65% and 71% of subjects for 5, 15 and 30 mg, respectively, compared to no 
subjects in the placebo group. Furthermore, besides the expected adverse events of nausea, 
abdominal pain, headache, and diarrhea of this drug class, no other safety signal was detected.  
As a high-affinity, potent agonist with high intrinsic activity at the human 5-HT4 receptor, velusetrag 
offers promise for the treatment of GI disorders, such as CIPO, in which enhanced motility may be 
beneficial.
The rationale for velusetrag treatment in patients with CIPO is that increased stomach small and 
large and intestine motility, together with putative visceral antihyperalgesic activity, will be associated 
with an improvement in CIPO symptoms.
Because velusetrag is highly selective for the 5-HT4 receptor and displays no significant affinity at a 
 
 

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variety of G protein coupled receptors, enzymes, and ion channels (including other 5-HT receptors 
or dopamine receptors), the potential for unwanted activity (i.e., side effects) is minimized.
5
STUDY OBJECTIVES AND ENDPOINTS
5.1
PRIMARY STUDY OBJECTIVE AND ENDPOINT
Primary Study Objective
Primary Study Endpoint
To investigate the efficacy of velusetrag in 
improving the symptoms severity associated with 
CIPO, in subjects with idiopathic CIPO and CIPO 
secondary to neurodegenerative or demyelinating 
conditions 
(e.g.,
Parkinsonian
Syndromes,
multiple sclerosis etc.).
Change in weekly global gastrointestinal 
symptoms average index score* from start to 
the end of each treatment period.
*The weekly global gastrointestinal symptoms 
average index score is obtained by averaging 
the scores for each of the 4 symptoms 
assessed weekly: abdominal pain, bloating, 
nausea and vomiting.
Rating of symptoms (i.e. abdominal pain, 
bloating, nausea and vomiting) is using a 
recall period of 7 days and a Likert scale with 
the following categories:
0 – Absent
1 - Mild (not influencing usual activities)
2 - Moderate (diverting from, but not urging 
modification of, usual activities)
3
-
Severe (influencing usual activities 
markedly enough to urge modifications)
4
-
Extremely severe (precluding daily 
activities)
 
 
 

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Study code: VE-CIP2001/2021                                                                    
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Study code: VE-CIP2001/2021                                                                    
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6
OVERALL STUDY DESIGN AND PLAN
This is a phase II, multicenter, double-blind, placebo-controlled, two-treatment four-period cross-
over, multiple (n=1) trial to evaluate the efficacy and safety of velusetrag 15 mg once a day,
compared to placebo, in subjects with a diagnosis of idiopathic CIPO or CIPO secondary to primary 
neurodegenerative or demyelinating conditions (e.g., Parkinsonian Syndromes, multiple sclerosis, 
etc.).
Eligible subjects will be treated for 4 periods of 4 weeks each with either velusetrag 15 mg (2 periods) 
or placebo (2 periods), once daily, with a wash-out period of 2 weeks between treatment periods. 
After an up to 7-day screening period (from Day -7 to Day -1, V1), at randomization visit (V2), eligible 
subjects will be randomly allocated to one of the following four sequences:
A.
VEL-PLA-VEL-PLA
B.
PLA-VEL-PLA-VEL
C.
VEL-PLA-PLA-VEL
D.
PLA-VEL-VEL-PLA
Where:
VEL= velusetrag 15 mg once daily for 4 weeks.
PLA= matching placebo once daily for 4 weeks.
There will be a 2-week wash-out period between each treatment period and a final 2-week follow-up 
period at the end of the last treatment period.
Subjects will be assessed during a total of 10 visits during the study, as detailed in the Study Schedule 
of Assessments, including the screening visit, a start of treatment visit (SOT) and an end of treatment 
visit (EOT) for each of the 4 treatment periods, for a total of 8 visits, and a final End of Follow (EFU)
up Visit, 2 weeks after the end of the last treatment period.
If the subject cannot go back to the clinical center for one or more of the following visits: EOT- 2
(Visit 5), the EOT- 3 (Visit 7), the EOT- 4 (Visit 9), End Of Follow Up (EFU)- Visit (Visit 10) or in case 
of an early termination visit (ETV), the visit will be scheduled at the subject’s home and it will be 
performed by a home nursing service. The clinical study staff at the clinical center may also attend 
the visit remotely.
Overall, each subject will be involved in the study for a screening period of up to 7 days before 
randomization and approximately a 24-week period after randomization.
Subjects under treatment with a 
 
must have a 5-day washout period before randomization (note: symptomatic treatments
other than 
 will be permitted throughout the study, see section 10.8 Prior and 
Concomitant Therapy).
In case, during a treatment period or during a washout period, a subject should experience an 
exacerbation of the CIPO related gastrointestinal symptoms that is not controlled by permitted 
medications and is not judged as an adverse event, he/she will attend an early switch visit (ESV) at 
the clinical site. After being reassessed, he/she will be offered to directly switch to the next scheduled 
treatment period (SOT-2 or SOT-3 or SOT-4) without completing the ongoing treatment or washout 
period. Only one early switch is possible during the study. ESV will be Day 1 of the relevant period 
(SOT-2 or SOT-3 or SOT-4) based on the timing of early switch.
In case of ESV/SOT-2 or ESV/SOT-3 or ESV/SOT-4, the subsequent visits will follow the relevant 
sequential number (see Study Schedule of Assessments).
 
 

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7
DISCUSSION OF STUDY DESIGN, INCLUDING THE CHOICE OF CONTROL GROUPS
This study will evaluate the safety, tolerability and efficacy of velusetrag 15 mg once a day versus 
placebo, in improving the symptoms severity associated with CIPO, in subjects with idiopathic CIPO 
and CIPO secondary to neurodegenerative conditions (e.g., Parkinsonian Syndromes, etc.).
CIPO is a chronic, rare disease, with fluctuating symptoms and differences in underlying pathology, 
which may respond differently to active treatment. Therefore, a standard parallel group placebo-
controlled study may not allow to detect clear benefit due to the large variability of clinical 
presentation.
A n=1 cross over, placebo-controlled study design, as the one chosen for the present study, allows 
to assess the treatment effect in every subject, thereby allowing individual subjects to act as their 
own control and evidencing a positive effect even in a single subject, avoiding under-estimation of 
the therapeutic efficacy (Emmanuel, 2012).
Subjects will be evaluated over a total of 16 weeks, receiving either velusetrag 15 mg or placebo,
once daily, for four randomized periods of 4 weeks each. The planned treatment time period is 
considered enough to demonstrate a difference between active treatment and placebo. The wash-
out periods’ duration has been selected based on velusetrag and active metabolite half-life.
Efficacy will be assessed after each 4 weeks of treatment for primary analysis. The choice of placebo 
as comparator will allow for estimation of the real treatment effect of velusetrag and is considered
acceptable due to: i) the lack of any approved treatment for CIPO; ii) the fact that symptomatic rescue 
therapies are allowed, and iii) the close monitoring during a relatively short treatment period.
Moreover, participants, that during the study should experience significant exacerbation of CIPO-
related gastrointestinal symptoms that are not controlled by permitted medications and are not 
judged as adverse events, after being reassessed may decide to continue the study and start the 
subsequent treatment period, or discontinue the study.
8
BENEFIT-RISK EVALUATION
Velusetrag was generally well tolerated in healthy subjects, elderly subjects, subjects with CIC, and 
subjects with gastroparesis. 
x
In the Phase 2 study in CIC, clinically significant improvements in symptoms associated 
with CIC as well as increased bowel movement frequency were observed over 4 treatment 
weeks.
x
In the Phase 2 studies in gastroparesis, improvement in GE t1/2 or higher rates of 
normalization of gastric emptying (44%-71%) compared to placebo (0%) were observed for 
all doses of velusetrag (both in diabetic and idiopathic patients). 
x
In the Phase 2b study, velusetrag at 5 mg was observed to reduce all gastroparesis 
symptoms including nausea, vomiting, post-prandial fullness, early satiety, bloating, 
abdominal pain and epigastric burning with higher response rates compared to placebo 
particularly in the idiopathic gastroparesis group.
Changes from baseline were similar in the idiopathic and diabetic subgroups for GCSI-24H 
domain scores, however a larger placebo effect was observed in diabetic subjects 
compared to idiopathic subjects on the GCSI-24H resulting in a smaller treatment effects in 
the diabetic subgroup compared to the idiopathic subgroup.
On the basis of these clinical studies, velusetrag was well tolerated without relevant AEs. The 
majority of observed AEs could be interpreted within its pharmacodynamic activities and most are 
common to the underlying disease.
 
 

Study code: VE-CIP2001/2021                                                                    
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9
SELECTION OF STUDY POPULATION
9.1
NUMBER OF PARTICIPANTS
Sixteen male and female subjects with a diagnosis of idiopathic CIPO or CIPO secondary to primary 
neurodegenerative or demyelinating conditions (e.g., Parkinsonian Syndromes, multiple sclerosis, 
etc.), who meet all the inclusion and none of the exclusion criteria will be enrolled in this study. 
Subjects will be enrolled in up to 5 centers.
9.2
INCLUSION CRITERIA
Men or women aged 18-80 years.
Subjects with history of chronic idiopathic intestinal pseudo-obstruction or CIPO secondary to 
neurogenerative or demyelinating disease. 
Subjects with estimated oral caloric intake of at least 30% of the daily age- and sex-
recommended caloric intake (Stage 0, 1 or 2 of the 
, see 21.3 Appendix 
3: 
 for CIPO patients).
Subjects with at least 2 out of 4 CIPO gastrointestinal symptoms (i.e., abdominal pain, bloating, 
QDXVHD DQG YRPLWLQJ HDFK RI WKH  ZLWK D VFRUH  RQ D  WR  VFDOH FROOHFWHG RQ WKH
gastrointestinal symptom questionnaire at Day -1.
Subjects accepting to provide and legally capable of providing free and informed consent to all 
procedures included in the protocol.
All sexually active male participants who are partner of women of childbearing potential must use 
condom during intercourse until the 90th day after the end of the entire study.
All female participants must be: 
ޤ
of non-childbearing potential, i.e.: i) post-menopausal (at least 2 years without 
spontaneous menses), or ii) surgically sterile (bilateral tubal occlusion, or 
hysterectomy), or iii) ablation of both ovaries
or
ޤ
of childbearing potential with a negative pregnancy test result at screening and 
randomization AND agreeing to use a highly effective method of contraception 
(i.e. with failure rate of less than 1% per year) until the end of the entire study. 
Note 1. Based on the EU Clinical Trial Facilitation Group recommendations, a highly effective method 
of contraception is one of the following: 
ޤ
Intrauterine device (IUD).
ޤ
Intrauterine hormone-releasing systems (IUS).
ޤ
Combined hormonal contraceptives (i.e. Estrogen and progestogen) in oral, 
intravaginal or transdermal form, with inhibition of ovulation as primary mode of 
action.
ޤ
Progestogen-only hormonal contraceptives in oral, injectable or implantable
form, with inhibition of ovulation as primary mode of action.
ޤ
True and absolute abstinence: when this is in line with the preferred and usual 
lifestyle of the subject. 
Note 2. Periodic abstinence, such as calendar, ovulation, symptom thermal, post ovulation methods, 
and withdrawal are not acceptable methods of contraception.
 
 
 
 
 
 
 
 
 

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Note 3. In each case of delayed menstrual period (over one month between menstruations), female 
participants of child-bearing potential will be strongly recommended to provide a confirmation of 
absence of pregnancy. This recommendation applies also to women of child-bearing potential with 
infrequent or irregular menstrual cycles.
9.3
EXCLUSION CRITERIA
Subjects with primary CIPO or CIPO secondary to other known endocrine/metabolic, 
autoimmune diseases and neurologic conditions other than neurodegenerative or demyelinating 
diseases.
Subjects with conditions characterized by mechanical intestinal obstruction.
Nasogastric tube, gastrostomy tube, or jejunostomy feeding tube in place at randomization or 
planned throughout the duration of the study, or 
 stage 3 (“total non-oral 
nutrition”, see 21.3 Appendix 3: 
 for CIPO patients).
Presence of untreated clinically relevant thyroid dysfunction or known thyroid dysfunction not 
well controlled by treatment (e.g., subjects with abnormal thyroid stimulating hormone [TSH], 
and, if available, triiodothyronine [T3] and thyroxin [T4] levels) deemed clinically significant by 
the Investigator.
Subjects with history of diabetes at screening.
Clinically significant ECG abnormalities (e.g., ST segment elevation or depression suggestive of 
ischemia, partial or complete left bundle branch block [LBBB]) at screening and randomization.
Screening ECG with a QTcF >450 msec in males or >470 msec in females or family history of 
sudden cardiac death.
Subjects requiring a low galactose diet.
Hypersensitivity or documented intolerance to lactulose, lactose, or any excipient of the lactulose 
preparation to be used for 
.
History of sensitivity to velusetrag, or any of the velusetrag or placebo excipients.
Use of scopolamine or erythromycin within 2 weeks prior to Screening and/or planned throughout 
the duration of the study.
Use of 
 within 
5 days prior to randomization and/or planned throughout the duration of the study.
Use of opioids within 8 weeks from screening and/or planned throughout the duration of the 
study.
Received strong cytochrome P450-isozyme 3A4 (CYP3A4) inhibitors (e.g., clarithromycin, 
indinavir, itraconazole, ketoconazole, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, 
grapefruit juice) or strong CYP3A4 inducers (e.g., rifampin, phenytoin, carbamazepine, 
phenobarbital, St. John's wort) within 2 weeks prior to screening and/or planned throughout the 
duration of the study.
Received strong P-glycoprotein (P-gp) transporter inhibitors (e.g., captopril, carvedilol, diltiazem) 
within 2 weeks prior to Screening and/or planned throughout the duration of the study.
Received strong breast cancer resistance protein (BCRP) transporter inhibitors (e.g., curcumin, 
cyclosporine A, eltrombopag) within 2 weeks prior to Screening and/or planned throughout the 
duration of the study.
Current swab-positive or suspected (under investigation) COVID-19 infection.
Cancer (excluding non-melanoma skin cancer) and/or need of any anti-cancer treatment (also 
including radiotherapy) within the last 5 years.
Severe kidney impairment (i.e., estimated glomerular filtration rate <30 ml/min). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Aspartate aminotransferase (AST) or alanine transaminase (ALT) levels >2.5 times the upper 
limit of normal (ULN); bilirubin (unless deemed to be due to Gilbert’s Syndrome) or alkaline 
phosphatase (ALP) >1.5 times ULN.
Severe hepatic impairment defined as Child-Pugh C.
History of any of the following cardiac disorders:
ޤ
Torsade de pointes, ventricular tachycardia, ventricular fibrillation.
ޤ
Previous myocardial infarction, unstable angina pectoris, acute coronary 
syndrome, coronary artery or cerebral revascularization procedure or stroke 
within the previous 18 months.
ޤ
Angina pectoris class 2-4 during the last 12 months prior to screening.
ޤ
Congestive heart failure NYHA class III-IV during the last 18 months prior to 
screening.
History of any alcohol or drug abuse or dependence within the last year (Investigator’s 
judgement).
Any current significant health condition (e.g., cardiovascular, respiratory, renal, hepatic, 
neurologic, psychiatric, hematologic, oncologic, immune, muscle and joint, etc.) that in the 
Investigator’s judgement may:
a.
jeopardize the subject’s safe participation in the trial; or
b.
make unlikely the subject’s completion of the study; or 
c.
make unlikely the subject’s compliance with the study procedures (e.g., highly anticipated 
need of non-permitted treatments, significant disability, terminal illness, etc.).
Pregnant or breastfeeding woman.
Use of any experimental drug within 12 weeks prior to screening.
9.4
PREMATURE DISCONTINUATION FROM THE STUDY PER SUBJECT
Any subject (or his/her legally authorized representative) may withdraw the consent to participate in 
the study at any time without prejudice. The investigator must withdraw from the study any subject 
who requests to be withdrawn. A subject’s participation in the study may be discontinued at any time 
at the discretion of the investigator and in accordance with his/her clinical judgment. When possible, 
the tests and evaluations listed for the ETV should be carried out.
If a subject withdraws before completing the study, the Investigator should determine the primary 
reason for premature discontinuation of the study, and the reason and date of withdrawal will be 
recorded on the e-CRF. The Sponsor will be notified of all subject withdrawals.
Reasons for which the investigator or the Sponsor MAY withdraw a subject from the study, or a 
subject MAY choose to terminate participation before completion of the study include, but are not 
limited to, the following:
x
Treatment failure including the use of 
 
 and scopolamine, erythromycin and opioids for analgesic use
during the study.
x
Positive COVID-19 test 
x
Adverse event: any (significant) adverse event that in the opinion of the investigator, 
sponsor, or subject is not compatible with study continuation.
x
Death.
x
Loss to follow-up: the loss or lack of continuation of a subject to follow-up.
x
Significant non-compliance with investigational product: an indication that a subject has not 
agreed with or followed the instructions related to the study medication.
 
 
 
 
 
 
 
 
 

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x
Physician or sponsor’s decision: any other reason that in the opinion of the Investigator or 
Sponsor may affect the safe participation of a subject in the trial or significantly jeopardize 
the study design. 
x
Subject’s withdrawal of the informed consent: study discontinuation requested by a subject 
for whatever reason.
x
Significant protocol violation.
x
Other: different than the ones previously specified.
In case of premature study discontinuation, a final evaluation should be completed at the time of 
discontinuation as per section 11.2.7 Early Termination Visit (ETV), when applicable. Subjects who 
discontinue treatment due to SAE will be followed up until the event resolves or stabilizes.
Subjects withdrawn from the study will not be replaced. The data of subjects who are withdrawn will 
be considered for evaluation.
The Sponsor reserves the right to discontinue this study at any time for any reason.
10
TREATMENTS
10.1 TREATMENTS TO BE ADMINISTERED
Eligible subjects will be randomly allocated in a 1:1:1:1 manner (4 subjects per treatment sequence),
in a blinded fashion, to one of the following four treatment sequences:
A.
VEL-PLA-VEL-PLA
B.
PLA-VEL-PLA-VEL
C.
VEL-PLA-PLA-VEL
D.
PLA-VEL-VEL-PLA
Where:
VEL= velusetrag 15 mg (
mg 
once a day for 4 weeks.
PLA= matching placebo (
) once a day for 4 weeks.
There will be a 2-week wash-out period between each treatment period and a final 2-week follow-up 
period at the end of the last treatment period.
Randomization will be stratified into 3 strata by CIPO diagnosis (idiopathic or secondary to 
neurodegenerative or demyelinating disease) and by 
 responder status 
(responder/naive or non-responder) as follows:
x
non-responder
x
responder/naïve and idiopathic CIPO
x
responder/naïve and CIPO secondary to neurodegenerative or 
demyelinating disease.
Non responders are defined as all subjects that based on Investigator’s judgement, have an history 
of a lack of benefit from 
The Investigator at each study site will be responsible for the handling and storage of the study 
material (in accordance with the Sponsor’s indications).
Important note: Investigational products are only allowed to be administered to subjects selected 
for this clinical trial according to the protocol.
 
 

Study code: VE-CIP2001/2021                                                                    
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for the IMP use; storage conditions; empty fields to be filled in by the Investigator: randomization N.,
Site number, Investigator’s Name, dispensing date.
Each medication pack will be labelled according to Volume 4, Good Manufacturing Practices, Annex 
13, Manufacture of Investigational Medicinal Products, 3rd February 2010.
10.2.3 Storage, Dispensing, Use and Disposal of the compound during and at the end of the 
study
All investigational products will be kept in a locked place with restricted access and maintained under 
controlled temperature conditions not above 25°C (do not refrigerate or freeze). 
At the end of each of the 4 treatment periods: Visit 3 (EOT-1), Visit 5 (EOT-2), Visit 7 (EOT-3), Visit 
9 (EOT-4) or in case of ETV or ESV, each subject will return to the Investigator the empty packs and 
the unused investigational product of the relevant period. In case the subject cannot go back to the 
clinical center for one or more EOT Visit (i.e. Visit 5, 7 and/or 9 or in case of ETV, the empty packs 
and the unused investigational product of the relevant period will be collected by the study nurse 
during the home visit. 
The Investigator undertakes not to supply the investigational product to persons other than enrolled
subjects or the authorized study personnel in charge of distribute it. Under no circumstances, the 
Investigator will supply the investigational product to other Investigators or clinics or allow the drug 
to be used other than as directed in the actual version of the protocol, without authorization by the 
Sponsor.
The Investigator must store the study medication separately from any other medication. The 
investigational products should be stored safely and properly, and they must not be used after the 
expiry date.
The investigational products will be self-administered by the subject, following instruction provided 
by the Investigator or personnel authorized by the Investigator and according to the treatment 
scheme detailed in section 10.1 Treatments to be Administered.
The investigator or designee is responsible for maintaining accountability records for all 
investigational product(s) received from the Sponsor, in accordance with applicable government 
regulations and study procedures. 
The final accountability records will reconcile shipment records with those of used and returned 
investigational product. Any discrepancy will be accounted for.
All unused investigational products will be returned or destroyed locally, based on the local 
regulation, but return and destruction will not occur until authorized by the Sponsor. Copies of the 
study medication accountability records will be provided to the Sponsor at completion of the study 
and will be made available for review by the site monitor during the course of the study. 
The Investigator must report any defect in the manufacturing and packaging or any deviation with 
respect to the prescribed storage conditions of the drugs immediately to the clinical monitor who will 
immediately inform the Sponsor QP.
10.3 METHOD OF ASSIGNING SUBJECTS TO TREATMENT GROUPS/RANDOMIZATION
A unique subject’s identification number, obtained concatenating the center number and the 
screening number, will be assigned to all subjects consenting to be enrolled in the study.
A subject who fails to meet the protocol eligibility criteria will be identified as screening failure; his/her 
identification number will not be reallocated.
Randomization will occur at Visit 2 (V2- Day 1), after all screening procedures have been performed 
and eligibility for the study has been assessed, prior to dispensing the first study medication. 
To each elected subject a unique Randomization Number will be assigned. Randomization will be 
 
 

Study code: VE-CIP2001/2021                                                                    
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and vomiting. Diarrhea was reported by 11% to 15% of the Velusetrag subjects compared 
with 1% of placebo subjects. The incidence of headache was similar for the Velusetrag 15 
mg and placebo treatment groups (6% each) and higher for the 30-mg and 50-mg treatment 
groups (10% and 21%, respectively). 
x
Results from a Phase 2a and Phase 2b study in subject with idiopathic or diabetic 
gastroparesis suggested that velusetrag improves gastric emptying. The Phase 2b study
was a multicenter, randomized, double-blind, placebo-controlled study to evaluate three 
doses (5, 15, or 30 mg) of Velusetrag compared to placebo administered once daily for 12 
weeks. Velusetrag 15 mg demonstrated improvement in gastric emptying delay on 
scintigraphy without unexpected concerning safety signals in 65% of subjects, compared to 
no subjects in the placebo group.
10.5 SELECTION AND TIMING OF DOSE FOR EACH SUBJECT
Subjects will take velusetrag 15 mg 
mg 
 or placebo (
) once daily during 
the 4 weeks of each of the 4 treatment periods. Subjects will be instructed to take orally three 
of blinded study medication, once daily at approximately the same time each morning, on 
an empty stomach, with water.
Investigational product will be administered under the supervision of the study personnel at 
randomization (V2) and on all other study visits, if the visit is performed at the clinical site and not in 
case of home visits. Each 4-week treatment period will be followed by a 2-week wash-out period. 
10.6 BLINDING
Blinding is intended to limit the occurrence of conscious and unconscious bias in the conduct and 
interpretation of a clinical trial arising from the influence which the knowledge of treatment may have 
on the recruitment and allocation of subjects, their subsequent care, the attitudes of subjects to the 
treatments, the assessment of end-points, the handling of withdrawals, the exclusion of data from 
analysis, and so on.
Velusetrag 5 mg 
 and matching placebo 
 are identical in appearance and will be 
packaged in individual treatment bottles. 
The Sponsor, CRAs, CROs, site staff and subjects will be blinded to treatment allocation. All the IMP 
packaging will not contain any information that could potentially unblind the treatment to the subjects 
and investigators.
Only in case of emergency, when knowledge of the study medication is essential for the safety of 
the subject, the investigator may unblind a subject’s treatment assignment (see section 11.5
Unblinding of randomization in case of emergency).
10.7 TREATMENT COMPLIANCE
Compliance with the dosing regimen will be assessed by reconciliation of used and unused 
investigational product. Compliance will be calculated at the end of each treatment period, counting 
the unused returned 
 and taking into consideration the total number of treatment days 
occurred from the previous visit in which the treatment kit has been delivered to the subject.
Any discrepancies will be reviewed by the site staff and the subject retrained on proper dosing as 
needed. 
Compliance to the study treatment is defined as subjects who are considered to have taken at least 
80% of the total number of doses that should have been administered during the study.
10.8 PRIOR AND CONCOMITANT THERAPY
Use of the following medications is not allowed within 2 weeks prior to Screening and/or planned 
throughout the duration of the study:
 
 

Study code: VE-CIP2001/2021                                                                    
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x
Scopolamine.
x
Erythromycin
x
Strong CYP3A4 inhibitors or strong CYP3A4 inducers (Table 10.1).
x
Strong P-gp transporter inhibitors (Table 10.1).
x
Strong BCRP transporter inhibitors (Table 10.1).
In addition, use of:
x
Opioids is not allowed within 8 weeks from screening and/or planned throughout the 
duration of the study.
x
 are not 
allowed starting from 5 days before randomization and throughout the duration of the study
x
Orally poorly absorbed opioids (i.e., loperamide) that could be used to treat potential 
adverse events, such as diarrhea, may be used if medically indicated.
In case a 
 or 
scopolamine, or erythromycin and an opioid for analgesic use is taken during the study, the subject 
will be considered a treatment failure and will be withdrawn from the study. 
Additional prescription and over-the-counter medications are permitted, provided that such agents 
are not known to be strong inducers or inhibitors of CYP3A4, P-gp and BCRP activity. 
Any addition or change in regimen of concomitant medications that affect CYP3A4, P-gp and BCRP 
activity should be in accordance with inclusion or exclusion criteria and recorded in the source 
documents and the electronic-case report form (eCRF).
Medications taken 30 days prior to the Screening visit through the end of the Follow-up period should 
 
 

Study code: VE-CIP2001/2021                                                                    
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be recorded. If subjects have previously taken a 
 
, the last treatment period (even if occurred more than 30 days before the 
screening visit) and the efficacy of such treatment (responder/not responder) for each subject will be 
recorded in the eCRF.
If clinically permitted, subjects should be encouraged not to change their current regimen (dose, 
frequency) of concomitant medications or not to start new concomitant medications.
Permitted treatments: Medication(s) used to relieve main symptoms of CIPO are allowed and the 
use of the following concomitant medications will be registered in the e-diary daily: 
x
Treatments for nausea and vomiting and/or non-serotoninergic prokinetics (e.g.,
metoclopramide, domperidone, pharmaceutical ginger preparations, pyridostigmine, 
prochlorperazine, promethazine, ondansetron and aprepitant, etc.).
x
Treatments for constipation (e.g., macrogol, bisacodyl linaclotide, laxative enemas, etc.).
x
Treatments for diarrhea (e.g., tannate, loperamide, etc.).
x
Treatments for abdominal pain (e.g., paracetamol. NSAIDs, trimebutine, mebeverine, 
gabapentin, duloxetine, amitriptyline, etc.).
x
Others (e.g.,
octreotide, somatostatin, pancreatic enzymes, probiotics, rifaximin, 
metronidazole, fluconazole, etc.).
x
Permitted medications for CIPO gastrointestinal symptoms taken right before the start of 
the first treatment period (Day -1) as well as all changes in concomitant treatment doses 
(increased/reduced) or number of concomitant drugs (added/removed) during the entire 
treatment and washout periods, until end of follow up, will be daily recorded in the e-diary 
by the subject.
11
STUDY PROCEDURES
11.1 VISIT SCHEDULE
Subjects will be assessed during a total of up to 10 visits during the study, as detailed in the following 
sections (see also Study Schedule of Assessments).
11.2 STUDY EVALUATIONS/PROCEDURES
11.2.1 Screening Period – Collectively named Visit 1 – from Day -7 to Day -1
The screening visit can be performed within Day -7 and Day -1 before randomization and screening 
activities will comprise the following:
Obtain written informed consent, signed and dated by the subject, after the nature of the study 
has been explained and before any study procedure is performed.
Demographic data: age, gender, ethnicity.
Record of relevant medical and surgical history including subject’s history of CIPO, number of 
pseudo-obstruction episodes and 
in the previous 6 months.
Assessment of responder status 
 (e.g., 
 
) according to investigator’s judgement and medical history (subjects who 
have history of benefit 
 or never treated (naïve) 
 
 and subjects non responders 
).
Record of relevant medication history: 
 
 
 
 
 
 
 

Study code: VE-CIP2001/2021                                                                    
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ޤ
all medications (i.e., prescription and over-the-counter medications, herbals, 
vitamins, and supplements) used within 30 days of the screening visit to be 
recorded. (Attention will be paid to prohibited treatments)
ޤ
Subject’s history of 
 within 30 days of the screening visit will 
also be recorded including the name of medication, date started and stopped, 
route of administration, indication, dose and reason for stopping, to be recorded 
in the e-CRF. Last 
 intake (e.g., 
 
), if previously taken by the subject, should be recorded as 
previous medication, even if taken more than 30 days before the screening visit.
COVID-19 rapid swab virus testing (to be performed on the same day of 
and results to be 
available before starting 
).
Biometric measures: weight in kilograms, height in centimeters, body mass index (BMI) to be 
calculated.
Blood collection (in fasting condition):
ޤ
 
 
 
 
 
 
 
 
4h Lactulose Breath Test (L-BT).
Dispense e-diary and instruct the subject on how to complete the electronic diary (e-diary), which 
encompasses the
 
These questionnaires should be completed by the subject on Day -1, 
before randomization and then weekly afterwards.
In addition, subjects will be instructed on how to record 
 
 of the day before randomization (Day -1) and 
daily throughout the study duration.
Verify inclusion and exclusion criteria. 
Record any adverse events occurred since signing the ICF.
Schedule Randomization visit (V2, if eligible).
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Study code: VE-CIP2001/2021                                                                    
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11.2.2 Visit 2 (Randomization Visit- V2)
The following procedures will be performed at the randomization visit: 
Pre-Randomization:
Review and record any AEs that occurred since the previous visit.
Review and record any concomitant medications taken since the previous visit (attention will be 
paid to prohibited treatments).
Re-instruct the subject on how to complete the electronic diary (e-diary), which encompasses 
the
 
 
e-diary review for eligibility according to inclusion criterium n 4. Questionnaires will be
completed at the clinical center before randomization if not already completed by the subject.
Confirmation of inclusion and exclusion criteria.
completion by the subject.
Randomization (if still eligible).
Blood collection (in fasting condition) sample (30 mins prior to drug administration) for proof for 
absorption.
Treatment dispensing (if subject has been randomized).
Dosing:
First investigational product dose will be administered under the supervision of the study personnel
in the morning, on an empty stomach, with water. Time of dosing will be registered.
After the investigational product administration, the following procedures will be completed:
Post-dose:
Retrain the subject on how to use the electronic diary (e-diary), instructing to complete:
ޤ
 
ޤ
The subject will be instructed to record, starting from Day 1, investigational 
product intake information daily.
Schedule next visit and remind the subject to not to take the investigational product in the 
morning of the next visit, but to take the bottle to the clinic.
11.2.3 Visit 3 (V3; Day 28±1)
The following procedures will be performed at V3:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Study code: VE-CIP2001/2021                                                                    
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Pre-dose
COVID-19 rapid swab virus testing (to be performed on the same day of 
 and results to be 
available before starting 
).
Blood collection (in fasting condition):
ޤ
 
 
 
 
 
Review and record any concomitant medications taken since the previous visit (attention will be 
paid to prohibited treatments).
Review and record any AEs that occurred since the previous visit.
Review the e-diary to assess the completeness and retrain the subject as needed.
Dosing:
Investigational product dose will be administered under the supervision of the study personnel in the 
morning, on an empty stomach, with water. Time of dosing will be registered.
After the investigational product administration, the following procedures will be completed:
Post-dose:
Blood samples for analysis for proof of absorption: 
Collect all investigational product bottles and account investigational product.
Schedule next visit.
11.2.4 Start of Treatment (SOT) Visits: Visit 4 (V4, Day 43 ± 1), Visit 6 (V6, Day 85 ± 1) and Visit 
8 (V8, Day 127 ± 1) 
The following procedures/assessments will be completed at V4, V6 and V8:
Pre-dose
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Study code: VE-CIP2001/2021                                                                    
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Blood collection (in fasting condition):
ޤ
 
 
 
 
 
 
Review and record any AEs that occurred since the previous visit.
Review the e-diary to assess the completeness and retrain the subject as needed.
Questionnaires not yet completed should be completed by the subject at the clinical center before 
investigational product administration
Dispense investigational product.
Dosing:
Investigational product dose will be administered under the supervision of the study personnel, in 
the morning, on an empty stomach, with water. Time of dosing will be registered. After the 
investigational product administration, the following procedures will be completed:
Post-dose: 
Schedule next visit and remind the subject not to take the investigational product in the morning 
of the next visit, but to bring the bottle to the clinic, if the visit is scheduled at the clinical center;
If the subject cannot go back to the clinical center for the next visit (EOT period), a home visit will 
be scheduled for the subject. 
11.2.5 End of Treatment (EOT) Visits: Visit 5 (V5, Day 70 ± 1), Visit 7 (V7, Day 112 ± 1) and 
Visit 9 (V9, Day 154 ± 1) 
The following procedures/assessments will be completed at V5, V7 and V9, if the subject can 
attend the visit at the clinical center:
Pre-dose
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Study code: VE-CIP2001/2021                                                                    
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.
Blood collection (in fasting condition):
ޤ
 
 
 
 
 
 
Review and record any AEs that occurred since the previous visit.
Review the e-diary to assess the completeness.
Home visit: In case the subject cannot attend the visit at the clinical center, this visit can be scheduled 
at home and a home nursing service will perform the visit. The clinical staff at the study center may 
attend the visit remotely. The data collected (source documents) during the home visits by the nurse 
will be transmitted on the same day to the clinical center in order to allow the study doctor to perform 
a preliminary clinical evaluation regarding safety. In case of home visits, the same procedures 
scheduled for the visit at the clinical center will be performed with the exception of physical 
examination that will not be performed. 
11.2.7 Early Termination Visit (ETV)
The following procedures/assessments will be completed during the ETV. if the subject agrees to 
perform the visit and can attend the visit at the clinical center:
Blood collection (in fasting condition):
ޤ
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Study code: VE-CIP2001/2021                                                                    
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Review and record any AEs that occurred since the previous visit.
Review the e-diary to assess the completeness. Weekly questionnaires will be completed during 
the ETV.
Collect all investigational product bottles and account investigational product.
Home visit: In case the subject cannot attend the visit at the clinical center, this visit can be scheduled 
at home and a home nursing service will perform the visit. The clinical staff at the study center may 
attend the visit remotely. The data collected (source documents) during the home visits by the nurse 
will be transmitted on the same day to the clinical center in order to allow the study doctor to perform 
a preliminary clinical evaluation regarding safety. In case of home visit the same procedures 
scheduled for the visit at the clinical center will be performed with the exception of physical 
examination that will not be performed.
The nurse will collect the empty packs and the unused investigational product of the relevant period 
during the ETV.
11.2.8 Early Switch Visit (ESV; anytime between Day 1 and Day 126)
The following procedures/assessments will be completed in case of ESV occurrence (see section 6
Overall Study Design and Plan): The ESV will be considered as Day 1 of SOT-2 or SOT-3 or SOT-
4, as appropriate.
Pre-dose
Blood collection (in fasting condition):
ޤ
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Study code: VE-CIP2001/2021                                                                    
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Review and record any AEs that occurred since the previous visit.
Review the e-diary to assess the completeness and retrain the subject as needed. Weekly 
questionnaire will be completed during this visit. Questionnaires not yet completed should be 
completed by the subject at the clinical center before investigational product administration
.
Collect all investigational product bottles and account investigational product (if applicable).
Dispense investigational product.
Dosing:
Investigational product dose will be administered under the supervision of the study personnel, in 
the morning, on an empty stomach, with water. Time of dosing will be registered. After the 
investigational product administration, the following procedures will be completed:
Post-dose: 
Schedule next visit and remind the subject not to take the investigational product in the morning 
of the next visit, but to bring the bottle to the clinic, if the visit is scheduled at the clinical center; 
If the subject cannot go back to the clinical center for the next visit (EOT), a home visit will be 
scheduled for the subject. 
After this visit, the subsequent visits will follow the relevant sequential number (see Study Schedule 
of Assessments).
11.2.9 Contingency activities in case of travel restrictions due to SArS-COV2 pandemic
In case the subject or the nurse cannot travel to attend/perform any of the scheduled visit due to 
travel restrictions due to sanitary emergency, the clinical site will implement all the procedures able 
to maintain the subject in the study, always taking in primary consideration the safety of the subject.
Tele-medicine visits could be implemented in order to collect as much as possible information, as 
foreseen by the specific study schedule, and if the case will organize the investigational product
delivery at the subject’s home, throughout a dedicated courier able to trace the transportation and 
guarantee the appropriate transport condition.
11.3 LABORATORY TESTS
During the study period, it can be estimated that a total volume of up to approximately 300 ml of 
blood will be drawn for each subject.
 
 
 
 
 
 
 
 
 

Study code: VE-CIP2001/2021                                                                    
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during the 2-week follow up period. Gastrointestinal symptom severity questionnaire will be also 
completed in case of ETV or ESV.
12.1.2 Secondary Efficacy Parameters
 
 

Study code: VE-CIP2001/2021                                                                    
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Study code: VE-CIP2001/2021                                                                    
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15
SAFETY ASPECTS
15.1 ADVERSE EVENTS
15.1.1 Definition of Adverse Events
An AE is any untoward medical occurrence in a patient or clinical trial patient administered a 
medicinal product which does not necessarily have a causal relationship with this treatment. An AE 
can therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), 
symptom, or disease temporally associated with the use of an investigational product, whether or 
not related to the investigational product.
For recording purpose, the Investigator must consider that:
An AE does include any:
• Symptoms associated with disease not previously reported by the patient.
• Exacerbation of pre-existing illness.
• Increase in frequency or intensity of a pre-existing episodic event or condition.
• Condition detected or diagnosed after investigational product administration even though it 
may have been present prior to the start of the study.
• Continuous persistent disease or symptoms present at baseline that worsen following the 
start of the study,
An AE does not include a/an:
x
Medical or surgical procedure (e.g., surgery, endoscopy, tooth extraction, transfusion); the 
event that leads to the procedure is an AE.
x
Planned medical or surgical procedures.
x
Pre-existing diseases or conditions present or detected at the start of the study and that do 
not worsen during the study.
x
Situations (e.g., hospitalization for cosmetic elective surgery, social and/or convenience 
admissions); where an untoward medical occurrence has not occurred.
x
Signs, symptom and/or altered laboratory values identified as study endpoints, unless more 
severe than expected for the patient’s condition.
x
Symptoms often associated with the disease under study (other than those mentioned 
above) that are consistent with the patient usual clinical course unless the symptom(s) 
meet(s) the criteria for “serious”.
x
Overdose of concurrent medications without signs or symptoms.
Observations matching an adverse event after ICF is signed but occurring when the study medication 
is not administered (during the screening/washout/follow-up period), by definition represent AEs, and 
should be recorded as such. In the report these observations will be described separately.
15.1.2 Definition of Serious Adverse Events
A SAE is any untoward medical occurrence in a patient or clinical trial patient administered a 
medicinal product which does not necessarily have a causal relationship with this treatment. A SAE 
can therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), 
symptom, or disease temporally associated with the use of an investigational product, whether or 
not related to the investigational product and resulting in:
x
Death.
x
Life-threatening.
x
In-patient hospitalization or prolongation of existing hospitalization.
x
Persistent or significant disability/incapacity.
x
Congenital anomaly/birth defect.
 
 

Study code: VE-CIP2001/2021                                                                    
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Study code: VE-CIP2001/2021                                                                    
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in case of emergency).
In accordance with local IEC requirements, the Investigator must also notify IEC of any SAEs 
according the guidelines of the Ethics Committee.
15.1.9 Regulatory Reporting Requirements for SAEs
The Sponsor has a legal responsibility to notify both the local regulatory authority and other 
regulatory agencies about the safety of a drug under clinical investigation.
Prompt notification of SAEs by the Investigator to the appropriate project contact for SAE receipt is 
essential so that legal obligations and ethical responsibilities towards the safety of other patients are 
met.
The Investigator must promptly report all SAEs to the Sponsor or his designee, in accordance with 
the procedures detailed in section 15.1.8 Prompt Reporting of SAE to the Sponsor.
The Investigator, or responsible person according to local requirements, must comply with the 
applicable local regulatory requirements related to the reporting of SAEs to regulatory authorities 
and the IEC.
15.1.10
Post study AEs and SAEs
A post-study AE/SAE is defined as any event that occurs outside the AE/SAE detection period as 
defined previously.
Investigators are not obliged to actively seek AEs or SAEs after the clinical study termination. 
However, if the Investigator becomes aware of any SAE, including death, at any time after a patient 
has been discharged from the study and he/she considers the event reasonably related to the 
Investigational Product, the Investigator should promptly notify the Sponsor, according to the process 
explained in section 15.1.8 Prompt Reporting of SAE to the Sponsor.
Serious and non-serious AEs will be recorded from the ICF signature to the Final/Early Termination 
Visit regardless of whether the participant is on treatment.
SAEs will be recorded and reported as appropriate and followed-up until resolution or stabilization.
Non-serious AEs will be recorded as appropriate and followed-up until Final/Early Termination Visit.
15.2 WARNINGS AND PRECAUTIONS
Clinical trial exclusion criteria must be followed.
 
 

Study code: VE-CIP2001/2021                                                                    
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The Modified-Full Analysis Set 1 (mFAS1) is defined as the set of all subjects responder/naïve to 
 randomized and treated who reported data on the primary endpoint at least 
once during a velusetrag treatment period and at least once during a placebo treatment period.
 
Following the intent-to-treat principle analysis on the FAS, mFAS1 
will be performed 
according to the treatment and stratum assigned at randomization.
16.2.4 Per Protocol Set (PPS)
The Per Protocol Set (PPS) is defined as the set of all subjects in the mFAS1 who fulfil the study 
protocol requirements in terms of compliance to treatment and collection of primary efficacy data 
and with no major deviations that may affect study results.
Examples of deviations are:
Intake of study treatment other than the one assigned by the IWRS 
Lack of compliance overall defined by percent compliance (number of 
 taken divided 
number of planned 
 *100) below 80%.
In addition, if within a period, the compliance is below 80%, the primary endpoint data of this period 
will be excluded from the analysis. E.g., if compliance data are 100%, 100%, 60%, 60%, the subject
is included in the PPS (overall compliance at 80%) but the observations of the third and fourth period 
are excluded. 
The complete list of deviations will be defined in a specific protocol deviations handling plan and a 
blind data review meeting will occur prior to unblinding. The decisions for exclusion of subjects from 
the PPS will be taken in a blinded manner and documented.
Subjects receiving a study treatment different from the randomized one will be excluded from the 
PPS. Subjects randomized to a wrong stratification factor level will not be excluded from the PPS 
and will be analyzed according to the actual stratum (not the randomized one).
16.2.5 Disposition, Demographic and Other Baseline Variables
The number of subjects screened, failed screening (and reason for screening failure), randomized, 
treated and completing the study treatment periods (and reason for not completing) will be presented 
in frequency tables by treatment sequence and stratum.
The number of subjects in each analysis population (SS, FAS, mFAS1, 
and PPS) will be 
summarized by treatment sequence and stratum.
All major protocol violations will be presented as a frequency table by treatment sequence.
Baseline values are the last recorded values collected prior to treatment initiation.
Subject demographics, medical
history and disease characteristics
and
others baseline 
characteristics measured before randomization will be summarized descriptively by treatment 
sequence on the FAS. Selected summaries will be done by treatment sequence and stratification 
factors (details to be provided prospectively in the SAP).
Selected baseline data will be also summarized on the mFAS1 and PPS.
 
 
 
 

Study code: VE-CIP2001/2021                                                                    
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An overview of the number and percentage of subjects with at least one TEAEs listed above will also 
be produced.
In addition, events will be classified as velusetrag emergent if the last treatment taken before the 
start of the adverse event was velusetrag, or placebo emergent if the last treatment taken before the 
start of the adverse event was placebo. All summaries described above will be done according to 
this classification.
16.3.5 Handling of Missing and Incomplete Data
Primary endpoint
Missing pairs (treatment difference velusetrag minus placebo) can occur when at least one of the 
following is missing:
x
Pre-treatment velusetrag value missing
x
End of treatment velusetrag value missing
x
Pre-treatment placebo value missing
x
End of treatment placebo value missing
If the pre-treatment value is missing for a period, the average of the values of other subjects starting
this period will be used. 
If, within a period, intermediate values (from pre-treatment value up to the end of a period) are 
available, the last observation carried forward will be used to impute the end of treatment value. ESV 
will be considered as SOT-2 or SOT-3 or SOT-4, as appropriate.
The above approach will be used for the FAS and as sensitivity analysis for mFAS1, PPS
 
Other endpoints: 
Missing continuous efficacy endpoints will be using the same approach as the primary endpoint.
For binary outcomes, missing data will be considered as failures.
Details will be provided in the SAP.
16.4 ADDITIONALLY PLANNED STATISTICAL ANALYSES
16.4.1 Interim Analyses and Data Monitoring Committee
No interim analysis data monitoring committee have been planned.
 
 

Study code: VE-CIP2001/2021                                                                    
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16.4.2 Multicenter study
Up to 5 centers will be initiated to enroll 16 subjects. Given the limited number of subjects expected 
per center, the effect of center will not be included in a statistical analysis model, nor in subgroup 
analysis.
16.4.3 Examination of Subgroups
The analysis of the primary endpoint will also be done by stratum (if sample size allows).
 
 

Study code: VE-CIP2001/2021                                                                    
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17
DOCUMENTATION, RECORD ACCESS AND ARCHIVING
17.1 DOCUMENTATION OF ESSENTIAL DOCUMENTS/SUPPLEMENTS AT STUDY CENTRE DURING THE TRIAL
An “Investigator Study File” will be established at the study center at the beginning of the trial. The 
investigator/institution must maintain the trial documents as specified in the Guideline for Essential 
Documents for the Conduct of a Clinical Trial (ICH E6 (R2) - EMA/CHMP/ICH/135/1995) and the 
applicable regulatory requirement(s). 
17.2 SCREENING/ENROLLMENT LOG
The date of screening of all subjects fulfilling the inclusion requirements before any study related 
action is taken will be documented on the “Screening/Enrolment Log”.
The Investigator will document that the subject satisfies the inclusion and exclusion criteria, and 
therefore if the subject is enrolled or is screening failure.
The screening list must not permit the identification of subjects. The original list will be handed to the 
sponsor, and a copy will be archived in the "Investigator's Study File" 
With this list the investigator documents the relationship between the general patient population in 
the specific indication and the study population. 
17.3 DOCUMENTATION OF SUBJECTS’ PARTICIPATION
The investigator must record all subject identification data (full name, initials, date of birth, screening 
number, randomization number, hospital admission-number and date of admission [if relevant], 
study termination date) for all subjects who have given informed consent - whether the subject has 
received any investigational product(s) or not - in the "Confidential Subject Identification List". The 
subject identification list must allow the definite identification of subjects who take part in this study. 
The subject identification list is kept by the investigator in his “Investigator Study File” and archived 
according to the requirements of the applicable national/international regulations, in particular, in 
compliance with the EU Regulation 2016/679.
The investigator should inform the subject's General Practitioner of the subject's participation in the
trial, if the subject agrees.
The clinical study personnel at the clinical center will provide the subject personal Information to the 
home nursing service to arrange home visits and to the travel agency for accommodation and travel 
services when the subjects need to attend clinic visits.
17.4 DATA PROTECTION
Personal data are securely stored to prevent unauthorized access, disclosure, dissemination, 
alteration or loss of information and unauthorized personal data processing. Access to personal 
information is restricted so that only personnel who are required to access personal data as part of 
their job role can do so. All personnel who access personal information are bound by a duty of 
confidentiality.
Technical arrangements surrounding the electronic storage and use of data are as follows:
Computers storing electronic personal data are protected by antivirus software and the network on 
which computers are linked are protected by industry grade firewalls
Electronic access of data is limited according to user roles
x
All data are stored on password protected computers
Organizational arrangements are as follows:
Manual files of personal data are stored within locked cabinets that can only be accessed by 
authorized personnel
x
Data security and/or confidentiality provisions are utilized in agreements with third parties
 
 

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x
Internal audit and compliance functions provide regulatory oversight
The identification data of the volunteers will be replaced in the records with appropriate codes;
therefore they will be pseudonymized and cannot be traced back to the individual except by the 
investigator, who will be responsible for keeping the decoder key safely from unauthorized access.
The Clinical Centre and the Sponsor will be acting as Data Controller in respect of the personal data 
of the study subjects collected in connection with the study, and shall act in accordance with the 
relevant data protection laws in relation to the collection and processing of those personal data.
The study subjects’ pseudonymized personal data shall be collected and processed for the purposes 
of the study and may also be added to research databases and used in the future by the Sponsor 
and its affiliates for certain additional clinical research, for product regulation and safety reporting 
purposes and for ensuring compliance with legal requirements. The study subjects’ pseudonymized
personal data may be processed for such purposes by other parties including: the Sponsor’s affiliates 
and licensing partners, its business partners, regulatory agencies and other health authorities, and 
ECs. The Sponsor is a company that resides in Italy and is subject to current European regulations 
also for what concerns the Data Protection.
Therefore, the Sponsor, as Data Controller shall give the subject a Privacy Notice, informing on how 
the data will be processed in compliance with article 13 of the European Regulation 2016/679.
The information provided shall include:
A.
the identity and the contact details of the controller and, where applicable, of the 
controller's representative.
B.
the contact details of the data protection officer, where applicable.
C.
where the processing is based on point (a) of Article 6(1) or point (a) of Article 9(2), the 
existence of the right to withdraw consent at any time, without affecting the lawfulness of 
processing based on consent before its withdrawal.
D.
the purposes of the processing for which the personal data are intended as well as the 
legal basis for the processing.
E.
the recipients or categories of recipients of the personal data, if any.
F.
where applicable, the fact that the controller intends to transfer personal data to a third 
country or international organization and the existence or absence of an adequacy 
decision by the Commission, or in the case of transfers referred to in Article 46 or 47, or 
the second subparagraph of Article 49(1), reference to the appropriate or suitable 
safeguards and the means by which to obtain a copy of them or where they have been 
made available. 
G.
the period for which the personal data will be stored, or if that is not possible, the criteria 
used to determine that period.
H.
the existence of the right to request from the controller access to and rectification or 
erasure of personal data or restriction of processing concerning the data subject or to 
object to processing as well as the right to data portability.
I.
the existence of the right to withdraw consent at any time, without affecting the lawfulness 
of processing based on consent before its withdrawal.
J.
the right to lodge a complaint with a supervisory authority.
 
 

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17.5 PERSONAL DATA BREACH
Each incident and violation of personal data must be communicated to the Sponsor within 48 hours 
at the latest and, in any case, without undue delay after becoming aware of a personal data breach. 
Notification must contain at least the following information:
x
a description of the nature of the data breach including the following elements:
x
the categories and the approximate number of data subjects involved.
x
the categories and the approximate number of personal data involved.
x
the data breach impact level.
x
the safety measures implemented.
x
the name and contact details of the Data Protection Officer or other contact point from which 
further information may be obtained.
x
the name of the Data Protection Officer or appropriate privacy office of any sub-responsible 
parties involved in the processing that can be contact for further information.
x
a description of the measures adopted and/or the measures that intends to adopt to remedy 
the data breach, including, where it is appropriate, measures to mitigate the possible 
negative consequences.
x
a description of the probable consequences of the personal data breach.
x
any further information necessary to notify the competent control Authority of the breach.
If it is not possible to provide all this information simultaneously, the information may be 
communicated at a later moment, without undue delay.
Every party shall be obliged to notify any case of data breach, regardless of its degree of severity. 
Any assessment of the seriousness of a possible data breach is assessed exclusively by the 
sponsor.
In any case, every party ensures the maximum collaboration in order to examine all the necessary 
and useful aspects to identify the causes and the consequences of the breach, also in terms of 
impact on adverse events. Once the reasons for the breach have been defined, the parties shall 
implement as quickly as possible all physical and/or logical and/or organizational security measures, 
designed to prevent the occurrence of a new breach of the same type as that occurred.
17.6 SOURCE DOCUMENTS
Source documents consist of inpatient hospital charts, clinic notes, outpatient records, original test 
results, laboratory data, worksheets, drug accountability records, consent forms, subject’s diaries, 
etc. Source documents must be available for review and inspection during on-site monitoring of the 
study by the Sponsor, its designees, IRB/IEC, and/or appropriate regulatory authorities.
17.7 SUBJECTS' RECORDS
Critical data collected for this clinical study will be verified against the source documents. This will 
include critical entries in subject Case Report Forms (CRFs) and laboratory data.
All required study data must be entered in the e-CRF created for the study. The investigator shall 
ensure that all data from participant visits are promptly entered into the eCRFs in accordance with 
the specific instructions given. The investigator must sign each e-CRF to verify the integrity of the 
data recorded.
It is the Investigator’s responsibility to ensure that all relevant data are recorded in the subject’s 
medical file, for example medical history/concomitant diseases, date of study enrollment, visit dates, 
results of examinations and AEs. In case of home visits performed by a nurse, all the collected data 
will be reported by the study nurse on a specific study dedicated home visit chart; this chart will be 
delivered as soon as possible to the study site in order to be entered in the e-CRF.
 
 

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The investigator must maintain source documents, such as laboratory reports, endoscopy or 
radiology reports, X-rays, ECGs, consultation reports, and complete medical history and physical 
examination reports. All information in the e-CRF must be traceable to the source documents in the 
participant’s file.
The investigator(s)/institution(s) will permit trial-related monitoring, audits, IRB/IEC reviews, and 
regulatory inspections, and provide direct access to source data/documents.
If an electronic data system is used to collect source data at investigational site, this system must 
be a validated system and the monitor should have a dedicated access authorizing him/her to read 
the medical records containing the study data only. If this is not the case, the investigator must print-
out, sign and date the subjects' data for data verification purposes at definite times (monitoring, 
audits and inspections). The investigator must assure in writing that the data on the printouts are 
identical to the electronic data and are complete.
These printouts are to be archived in the “Investigator’s Study file”.
17.8 CASE REPORT FORMS
An e-CRF is used to record clinical trial data and is an integral part of the trial and subsequent 
reports. They must reflect subject’s status at each phase during the trial. 
All information requested on the e-CRF should be entered. If one is not available or is not applicable, 
this must be indicated. A User Manual with detailed instructions about e-CRF filling in will be provided 
to each Investigator and a specific training will be performed.
Subjects must not be identified on the e-CRF by name, but by subject’s identification number. The 
e-CRF is specifically designed to record the data required by this protocol. 
The eCRFs system will foresee an audit trail allowing the tracking of all the changes and corrections 
performed to the eCRFs, with the indication of date and author of entry and of correction.
17.9 DATA MANAGEMENT
The contract research organization (CRO) Data Management will identify and implement the most 
effective data acquisition and management strategy for the clinical trial protocol and deliver datasets 
which support the protocol objectives. Subject’s data will be entered into a defined eCRFs and then 
combined with data provided by other sources (e.g., electronic Subject Diary, Central Lab, central 
ECG Lab, etc.). Clinical data management will be performed in accordance with CRO standards and 
data cleaning procedures with the objective of removing errors and inconsistencies in the data, which 
would otherwise impact on the analysis and reporting objectives, or the credibility of the Clinical 
Study Report. Adverse events, Medical History and concomitant medication terms will be coded 
using validated dictionaries such as MedDRA and Who-Drug.
This study will conform to SDTM standards and Analysis Data Model (ADaM) and will be fully Clinical 
Data Interchange Standards Consortium (CDISC) compliant adhering to the latest CDISC standards 
including all associated documentation to aid review such as the study data reviewers guide, the 
analysis data reviewers guide, metadata and Define.xml for both SDTM and ADaM.
17.10 DATABASE PROCESSING
Clinical data will be captured using a study specific e-CRF using a validated and Code of Federal 
Regulations (CFR) Part 11 compliant Electronic Data Capture (EDC) system. Sites will receive 
training and have access to the study specific e-CRF completion guidelines.
Pre-defined data validation checks will be run within the e-CRF as the data are entered and 
submitted by authorized site staff. The resulting data queries will be reviewed by the clinical site and 
resolved.
An electronic audit trail of all changes made to the e-CRF will be kept within the EDC system. This 
 
 

Study code: VE-CIP2001/2021                                                                    
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audit trail identifies the user making the change and date and time of change.
At the end of the study, each site will receive their subject’s data in an electronic readable format 
(i.e., PDF format) burned on an adequate media (e.g., CD or DVD).
17.11 ARCHIVING REQUIREMENTS FOR SPONSOR AND INVESTIGATOR
Essential documents (as defined in the Guideline for Good Clinical practice E6 (R2) 
EMA/CHMP/ICH/135/1995) must be retained until at least 2 years after the last approval of a 
marketing application in an ICH region and until there are no pending or contemplated marketing 
applications in an ICH region or at least 2 years have elapsed since the formal discontinuation of 
clinical development of the investigational product. These documents must be retained for a longer 
period however if required by the applicable regulatory requirement(s) or if required by Alfasigma 
S.p.A. The subject identification list must be retained according to the requirements of the applicable 
national/international regulations after the completion, or discontinuation, of the study. Alfasigma 
S.p.A will notify the Investigator(s)/Institution(s) in writing when the trial related records are no longer 
needed. If an investigator moves, withdraws from a trial or retires, the responsibility for maintaining 
the records may be transferred to another investigator who accepts this responsibility. Notice of this 
transfer must be given to and agreed upon by Alfasigma S.p.A.
18
PROJECT MANAGEMENT
18.1 INVESTIGATOR INFORMATION AND TRAINING
The Investigators and essential support staff will be trained by the Sponsor or its designee with 
regards to the International Council on Harmonization (ICH) GCPs and all aspects of protocol 
application and study management. It is the responsibility of the Investigator to train ancillary study 
staff and to document such training.
18.2 QUALITY ASSURANCE AND QUALITY CONTROL
The sponsor will implement and maintain quality assurance and quality control systems with written 
Standard Operating Procedures (SOPs) in accordance with the Guidelines for Good Clinical Practice 
E6 (R2) (EMA/CHMP/ICH/135/1995). 
18.2.1 Audit and Supervision of the Study
The study may be audited by the Sponsor or its designee. If such an audit occurs, the Investigator 
agrees to allow the auditor direct access to all relevant documents and to allocate his/her time and 
his/her staff to the auditor to discuss findings on any relevant issue. In the event that on-site auditing 
visits cannot occur, alternative measures (e.g., remote audits) may be considered, as allowed by 
local regulations and according to the relevant SOPs.
An independent representative for quality assurance will ensure quality by auditing the conformity of 
protocol, monitoring data handling and archiving (trial master file) with the Guidelines for Good 
Clinical Practice E6 (R2) (EMA/CHMP/ICH/135/1995), national drug law(s) and SOP(s). 
In addition, regulatory agencies may conduct a regulatory inspection of this study. If such an 
inspection occurs, the Investigator agrees to allow the inspector direct access to all relevant 
documents and to allocate his time and his staff to the inspector to discuss findings and any relevant 
issue. Inspections may be performed by regulatory authorities.
18.2.2 Monitoring
This study will be monitored by the Sponsor or its designee, in accordance with the Guidelines for 
Good Clinical Practice E6 (R2) and the “Regulation (EU) 2016/679”. By signing this protocol, the 
Investigator agrees to periodic, on-site monitoring of all appropriate study documentation.
The monitors will establish contact between the investigator and the Sponsor.
 
 

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The monitors will evaluate the competence of each study center and inform the sponsor of any 
problems relating to the facilities and technical staff. During the study the monitors will check that 
informed consent was obtained from all subjects, that the data are recorded correctly and completely, 
the Investigator providing direct access to source data/documents for data verification, and that the 
investigator complies with the protocol (and any amendments), GCPs, and all applicable regulatory 
requirements.
Study monitors will perform ongoing source data verification to confirm that data entered into the e-
CRF by authorized site personnel are accurate, complete, and verifiable from source documents; 
that the safety and rights of subjects are being protected; and that the study is being conducted in 
accordance with the currently approved protocol and any other study agreements, ICH GCP, and all 
applicable regulatory requirements. The investigator shall permit the site assigned Monitor to review 
study data as frequently as deemed necessary to ensure that data are being recorded in an adequate 
manner and that protocol adherence is satisfactory.
The investigator shall access medical records for the Monitor in order that entries in the e-CRF may 
be verified. In case of restrictions to on-site monitoring visits due to SARS-CoV2 pandemic, remote 
monitoring activities will be implemented in order to remotely check the correspondence of the data 
inputted in the e-CRF throughout the sharing of Pseudonymized copy of the source data, protecting 
the subjects’ privacy.
The investigator may not recruit subjects into the study until all regulatory approvals are in place, the 
site initiation visit has been made by a sponsor/CRO monitor (in which a detailed review of the 
protocol and all study related documents is performed and all the site staff has been properly trained) 
and finally the site receive the official activation.
Monitoring details describing strategy (e.g., risk-based initiatives in operations and quality such as
Risk Management and Mitigation Strategies and Analytical Risk-Based Monitoring, assessment of 
the impact of the envisaged processing operations on the protection of personal data), methods, 
responsibilities and requirements, including handling of non-compliance issues and monitoring 
techniques (central, remote, or on-site monitoring) are provided in the Monitoring Plan.
18.3 TRIAL STEERING COMMITTEE
For the present study, a trial steering committee (TSC) was established, in order to provide scientific 
input for the study design. The TSC has the responsibility to approve the study protocol and any 
amendments, monitor and supervise the trial towards its overall objectives. The TSC will support the 
sponsor in maintaining adequate the quality standards, by raising the attention on any specific 
repeated operational or safety issue occurring during the study conduct.
18.4 DATA MONITORING COMMITTEE
No data monitoring committee has been planned for this study.
18.5 AMENDMENTS TO THE PROTOCOL
Modifications of the signed protocol are only possible by protocol amendments with the agreement 
of all responsible persons. 
The investigator should not implement any deviation from, or changes to the protocol without 
agreement by Alfasigma S.p.A. and prior review and documented approval/favorable opinion from 
the IRB/IEC of an amendment, except where necessary to eliminate an immediate hazard(s) to trial 
subjects, or when the change(s) involves only logistical or administrative aspects of the trial.
Protocol amendments must be submitted to the appropriate regulatory authorities.
Alfasigma S.p.A. and the Investigator/Institution must have approval/favorable opinion from the 
IRB/IEC for any amendment to the protocol.
Any protocol amendment must be distributed to those who received the original protocol and be 
 
 

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appended to it.
18.6 CLOSURE OR DISCONTINUATION OF STUDY AND SITE
Upon completion of the study, the following activities, when applicable, must be conducted by the 
monitor in conjunction with the Investigator, as appropriate:
x
Return of all study data to the Sponsor or its designee
x
Data clarifications and/or resolutions
x
Accounting, reconciliation, and final disposition of used and unused investigational product
x
Review of site study records for completeness.
18.7 PREMATURE DISCONTINUATION OF THE STUDY IN A TRIAL SITE
The study site can be discontinued at the request of the Sponsor, the Investigator, or regulatory 
authorities.
Conditions that may warrant discontinuation of the study site include, but are not limited to the 
following:
x
The center cannot include an adequate number of subjects within the planned time.
x
Serious and/or persistent non-compliance with the protocol.
x
Careless or premeditated false documentation in the CRFs.
x
Inadequate co-operation with the Sponsor.
x
Non-compliance with GCP, SOPs or regulatory requirements.
x
The investigator asks to discontinue the trial.
x
The submission of knowingly false information from the research facility to regulatory 
authorities
If the trial is prematurely terminated or suspended for any reason, the subjects will be informed 
promptly, appropriate therapy and follow-up will be assured and where required the relevant 
regulatory authorities will be informed. The IRB/IEC will be promptly informed and provided with a 
detailed written explanation.
18.8 PREMATURE DISCONTINUATION OF THE WHOLE STUDY
If the trial is prematurely terminated or suspended, the Sponsor will promptly inform the 
Investigators/Institutions, and the regulatory authorities with reasons. A written explanation will be 
promptly sent to the IRB/IEC by the Sponsor or the Investigator/Institution, as specified in the 
regulatory requirements.
Conditions that may result in the termination of the study or part thereof include, but are not limited 
to the following:
1. The principal Investigator and/or the Sponsor feel that the number and/or severity of AEs 
justify discontinuation of the study.
2. The Sponsor considers the applied doses of the investigational product to be no longer 
relevant.
3. Data not known before become available and raise concern about the safety of the 
investigational product so that continuation would pose potential risks to the subjects.
Premature termination of the study must be mutually agreed upon by the Coordinating Investigator 
and the Sponsor and must be documented. However, study results must be reported according to 
the requirements outlined in this protocol as far as applicable.
 
 

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If the study is prematurely discontinued, all study data must be returned to the Sponsor or its 
designee. In addition, the site must conduct final disposition of all unused investigational products in 
accordance with Sponsor’s procedures for the study. Study termination and follow-up will be 
performed in compliance with the conditions set forth in ICH GCPs.
Financial compensation to Investigators and/or Institution will be in accordance with the agreement 
established between the Investigator and the Sponsor.
18.9 INSURANCE FOR SUBJECTS
Alfasigma S.p.A will arrange insurance for all study subjects. The following guidelines must be taken 
into account: 
x
Any serious adverse event which may be correlated or not to investigational product or 
diagnostic procedures during the trial must be reported to the sponsor or the CRO 
immediately.
x
The insurance company is entitled to ask all doctors involved in the treatment of a subject, 
other insurance companies and the national insurance for information which might help to 
clarify the cause of injury. Before enrolment in the study a subject must be informed of 
insurance against trial-related injuries and who to contact for compensation.
The terms of the insurance will be included in the Investigator’s Study File. 
18.10 DISCLOSURE OF ALL INFORMATION AND RESULTS
By signing the protocol, the investigator agrees to keep confidential all information and results 
concerning the study and the investigational product, until the data are published.
18.11 PUBLICATION POLICY
The Sponsor declare its intent to publish the results of the study, after completion of the regulatory
Report.
The personal data especially sensitive data regarding the clinical trial, will be only disseminated in 
strictly anonymous form.
The Sponsor will work with the protocol development team and will identify a lead author for the 
manuscript development. The authors for the manuscript will be determined by the amount of effort 
and participation each Investigator contributes towards the study design, the study conduct, as well 
as the analysis of study results.
All of the parties agree to provide the other with the text sufficiently in advance to allow
examination, prior to submission to a scientific journal.
It is understood by the Investigator that the information developed in the clinical study may be 
disclosed, as required, to other clinical Investigators, and regulatory authorities. 
In the case of a multicenter trial an investigator cannot publish the study results relevant to his/her 
single center separately, unless global results have already been published.
18.12 OWNERSHIP
All data and records provided by the Sponsor or generated during the study (other than a subject’s 
medical records) and all inventions discovered in the course of conducting the study are the property 
of the Sponsor. If a written contract for the conduct of the study which includes ownership provisions 
inconsistent with this statement is executed, then contract’s ownership provisions shall apply rather 
than this statement.
18.13 CONTRACTS, FINANCES
In addition to the protocol trial-related duties, functions and financial aspects must be specified in a 
 
 

Study code: VE-CIP2001/2021                                                                    
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separate contract between Alfasigma S.p.A., the investigator and any other parties involved in the 
clinical trial.
19
Reporting
After completion of the study an "integrated" full report will be prepared (according to the ICH 
Harmonized Tripartite Guideline Topic E3 “Structure and Content of Clinical Study Reports”).
 
 

Study code: VE-CIP2001/2021                                                                    
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20
REFERENCE LIST
Abell TL, Camilleri M, DiMagno EP, Hench VS, Zinsmeister AR, Malagelada JR. Long-term efficacy 
of oral cisapride in symptomatic upper gut dysmotility. Dig Dis Sci. 1991 May;36(5):616-20. 
Ahn, A. et al., Su1426 Velusetrag Improves Gastric Emptying Time in Subjects with Diabetic or 
Idiopathic Gastroparesis. Gastroenterology. 148(4): p. S-507.2015.
Antonucci A, Fronzoni L, Cogliandro L, Cogliandro RF, Caputo C, De Giorgio R, Pallotti F, Barbara 
G, Corinaldesi R, Stanghellini V. Chronic intestinal pseudo-obstruction. World J Gastroenterol. 2008 
May 21;14(19):2953-61.
Antonucci A, Fronzoni L, Cogliandro L, Cogliandro RF, Caputo C, De Giorgio R, Pallotti F, Barbara 
G, Corinaldesi R, Stanghellini V. Chronic intestinal pseudo-obstruction. World J Gastroenterol. 2008 
May 21;14(19):2953-61.
Barbara G, Stanghellini V, De Giorgio R, Cremon C, Cottrell GS, Santini D, Pasquinelli G, Morselli-
Labate AM, Grady EF, Bunnett NW, Collins SM, Corinaldesi R. Activated mast cells in proximity to 
colonic nerves correlate with abdominal pain in irritable bowel syndrome. Gastroenterology. 2004 
Mar;126(3):693-702. 
Camilleri M. Chronic Intestinal Pseudo-Obstruction. Up to Date (Wolters Kluwer); Feb 2021 
https://www.uptodate.com/contents/chronic-intestinal-pseudo-obstruction/print
Catnach SM, Fairclough PD. Erythromycin and the gut. Gut. 1992 Mar;33(3):397-401. 
Chami TN, Schuster MM, Crowell MD, et al. Effects of low dose erythromycin on gastrointestinal 
motility and symptoms in chronic intestinal pseudoobstruction (abstract). Gastroenterology 1991; 
100:41.
Emmanuel AV, Kamm MA, Roy AJ, Kerstens R, Vandeplassche L. Randomised clinical trial: the 
efficacy of prucalopride in patients with chronic intestinal pseudo-obstruction--a double-blind, 
placebo-controlled, cross-over, multiple n = 1 study. Aliment Pharmacol Ther. 2012 Jan;35(1):48-55.
Emmanuel AV, Shand AG, Kamm MA. Erythromycin for the treatment of chronic intestinal pseudo-
obstruction: description of six cases with a positive response. Aliment Pharmacol Ther. 2004 Mar 
15;19(6):687-94. 
Goldberg M, Li YP, Johanson JF, Mangel AW, Kitt M, Beattie DT, Kersey K, Daniels O. Clinical trial: 
the efficacy and tolerability of velusetrag, a selective 
 with high intrinsic activity, in 
chronic idiopathic constipation - a 4-week, randomized, double-blind, placebo-controlled, dose-
response study. Aliment Pharmacol Ther. 2010 Nov;32(9):1102-12.
Iida H, Ohkubo H, Inamori M, Nakajima A, Sato H. Epidemiology and clinical experience of chronic 
intestinal pseudo-obstruction in Japan: a nationwide epidemiologic survey. J Epidemiol. 
2013;23(4):288-94.
Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J 
Gastroenterol. 1997 Sep;32(9):920-4.
Manini ML, Camilleri M, Goldberg M, Sweetser S, McKinzie S, Burton D, Wong S, Kitt MM, Li YP, 
Zinsmeister AR. Effects of Velusetrag (TD-5108) on gastrointestinal transit and bowel function in 
health and pharmacokinetics in health and constipation. Neurogastroenterol Motil. 2010 
Jan;22(1):42-9.
Scarpellini E, Abenavoli L, Balsano C, Gabrielli M, Luzza F, Tack J. Breath tests for the assessment 
of the 
. Eur Rev Med Pharmacol Sci. 2013;17 Suppl 2:39-44.
Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual 
framework and item selection. Med Care. 1992 Jun;30(6):473-83. 
 
 

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Ware, J. E., Jr., Snow, K. K., Kosinski, M., & Gandek, B. (1993). SF-36® health survey: Manual and 
interpretation guide. Boston, MA: The Health Institute
Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and 
preliminary tests of reliability and validity. Med Care. 1996 Mar;34(3):220-33. 
 
 

Study code: VE-CIP2001/2021                                                                    
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21
APPENDICES
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Study code: VE-CIP2001/2021                                                                    
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21.2 APPENDIX 2: SUBJECT’S ELECTRONIC (E)-DIARY
 
 

Study code: VE-CIP2001/2021                                                                    
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Study code: VE-CIP2001/2021                                                                    
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Study code: VE-CIP2001/2021                                                                    
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Study code: VE-CIP2001/2021                                                                    
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Study code: VE-CIP2001/2021                                                                    
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Study code: VE-CIP2001/2021                                                                    
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21.3 APPENDIX 3: “ARTIFICIAL FOOD NEED" (AFN) SCALE FOR CIPO PATIENTS