A Randomized, Open-label, Multicenter Study of Liposomal Amikacin for Inhalation (LAI) in Adult Patients With Nontuberculous Mycobacterial (NTM) Lung Infection Caused by Mycobacterium Avium Complex (MAC) That Are Refractory to Treatment
Phase: PHASE3
Conditions: Mycobacterium Infections, Nontuberculous
Sponsor: Insmed Incorporated

Liposomal Amikacin for Inhalation (LAI) 
INS-212 
A Randomized, Open-Label, Multicenter Study of Liposomal Amikacin for 
Inhalation (LAI) in Adult Patients with Nontuberculous Mycobacterial (NTM) 
Lung Infections Caused by Mycobacterium avium complex (MAC) That are 
Refractory to Treatment 
Phase 3 
Protocol Amendment #3  
Version Date: 22 February 2016 
EudraCT Number 
2014-005010-31  
Insmed Incorporated 
10 Finderne Avenue, Building 10 
Bridgewater, NJ 08807-3365 
Confidential
NCT02344004

Confidential

Confidential

Page 4 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
IMPORTANT CONTACTS 
Insmed Incorporated 
10 Finderne Avenue, Building 10 
Bridgewater, NJ 08807-3365 
Insmed Global Clinical And Drug Safety 
Name: 
Title 
Telephone 
e-Mail Address
Clinical Research Organization 
Vendor Name 
SynteractHCR
Address 
5759 Fleet Street 
Suite 100 
Carlsbad, CA  92008
Telephone Number 
Fax Number 
E-mail Address
www.synteracthcr.com
Confidential

Page 5 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
SUMMARY OF CHANGES 
Section 
Change 
Rationale 
Various 
Typographical errors 
Corrected any misspellings, removed extra punctuation marks and 
spaces and revised phrases to ensure consistency throughout the 
document 
Important 
Contacts 
Updated Insmed 
personnel. 
Decision was made to change the department included in the contact 
information and to add email addresses. 
Table 3-1 
Schedule of 
Events 
Changed from Table 1 to 
Table 3-1. 
Changed visit windows 
for Months 10, 12, 14, 
EOT, and 28-day 
follow-up (Visits 10, 11, 
12, 13, and 14) from 
3 days to 5 days.
Changed the location of 
the row for the CT Scan 
Substudy and added a 
row for the Japan CT 
Scan Substudy. 
Added row for starting 
the consent process for 
Study INS-312 with the 
activity added to Month 6 
(Visit 8). 
Changed to have consistent table numbering format throughout. 
Change required for practical reasons related to scheduling visits. 
Rows reorganized for clarity. Row for Japan CT Scan Substudy added 
because Japan requested to have a CT Scan Substudy substantially 
different from the one for the rest of the world. 
Subjects will be provided with information about Study INS-312 at 
Month 6 so that they have time to make an informed decision before 
Month 8 when some subjects will become eligible for Study INS 312. 
Table 3-1 
Schedule of 
Events and 
Sections 6.3, 
7.2.2.1, and 
7.2.3.1 
Physical examination and 
vital signs removed from 
Months 1, 2, and 5 (Visits 
3, 4, and 7). 
Removed physical examination and vital signs at Months 1, 2, and 5 to 
simplify study procedures. 
Table 3-1 
Schedule of 
Events 
Deleted “in a subset of 
subjects” from the row 
for the Population PK 
sampling. 
The phrase was redundant as “Sub-Set” is already at the top of the 
row. 
Table 3-1 
Schedule of 
Events 
“Comprehensive” was 
added as a descriptor for 
the PK sampling in 
Japanese subjects. 
Sample type and 
Japanese subjects were 
removed. 
The name of the Japanese PK substudy was changed to include the 
word “Comprehensive”. The sample type and the inclusion of only 
Japanese subjects in this substudy are both described in the footnote. 
Confidential

Page 6 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
Table 3-1 
Schedule of 
Events 
Remove dosing at EOT 
visit. 
There is no dosing at EOT visit. 
Table 3-1 
Schedule of 
Events 
Table footnotes were 
modified (see rationale). 
Footnote lettering was 
updated.  
Some footnotes were deleted and others modified/added. Wording and 
typographical errors were edited/fixed for clarity. The abbreviations 
list was modified to include all abbreviations used in the table and its 
footnotes. Redundant visit window footnotes were deleted. Redundant 
footnote on patient-reported outcomes being assessed before study 
drug administration was deleted.  
The pregnancy test footnote was modified to reflect a serum 
pregnancy test only at screening with all other pregnancy tests done 
using urine. A footnote for the treatment blinding requirement for the 
site personnel conducting the 6MWT was added. The audiology and 
chest CT scan footnotes were edited for clarity. The chest CT scan 
footnote was modified to reflect the desire for a high resolution scan if 
possible. The AE footnote was edited for clarity. The footnote on 
discontinuation procedures was deleted. The 2 footnotes on population 
PK were combined and edited for clarity and inclusion of geographic 
region. The Japanese PK substudy footnote was changed to the 
Comprehensive PK substudy footnote to reflect the change in the 
name of the substudy and details were replaced with a reference to the 
substudy protocol. The study drug dispensing footnote was edited for 
clarity. The 28-day safety follow-up footnote was deleted because it 
was confusing and not necessary.  
New footnotes were added to provide details on the length of the 
Screening period and scheduling the Day 1 visit in case of delays in 
obtaining Screening sputum results; to provide for home health visits 
for Months 1, 2, and 5 for qualifying patients who may have difficulty 
attending clinic visits; to start the Study INS-312 consent process at 
Month 6; and to specify that PFTs will be performed at sites with 
appropriate equipment and trained personnel. 
Synopsis and 
Section 2.1 
Changed 3 consecutive 
negative cultures to 
3 consecutive monthly 
negative cultures. 
Clarified the frequency of sputum cultures 
Synopsis and 
Sections 2.2 
and 2.3 
In secondary objective 4, 
changed 2 consecutive 
broth positive cultures to 
2 consecutive monthly 
broth positive cultures. 
In exploratory objective 
8, added EOT as a 
timepoint. 
Clarified the frequency of sputum cultures 
Changed for consistency. The secondary objective of evaluation of 
EQ-5D-3L change from baseline applies to both Month 6 and EOT. 
Synopsis and 
Sections 2.5, 
6.3, and 7.4.1 
Changed 72 hours off 
LAI to 2 days 
interruption of LAI. 
Sputum sample for PK will be collected at the clinic visit which is 
preceded by 2 days of a scheduled/planned interruption in LAI dosing 
for subjects randomized to LAI plus multi-drug per Section 7.1.1. The 
original intent of the protocol was for subjects to interrupt dose for 2 
Confidential

Page 7 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
days as described. 72 hours assumes the subject takes the dose in the 
morning, have 2 days of interruption, and have their clinic visit in the 
morning of the next day (accounting for 72 hours). Since 72 hours was 
being misunderstood as 3 days, the protocol was revised to reflect 2 
days of interruption as per original intention and per protocol. There is 
no change from 3 to 2 days.  
Synopsis and 
Sections 2.5.1 
and 7.4.3. 
Changed Japanese to 
Comprehensive. 
In Section 2.5.1, listed 
the 3 specific substudy 
objectives. 
The name of the substudy was changed from Japanese PK Substudy to 
Comprehensive PK Substudy based on a request from Japan.  
Section 2.5.1 was modified to match the synopsis and the objectives 
listed in the substudy. 
Synopsis and 
Section 1 
Background and rationale 
were updated/edited. 
Edits were made for clarity. In Section 1.3, but not synopsis, 
information about treatment-related lung tumors observed at the end of 
2 years of dosing in 2 of 120 rats was added. 
Synopsis and 
Section 3.1 
Study description and 
design were extensively 
edited. 
Incorporated changes from Japanese specific amendment and clarified 
exceptions to the study entry requirement for 6 consecutive months of 
multi-drug treatment regimen. Exceptions included treatment 
doses/frequencies below those recommended by guidelines and/or 
drug interruptions due to safety/tolerability issues. This was done to 
represent clinical practice, as medications are tailored based on patient 
needs. Clarified that a multi-drug regimen consists of at least 2 
antibiotics. Removed RNA sequencing and replace with MIC 
determination to clarify that study eligibility will be based on MIC 
determination instead of RNA sequencing. Clarified definitions of 
converters and non-converters. Clarified process for determining 
converter/non-converter status and subsequent study progress. 
Clarified that all NTM treatment ends at the EOT visit and that no 
NTM treatment will be given during the safety follow-up or off-
treatment period. Clarified that subjects eligible for a separate open-
label study will include non-converters and converters who 
experienced a relapse/recurrence by Month 6. Removed detailed 
information on follow-up procedure for patients who prematurely 
discontinue from the study (not needed here in the synopsis). Added 
the option for home health visits for Months 1, 2, and 5 for qualifying 
patients who may have difficulty attending clinic visits. More details 
are in Section 3.1 than the synopsis. 
Added instructions regarding the scheduling of Day 1 in case of delays 
in obtaining Screening sputum culture results. 
Synopsis 
PK assessments and their 
time points were edited 
and placed clearly in 
specific categories based 
on activity, region, and 
sample type.  Removed 
details about timing 
relative to dosing for the 
Population PK blood 
Activities were placed in one of the following 3 categories to clarify 
which samples would be taken from subjects in what locations for 
what purpose: 

Population PK Serum and Sputum (US and Japan only)

Sputum PK Substudy (Global)

Comprehensive PK Serum and Sputum Substudy (Japan
only)
Confidential

Page 8 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
draws. Added baseline as 
a timepoint and changed 
72 hours after LAI dosing 
to 2 days interruption of 
LAI dosing for Months 4, 
5, and 6 for Sputum PK 
Substudy. Changed 
Japanese to 
Comprehensive for the 
serum and sputum PK 
substudy in Japan only. 
Added “in a subset” of 
Japanese subjects to the 
activity for the 
Comprehensive PK 
Serum and Sputum 
substudy (Japan only). 
Removed unnecessary details from the synopsis. Added necessary 
details to the synopsis. Changed the name of the Japan only substudy 
to reflect the change in the substudy’s name.  
Synopsis and 
Section 4.1 
Limited subject age to 20 
or older in Japan in 
criterion #1. 
Revised wording about 
prior multi-drug regimens 
in criterion #2. 
Made the high-resolution 
aspect of the diagnostic 
CT scan a preference 
rather than mandatory in 
criterion #3. 
Revised text for the 
requirement of MAC 
positive cultures in 
criterion #4. 
Revised text for the 
contraception methods in 
criterion #8. 
Japan requested a lower limit of 20 years old rather than 18 years old. 
Incorporated changes from Japanese specific amendment and clarified 
exceptions to the study entry requirement for 6 consecutive months of 
multi-drug treatment regimen. 
Clarified that high resolution CT scan is not required for inclusion 
criteria 3. High resolution CT scan is preferred, if available. Regular 
CT scan can be used. 
Clarified that at least 2 positive cultures are needed to be eligible to 
participate in the study. One positive culture should be obtained within 
6 months prior to Screening, and one positive culture at Screening. 
Edited for clarity. 
Synopsis and 
Section 4.2 
Revised MIC 
susceptibility to >64 
g/mL in criterion #2.
Changed gentamicin to 
kanamycin in criterion 
#13. 
Changed criterion #22 
from disallowing 
continuous oxygen use to 
disallowing subjects 
unlikely to survive long 
Added units for MIC. Clarified from amendment 2 that MICs with 
>64 g/mL will be excluded. Subjects with MIC = 64 g/mL can be
included.
Corrected the antibiotic that was listed as an example. 
Oxygen use (continuous or otherwise) is allowed. The concern was 
including subjects too sick to survive the duration of the study. 
Modified exclusion criterion to address the concern directly. 
Confidential

Page 9 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
enough to finish the 
study. 
Synopsis and 
Section 4.3 
Reason 2 was edited to 
clarify that not all AEs 
automatically lead to 
discontinuation. 
Reason 4 was edited to 
provide more detail. 
Added Reason 8: Any 
subject who has to have 
rescue medication will be 
discontinued. 
Clarified that Investigator and/or subject discretion should be applied 
when deciding if an AE should result in subject withdrawal from the 
study. 
Added definition of subject noncompliance and clarified that 
Investigator discretion should be applied in deciding if the subject 
should be withdrawn from the study. 
Added for consistency throughout the protocol. 
Section 4.3 
Reference to end-of-study 
visit replaced with end-
of-treatment visit and 
added a reference to 
Section 5.12.1. 
Discontinued subjects are supposed to have an EOT visit, not an EOS 
visit. Section 5.12.1 is a new section with scenarios for follow-up 
procedures based on when (during the study) the subject discontinues 
study drug or study participation. 
Synopsis and 
Sections 3.2 
and 3.3 
Added “monthly” and 
deleted “collected 
monthly without relapse 
or recurrence” from the 
description of sputum 
cultures in the primary 
endpoint. 
Month 6 was added as 
timepoint for exploratory 
endpoint 8. 
Modified to include the frequency of sputum cultures and match the 
text in the primary objective. Clarified the definition of culture 
conversion. 
Added Month 6 as a timepoint to match the corresponding exploratory 
objective.  
Synopsis and 
Sections 9.4 
and 9.6.2 
Analysis specified as the 
final analysis for the 
primary endpoint and 
other key endpoints based 
on Month 6 data. 
Primary and sensitivity 
analyses methods for 
comparing the treatment 
groups for the change 
from baseline to Month 6 
in 6MWT distance were 
switched (flipped). 
Analyses specified per agreement with FDA. 
Analyses methods for primary and sensitivity analyses were switched 
per FDA recommendation. 
Synopsis and 
Section 3.6.3 
Recruitment time for the 
study changed from 
12 months to 18-24 
months. 
Recruitment period modified to reflect latest feasibility assessment. 
Study 
Schematic 
Modified figure. 
Modified to reflect clarifications in the Synopsis/Section 3.1 Study 
Design 
Confidential

Page 10 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
Figure (in 
synopsis and 
Figure 3-1) 
Section 3.6.3 
Added reference to 
Section 5.12.1 for 
procedures for study 
discontinuation. 
Section 5.12.1 is a new section with scenarios for follow-up 
procedures based on when (during the study) the subject discontinues 
study drug or study participation. 
Section 4.4 
and Section 
6.2 
Added instructions 
regarding the scheduling 
of Day 1 in case of delays 
in obtaining Screening 
sputum culture results. 
Added for consistency with the rest of the protocol. 
Section 4.6 
Added “and Converter” 
to the section heading. 
Added definition of 
converter, 
relapse/recurrence, and 
non-converter. 
For the definition of 
completer, switched the 
order of presentation to 
converters before 
non-converters. 
Added definitions of converter, relapse/recurrence, and non-converter 
for clarity. Switched the order of converters and non-converters in the 
definition of completer to parallel the order of the definitions of 
converter and non-converter. 
Section 5.3 
Updated LAI 
administration time from 
13 minutes to 14 minutes. 
LAI administration is projected to last approximately 14 minutes. 
Section 5.3 
and Section 
5.4 and 
Section 5.8.4 
Added dose interruption 
information. 
Clarified that LAI dose interruptions are allowed if due to respiratory 
adverse events that may affect continuation in the study. Re-
introduction of LAI is recommended. 
Section 5.8.5 
Added text to the 
description of dispensing 
of study drug. 
Clarified that the amount of LAI dispensed to subjects in that 
treatment group would include extra supply in case of delays in visit 
scheduling. 
Section 5.8.6 
Added text regarding 
documentation of 
destruction of drug 
supplies. 
Clarified that documentation should be provided to the Sponsor. 
Section 5.9 
Defined multi-drug 
regimen as including at 
least 2 antibiotics. 
Added text regarding the 
cessation of all NTM 
lung infection treatment 
after the EOT visit. 
Clarified what is a multi-drug regimen and that it can be based on 
local guidelines. Clarified that all NTM treatment ends at the EOT 
visit and that no NTM treatment will be given during the safety 
follow-up period. Specified that the Sponsor will pay for it where 
allowed. Provided examples of drugs that could be part of it. 
Confidential

Page 11 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
Added text specifying 
payee for multi-drug 
regimen and drugs that 
could be in that regimen. 
Section 5.11 
Removed paragraph 
restricting certain types 
of oxygen therapy. 
Added a Table with 
examples of 
precautionary 
medications that may 
interact with LAI. 
Subjects are allowed to use oxygen therapy. 
Provided concrete examples of potential drug-drug interactions. Per 
agreement with PMDA. 
Section 5.12 
Added “and/or Study 
Participation” to the 
section heading. 
Modified existing text 
and added text specifying 
that discontinuation of 
study drug does not 
automatically mean 
discontinuation from 
study participation 
(except in Japan). 
Added Section 5.12.1 
Procedures for 
Discontinuation 
This section is about discontinuation of study drug and/or study 
participation not just discontinuation of study drug. It is possible to 
discontinue study drug but continue study participation, depending on 
the circumstances. 
Text was edited for clarity and to incorporate the requirement that 
discontinuing study drug also means discontinuing study participation 
only in Japan. 
Added scenarios for follow-up procedures based on when (during the 
study) the subject discontinues study drug or study participation. 
Section 6 
(multiple 
places in this 
section) 
Added cross references to 
Appendix 5 for CT scans. 
Added activities in the 
Japan-specific CT Scan 
Substudy. 
Changed Japanese to 
Comprehensive. 
Changed cross reference 
for sputum collection 
containers from Section 
7.2.7 to 7.1.1. 
Changed 72 hours to 2 
days interruption of LAI 
for the sputum-only PK 
substudy. 
Request from Japan to have a CT Scan Substudy substantially 
different from the one for the rest of the world. 
Request from Japan to change the title of the Japan-specific PK 
substudy. 
Corrected a previous error. 
Sputum sample for PK will be collected at the clinic visit which is 
preceded by 2 days of a scheduled/planned interruption in LAI dosing 
for subjects randomized to LAI plus multi-drug per Section 7.1.1. The 
original intent of the protocol was for subjects to interrupt dose for 2 
days as described. 72 hours assumes the subject takes the dose in the 
morning, have 2 days of interruption, and have their clinic visit in the 
morning of the next day (accounting for 72 hours). Since 72 hours was 
being misunderstood as 3 days, the protocol was revised to reflect 2 
days of interruption as per original intention and per protocol. There is 
no change from 3 to 2 days.  
Confidential

Page 12 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
Added “and sputum” and 
“in Japanese subjects 
only” for the bullet about 
the Japanese (now 
Comprehensive) PK 
Substudy. 
Visit windows for 
Months 10, 12, 14, EOT, 
and 28-day safety follow-
up were changed from 3 
days to 5 days. 
Sampling includes sputum as well as blood (serum). Clarified to the 
rest of the world that the Comprehensive PK Substudy applies only in 
Japan. 
Change required for practical reasons related to scheduling visits. 
Section 6.3 
Added sentence on home 
healthcare visits for 
qualified subjects for 
Months 1, 2, and 5. 
Removed physical 
examinations and vital 
signs at Months 1, 2, and 
5 
Added “and sputum” and 
specified only at Month 6 
for biomarker samples. 
Added “by the central 
microbiology laboratory” 
in regards to culture 
conversion assessment. 
Deleted definitions of 
converter, relapse, and 
other details about 
assessing conversion, 
remaining in this study, 
or going to the separate 
open-label study. 
Added the option for home health visits for Months 1, 2, and 5 for 
IRB/EC approved sites approved to conduct Home Healthcare visits, 
and for qualifying patients who may have difficulty attending clinic 
visits. 
Physical examinations and vital signs no longer done at Months 1, 2, 
and 5.  
Biomarkers are being assessed in sputum as well as serum. 
Added to specify who makes the culture conversion assessment and to 
discourage sites from using local laboratories for this. 
This information is provided in Section 3.1. Unnecessarily repeated 
information was deleted. 
Section 6.7 
Removed administer 
study drug at the study 
site. Removed references 
to before or after study 
drug administration. 
Study drug is not administered at the EOT visit. 
Section 6.8 
Added “for subjects who 
complete 12 months of 
treatment” to the section 
heading. 
Added dispense sputum 
collection containers to 
the 28-day, 3-month, and 
Subjects who do not finish 12 months of treatment starting from the 
first of 3 negative cultures that defines culture conversion will not 
participate in the off-treatment phase.  
Subjects are still collecting 3 sputum samples (2 at home on the 
2 consecutive days before the clinic visit) per timepoint. 
Confidential

Page 13 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
6-month off treatment
visits.
Section 6.9 
Modified text regarding 
timing of the visit. 
Clarified timing of the EOS visit as occurring 12 months after the EOT 
visit. Clarified the EOS visit is for all subjects who complete 12 
months of treatment from their first of 3 negative cultures that 
classified them as a converter. 
Section 7.1.1 
Instructed sites not to 
perform local 
mycobacterium sputum 
cultures 
Clarification why sites cannot perform their own sputum cultures for 
mycobacteria.  Performing local mycobacterium sputum cultures 
would introduce bias to patient treatment plans. 
Section 7.2.4 
Include provision for 
PFTs before and after 
LAI dosing for subjects 
randomized to LAI plus 
multi-drug. 
Included provision for airway hypersensitivity testing for patients prior 
to LAI administration if necessary. 
Sections 
7.2.5.1 and 
7.2.5.2 
Specified that the 
baseline ECG will be 
done at Screening. 
Revised for consistency within protocol. 
Section 7.2.7.2 Added “and hematology” Central laboratory will be used to perform hematology assessments as 
well as clinical chemistry assessments. 
Section 7.3.3 
Section 7.3.3.1 
Section 7.3.3.2 
Added “or Different” to 
section heading. 
Included more details on 
the methodology of MAC 
identification. 
Modified text. 
Clarified that strain or species of MAC will be analyzed in subjects 
who achieved culture conversion but subsequently have a positive 
culture to determine causative agent of recurrence or relapse of NTM 
disease.  
Section 7.3.4 
Included wording that 
high resolution CT scan 
is preferred, if available. 
Added cross reference to 
Appendix 5. 
Clarification that high resolution CT scan is preferred, if available. 
Request from Japan to have a CT Scan Substudy substantially 
different from the one for the rest of the world. 
Section 7.4.1 
Modified text for the 
population PK subset. 
Added Baseline 
timepoint for the sputum-
only PK substudy. 
Clarify that the population PK subset only applies to US and Japan 
sites. Other edits were also made for clarity. 
Sputum sample for PK assessment will be collected at Baseline for 
this substudy. 
Section 7.5 
Added “except Month 10, 
14, and off-treatment 
visits.” 
Healthcare resource utilization is not being assessed at these visits. 
Section 8.1 
Added clinically relevant 
laboratory abnormalities 
to the list of examples of 
AEs. 
Added for clarity. 
Confidential

Page 14 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
Section 8.2 
Identified the IB as the 
reference safety 
information for 
determining expectedness 
of an AE. 
Modified previous text to be more relevant. 
Section 8.3 
Added paragraph on how 
to handle expected events 
of pulmonary 
exacerbations. 
Provided instructions on how to define and report pulmonary 
exacerbations. 
Section 8.4 
Specified that corrections 
and additions to an SAE 
report should be reported 
to the Sponsor/delegate 
within 24 hours. 
Deleted text that 
appeared to request the 
site to notify health 
authorities of deaths and 
life-threatening events. 
Deleted Section 8.4.3. 
Corrected previous text that specified 48 hours. 
The Sponsor or designee will notify the health authorities of such 
events as required. 
No such “other reportable events” have been identified. Pulmonary 
exacerbation text was modified and moved to Section 8.3. 
Section 8.6 
Changed SAEs to 
SUSARs. 
Corrected a previous error. 
Section 9.5.2 
Deleted “did not miss 
more than 20% of doses 
to Month 6.” 
Modified text to clarify the definition of per protocol analysis based on 
allowance of dose interruptions due to respiratory events per 
Investigator discretion and medical monitor discussion. 
Section 9.6.1. Added text to the 
sentence on subjects with 
missing sputum cultures 
being identified as non-
converters. 
Text was modified because, depending on which culture timepoints 
are missing and the results of the cultures surrounding those missing 
timepoints, it may be possible to classify a subject with limited 
missing sputum cultures as a converter. 
Section 9.6.2 
Added statement that 
LOCF will be used in a 
supportive ANCOVA for 
change from Baseline to 
Month 6 in 6MWT 
distance for the ITT 
population. 
Added for clarity. 
Section 9.6.3 
Specified that a prior CT 
scan will be used in the 
analysis if an EOT CT 
scan is not performed. 
Added for clarity. 
Section 9.7 
Removed text about how 
to follow up subjects who 
Text is redundant with content in Section 5.12 and does not belong in 
the Safety Analysis section. 
Confidential

Page 15 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
prematurely discontinue 
the study. 
Sections 12.4 
and 12.5 
Modified text regarding 
sample storage. 
Specified which samples for what purpose will be stored in what 
location for how long. 
Appendix 1 
Language was softened to 
show the information 
provided is a suggestion 
and not mandatory. 
Original text was too prescriptive and did not allow sites to follow 
their standard procedures for sputum induction. 
Appendix 3 
Table 14-2 
Changed “Japanese” to 
“Comprehensive” in the 
name of the substudy. 
Revised wording and 
schedule of events.  
Name changed per request from Japan. Clarified procedures for 
including Japanese subjects in Japan in the substudy. Provided more 
details on sampling times for both sputum and blood (serum). 
Appendix 4 
Added preference for 
high resolution chest CT 
scans, if available. 
Modified text to be in alignment with the preference for high 
resolution CT scans everywhere else in the protocol. 
Appendix 5 
Added Appendix 5 
Request from Japan to have a CT Scan Substudy substantially 
different from the one for the rest of the world. 
Confidential

Page 16 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
STUDY SYNOPSIS 
Study Title 
A Randomized, Open-Label, Multicenter Study of Liposomal Amikacin for Inhalation 
(LAI) in Adult Patients with Nontuberculous Mycobacterial (NTM) Lung Infections 
caused by Mycobacterium avium complex (MAC) that are refractory to treatment 
Name of Test Drug/ 
Investigational 
Product 
Liposomal Amikacin for Inhalation (LAI) 
Active 
Pharmaceutical 
Ingredient 
Amikacin sulfate 
Objectives 
Primary Objective 
1.
To evaluate the efficacy of LAI (590 mg) administered once daily (QD),
when added to a multi-drug regimen, for achieving culture conversion (3
consecutive monthly negative sputum cultures) by Month 6 compared to a
multi-drug regimen alone
Secondary Objectives 
1.
To evaluate the efficacy of LAI (590 mg) administered QD when added to a
multi-drug regimen on the six-minute walk test (6MWT) at Month 6
compared to a multi-drug regimen alone
2.
To evaluate the efficacy of LAI (590 mg) QD when added to a multi-drug
regimen on the durability of treatment success 3 months after the end of total
treatment course (negative sputum culture after 3 months off treatment)
3.
To evaluate the efficacy of LAI (590 mg) administered QD when added to a
multi-drug regimen for time to culture conversion compared to a multi-drug
regimen alone
4.
To evaluate the efficacy of LAI (590 mg) administered QD, when added to a
multi-drug regimen for achieving sustainability (consecutive negative sputum
cultures [with no more than 2 consecutive monthly broth positive cultures]
for 12 months on treatment) compared to a multi-drug regimen alone
5.
To evaluate the efficacy of LAI (590 mg) administered QD when added to a
multi-drug regimen on the 6MWT at End of Therapy (EOT) compared to a
multi-drug regimen alone
6.
To evaluate patient-reported symptoms of NTM and change from Baseline
(Day 1) in quality of life scores on the St. George’s Respiratory
Questionnaire (SGRQ) at Month 6
Exploratory Objectives 
Confidential

Page 17 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
1.
To evaluate the change from Baseline to Month 6 on the 6MWT for
converters versus non-converters within the LAI (590 mg) administered QD
added to a multi-drug regimen arm
2.
To evaluate the change from Baseline to Month 6 on the 6MWT for
converters versus non-converters for all subjects
3.
To evaluate the change from Baseline to Month 6 on the 6MWT for
converters versus non-converters within the multi-drug regimen alone arm
4.
To evaluate the change from Baseline to Month 6 on Body Mass Index (BMI)
for those randomized to LAI (590 mg) administered QD added to a
multi-drug regimen compared to a multi-drug regimen alone
5.
To evaluate the efficacy of LAI (590 mg) administered QD when added to a
multi-drug regimen on the 6MWT at Month 8 and 3 months off-treatment
compared to a multi-drug regimen alone
6.
To evaluate the proportion of subjects achieving culture conversion with
durability after 12 months off treatment (EOS) in the LAI arm compared to a
multi-drug regimen alone
7.
To compare patient-reported symptoms of NTM and change from Baseline
(Day 1) in quality of life scores on the SGRQ – Part 2 (Activities of Daily
Living) at Month 6
8.
To compare change from Baseline (Day 1) in the EQ-5D-3L patient reported
health outcomes at Month 6 and EOT
9.
To evaluate the number of subjects in each treatment arm who develop a new
strain of MAC during the study at EOS
10. To compare all-cause mortality between treatment arms 12 months after
treatment (EOS)
Safety Objective 
1.
To evaluate the safety and tolerability of LAI (590 mg) QD added to a multi-
drug regimen arm
Pharmacokinetic Objectives 
1.
To evaluate the pharmacokinetics (PK) of LAI via a population PK approach
2.
To evaluate the concentration of amikacin in sputum after 2 days interruption
of LAI dosing in a subset of subjects
3.
To evaluate the concentration of amikacin in sputum after 28 days off-LAI in
a subset of subjects
4.
To evaluate the concentration of amikacin in sputum after 3 months off-LAI
in a subset of subjects
Comprehensive Pharmacokinetic Sub-Study Objectives 
Confidential

Page 18 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
1.
To characterize systemic amikacin exposure, including approximate systemic
bioavailability in Japanese subjects, using a population PK model to describe
the disposition of amikacin in the serum
2.
To compare population PK modeling between Japanese subjects to historical
population PK modeling for LAI
3.
To evaluate the amikacin concentration in sputum
CT Scan Sub-Study Objective 
1.
To compare assessments of chest CT scans, read by a trained medical
professional, from Baseline (Day 1) to EOT in a subset of subjects within
each treatment arm
Study Description 
Study Rationale 
Treatment guidelines for patients with MAC lung infection in the published American 
Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) consensus 
document were based primarily on small uncontrolled or non-comparative studies in 
subjects with predominantly severe or refractory MAC disease [Griffith et al, 2007].  
Overall, there remains a lack of sufficiently powered, prospective clinical trials aimed 
at the treatment of pulmonary MAC infection. Many of the drugs used in the prolonged, 
recommended multi-drug regimens are expensive and poorly tolerated [Ballarino, et al 
2009]. It is clear from these single-site studies that there is an unmet need for more 
effective, less-toxic therapeutic options. 
Study TR02-112 was a randomized double–blind placebo controlled study that dosed 
89 subjects with LAI or placebo added to a background multi-drug regimen. At Day 84, 
25.0% of subjects with add-on LAI had a negative sputum culture compared to 6.7% of 
subjects with add-on placebo. This is an important result in this population as subjects 
were refractory to therapy for a minimum of 6 months to more than 2 years prior to 
enrollment.  
Study INS-212 will evaluate whether the signal identified in TR02-112 is further 
confirmed with a longer duration of LAI treatment in subjects with NTM MAC lung 
infections who are refractory to a stable multi-drug regimen for at least 6 months. 
INS-212 is a randomized, open-label study of efficacy, safety and tolerability of once 
daily dosing of 590 mg LAI plus a multi-drug regimen compared to a multi-drug 
regimen alone in subjects with NTM lung infections that are refractory to therapy.  
Eligible subjects are those diagnosed with MAC and with persistently positive cultures 
while being treated with a multi-drug treatment regimen (at least 2 antibiotics) for a 
minimum duration of 6 consecutive months that is either ongoing or completed no 
more than 12 months before Screening (exceptions to multi-drug treatment regimen 
for 6 consecutive months include treatment with doses or frequencies below those 
recommended by guidelines and/or short interruptions of therapy, both occurring due 
to safety/tolerability issues). 
One to three sputum samples collected at Screening will be used to determine 
eligibility of the subject.  At Baseline, subjects will start or continue on a multi-drug 
anti-mycobacterial regimen (at least 2 antibiotics) and will be randomized to LAI 
(590 mg) QD plus a multi-drug regimen or to a multi-drug regimen alone for a 
Confidential

Page 19 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
minimum of 8 months.  Subjects who demonstrate culture conversion by Month 6 will 
complete a total treatment course of 12 months starting from the first of 3 negative 
cultures that defines culture conversion. 
Randomization will be stratified according to subject smoking status (current smoker 
or not) and current multi-drug regimen status (on treatment or off treatment for at least 
3 months) at Screening. 
Design 
The Screening window allows time for sputum culture results, susceptibility by 
minimum inhibitory concentration (MIC) determination, and scheduling of Screening 
assessments. Any delay in obtaining microbiological results and MICs must be 
reported to the Sponsor immediately and documented within the study source 
documents. In the event that sputum culture results are not known by 8 weeks (Day -
14), the Baseline (Day 1) visit should be scheduled as soon as possible in order to 
maintain the Screening window, and an extension of the Screening window to 14 
weeks is allowed, if necessary. If sputum culture results are known prior to 8 weeks 
(Day -14), the Screening window of 10 weeks must be maintained. Once Screening 
assessments are complete and sputum culture results are known, eligible subjects will 
be randomized 2:1 to LAI administered QD plus a multi-drug regimen or a multi-drug 
regimen alone.  The primary efficacy endpoint is the proportion of subjects achieving 
culture conversion (3 consecutive monthly negative sputum cultures) by Month 6 in 
the LAI plus a multi-drug regimen arm compared to a multi-drug regimen alone. 
Converters are defined as subjects who have 3 consecutive monthly MAC-negative 
sputum cultures at any time within the first 6 months of the study. After culture 
conversion, relapse or recurrence is defined as having MAC-positive sputum cultures 
in liquid broth media (agar negative) for 3 or more consecutive months, or having 1 
MAC-positive sputum culture on solid media (agar positive). Non-converters are 
defined as subjects who do not have 3 consecutive monthly MAC-negative sputum 
cultures at any time within the first 6 months of the study. 
Sputum culture results will only be available to the site after the Month 6 sputum 
result is known, in time for the Month 8 visit. At Month 8 (-28 to +7 days), after all 
sputum culture results are known, up to and including Month 6, subjects will be 
assessed as converters or non-converters. 
All converters will remain in Study INS-212. All converters who, after culture 
conversion, subsequently have MAC-positive sputum cultures in liquid broth media 
(agar negative) for 1 or 2 consecutive months only, will also remain in Study INS-212. 
These subjects will continue on their randomized treatment regimen until they 
complete a total of 12 months of treatment (EOT), starting from the first of 3 negative 
cultures that defines culture conversion. These subjects will return after the EOT visit 
for 28 day, 3, 6 and 12 months off-treatment follow-up visits.  The 12 months off-
treatment follow-up visit will be the end of study (EOS) visit. No NTM treatment will 
be administered during the off-treatment phase. 
At Month 8, all non-converters will be discontinued from INS-212. All subjects who 
experienced a relapse or recurrence after culture conversion by Month 6 will also be 
discontinued from INS-212 at their Month 8 visit. These subjects may be eligible to 
Confidential

Page 20 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
enter a separate open-label study of LAI (Study INS-312), provided all entry criteria 
have been met for that study.  
Expectorated sputum (spontaneous or induced e.g., with nebulized hypertonic saline 
solution as needed) will be collected at Day 1 and every month through Month 6, at 
Month 8, Month 12, EOT, and at 28 days, 3, 6, and 12/EOS months off-treatment. 
All subjects will come in monthly for routine visits through Month 6, at Month 8, 10, 
12, 14, EOT, and at 28 days, 3, 6 and 12/EOS months off-treatment. Home Healthcare 
visits may be available at Months 1, 2, and 5 for sites with IRB/EC approval to 
conduct Home Healthcare visits, and for qualifying subjects who may have difficulty 
attending clinic visits. Unscheduled visits will occur as needed should subject’s 
symptoms worsen between visits. 
Pharmacokinetics 
Population PK Serum and Sputum (US and Japan only) 
1.
Sputum and serum samples will be collected at Months 1, 3 and 6 in a subset
of subjects on LAI.
Sputum PK Sub-Study (Global) 
1.
Sputum samples only will be collected at Baseline, Months 4, 5, 6 (after 2
days of interruption of LAI dosing) and at the 28-day follow-up visits in a
separate subset of subjects on LAI.
2.
Sputum samples only will be collected at the 3-month follow-up visit in a
separate subset of subjects on LAI identified at EOT.
Comprehensive PK Serum and Sputum Sub-Study (Japan only) 
1.
Comprehensive PK sampling of blood and sputum will be collected at
Baseline, Months 1, 3, and 6 in a sub-set of Japanese subjects.
Study Duration 
This study has an anticipated recruitment period of 18-24 months, with each subject 
receiving treatment in the study for up to 16 months (excluding Screening and 
observational follow-up).  Subjects will remain in the study for up to 31 months, 
including approximately 2.5 months for Screening, up to 16 months in the randomized 
open-label treatment phase, and 12 months in the off-treatment phase. 
Study Population 
The study is designed to enroll enough subjects to ensure at least 261 evaluable 
subjects reach Month 6.  Accounting for discontinuation, it is anticipated that up to 
approximately 351 randomized subjects may be required. Eligible subjects are those 
diagnosed with NTM lung infections caused by MAC who meet the entry criteria 
below. Subjects will be randomized 2:1 to treatment with LAI plus a multi-drug 
regimen or a multi-drug regimen alone.  This study is planned to be conducted at 
approximately 150 sites in North America, Europe, and the Asia-Pacific regions. 
Inclusion Criteria 
To be eligible for enrollment, a patient must meet all of the following criteria: 
1.
be male or female, 18 years or older (20 years or older in Japan)
2.
be positive for MAC on culture as defined in inclusion criterion No. 4, while
being treated with a multi-drug treatment regimen (at least 2 antibiotics) for a
minimum duration of 6 consecutive months  that is either ongoing or was
Confidential

Page 21 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
stopped no more than 12 months before Screening (exceptions to multi-drug 
treatment regimen for 6 consecutive months include treatment with doses or 
frequencies below those recommended by guidelines and/or short 
interruptions, both occurring due to safety/tolerability issues) 
3.
be diagnosed with MAC NTM lung infection with evidence of underlying
lung disease such as nodular bronchiectasis and/or fibrocavitary disease by
chest radiography (CXR) or chest computed tomography. High resolution CT
(HRCT) scan is preferred, if available.
4.
have a MAC lung infection documented by at least 2 positive cultures (MAC
or mixed infection with MAC as the dominant species), consisting of at least
one positive culture obtained within 6 months prior to Screening and one
positive culture at Screening (cultures to be at least 1 month apart).  Cultures
may be obtained from sputum or bronchoscopy.
5.
have a MAC-positive sputum at Screening
6.
be willing to adhere to multi-drug treatment regimen during the course of the
study
7.
be able to produce approximately 3 mL of sputum or be willing to undergo an
induction that produces approximately 3 mL of sputum for mycobacteriology
8.
female of child bearing potential agrees to practice an acceptable method of
birth control (e.g., true abstinence [refraining from heterosexual intercourse
during the entire study], hormonal or barrier methods, partner sterilization, or
intrauterine device [IUD]) while participating in the trial. Periodic abstinence
(e.g., calendar, ovulation, symptothermal, post-ovulation methods),
declaration of abstinence for the duration of the study, and withdrawal are not
acceptable methods of contraception.
9.
the patient will provide written informed consent before performing any study
related procedure
10. be willing to have serum specimens stored
11. be able to comply with study drug use, study visits, and study procedures as
determined by the Investigator
Exclusion Criteria 
A patient with any of the following conditions must be excluded from this study: 
1.
patients with cystic fibrosis
2.
patients whose MAC NTM infection is resistant to amikacin (as identified by
MIC susceptibility >64 µg/mL)
3.
patients who are not able to perform the 6MWT
4.
positive pregnancy test or lactation at Screening.  All women of child bearing
potential will be tested.  Women not of child bearing potential are defined as
postmenopausal (i.e., amenorrheic for at least 1 year), or surgically or
naturally sterile.
Confidential

Page 22 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
5.
active pulmonary malignancy (primary or metastatic) or any malignancy
requiring chemotherapy or radiation therapy within 1 year before Screening
or anticipated during the study period
6.
active allergic bronchopulmonary mycosis or any other condition requiring
chronic systemic corticosteroids at a dose greater than the equivalent of
10 mg/day of prednisone within 3 months before Screening
7.
active pulmonary tuberculosis requiring treatment at Screening
8.
history of lung transplantation
9.
initiation of chronic therapy (e.g., high-dose ibuprofen, inhaled
anti-inflammatory agents including steroids, low dose maintenance steroids,
recombinant human deoxyribonuclease [rhDNase]) within 28 days before
Day 1.
10. administration of any investigational drug within 8 weeks before Screening
11. prior exposure to LAI (including clinical study).
12. known hypersensitivity to aminoglycosides
13. use of inhaled or systemic aminoglycosides with activity against MAC (e.g.,
amikacin, kanamycin, or streptomycin) within 28 days before Day 1
14. acquired and primary immunodeficiency syndromes (e.g. HIV-positive
patients regardless of CD4 counts)
15. significant (as determined by the Investigator) hearing loss, vestibular
dysfunction,  neuromuscular weakness or a diagnosis of myasthenia gravis
where the potential risk of aminoglycoside toxicity outweighs the potential
benefit
16. aspartate aminotransferase or alanine aminotransferase ≥ 3 times the upper
limit of normal (ULN) or total bilirubin ≥ 2 times the upper limit of normal
(ULN)  at Screening
17. absolute neutrophil count ≤500/μL at Screening
18. serum creatinine >2 times ULN at Screening
19. current alcohol, medication or illicit drug abuse
20. any condition that, in the opinion of the Investigator, interferes with ability to
safely complete the study or adhere to study requirements
21. persons who have been committed to an institution by virtue of an order
issued either by the judicial or the administrative authorities
22. in the opinion of the Investigator, patients who are not expected to survive
the duration of the study
23. patients with disseminated MAC infection
Confidential

Page 23 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
Study Withdrawal 
Criteria 
A subject may be withdrawn from the study for any of the following reasons: 
1.
the event of a subject’s death
2.
the subject experiences an AE and the Investigator or the subject determines
that withdrawal from the study is appropriate
3.
a major protocol deviation that interferes with the integrity of the study data
for this subject
4.
the subject is noncompliant (does not comply with dosing instructions
provided by the Investigator or does not comply with the study visit schedule)
and the Investigator determines that withdrawal of the subject is appropriate
5.
the subject withdraws consent to participate in the study
6.
the site is unable to contact the subject after all reasonable efforts have been
exhausted (Lost to Follow-Up)
7.
any condition that, in the judgment of the Investigator, would compromise the
ability of the subject to comply with the study protocol or complete the study
(physician decision).
8.
any subject who has to have “rescue” medication will be discontinued
Study Drug 
Administration 
LAI will be supplied by Insmed in clear glass 10 mL vials via nebulization for a 
delivered dose of 590 mg.  The study drug will be administered via inhalation using 
the PARI eFlow® nebulizer (eFlow®), a small machine that delivers medication in the 
form of a mist inhaled into the lungs, which is approved by the European Medicines 
Agency for use in European Union (elsewhere it is an investigational medical device 
that is not yet commercially approved). 
Study drug will be administered QD.  Subjects who develop bronchospasm may be 
pre-treated with a bronchodilator before study drug administration. 
Methodology and 
Study Procedures 
See Table 3-1 Schedule of Events 
Study Endpoints 
PRIMARY EFFICACY ENDPOINT 
The primary endpoint is the proportion of subjects achieving culture conversion 
(3 consecutive monthly negative sputum cultures) by Month 6 in the LAI arm 
compared to multi-drug regimen alone. 
SECONDARY EFFICACY ENDPOINTS 
1.
Change in 6MWT distance at Month 6 in the LAI arm compared to a
multi-drug regimen alone
2.
Proportion of subjects achieving culture conversion with durability after
3 months off treatment in the LAI arm compared to a multi-drug regimen
alone
Confidential

Page 24 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
3.
Time to culture conversion in the LAI arm compared to a multi-drug
regimen alone by Month 6
4.
Proportion of subjects achieving culture conversion with sustainability at
the EOT in the LAI arm compared to a multi-drug regimen alone
5.
Change in 6MWT distance at EOT in the LAI arm compared to a
multi-drug regimen alone
6.
Change from Baseline (Day 1) at Month 6 in the SGRQ.
EXPLORATORY ENDPOINTS 
1.
Change in 6MWT distance at Month 6 for converters versus non-
converters in LAI arm
2.
Change in 6MWT distance at Month 6 for converters versus non-
converters for all subjects
3.
Change in 6MWT distance at Month 6 for converters versus non-
converters in the multi-drug regimen alone arm
4.
Change in BMI at Month 6 in LAI arm compared to a multi-drug
regimen alone
5.
Change in 6MWT distance at Month 8 and 3 months off-treatment in the
LAI arm compared to a multi-drug regimen alone
6.
Proportion of subjects achieving culture conversion with durability after
12 months off treatment (EOS) in the LAI arm compared to a multi-drug
regimen alone
7.
Change from Baseline (Day 1) at Month 6 in the SGRQ –
Part 2 (Activities of Daily Livings)
8.
Change from Baseline (Day 1) at Month 6 and EOT in the EQ-5D-3L
9.
Proportion of subjects who develop a new strain of MAC in the LAI arm
compared to multi-drug regimen alone
10.
Radiological changes in chest CT Scan at EOT in the LAI arm compared
to multi-drug regimen alone, in a sub-set of subjects
11.
Mortality at EOS.
Efficacy Variables 
Organisms identified in sputum specimens cultured in agar and broth, 6MWT 
results, SGRQ scores 
Safety Variables 
The frequency of AEs, AEs leading to withdrawal from study and 
treatment-emergent serious AEs, laboratory test results, vital signs and pulmonary 
function measurements will be summarized. 
AEs of special interest include bronchospasm, hemoptysis, ototoxicity, and allergic 
alveolitis. 
Confidential

Page 25 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
Statistical Methods 
Sample Size Determination 
The sample size was determined for the primary comparison between the treatment 
arms LAI plus a multi-drug regimen and a multi-drug regimen alone with respect to 
the proportion of subjects achieving culture conversion by Month 6 using nQuery 
Advisor® 7.0.  Assuming a culture conversion rate by Month 6 of no less than 20% 
for the LAI plus a multi-drug regimen treatment arm, the rate by Month 6 of 5% for 
the multi drug regimen alone treatment arm, and a 2:1 randomization ratio, a sample 
size of 261 subjects (174 for LAI plus a multi-drug regimen and 87 for the multi-
drug regimen) will provide at least 90% power for the continuity corrected Chi 
square test at the 2 sided significance level of 0.05. 
The sample size was also evaluated for the secondary endpoint of change from 
Baseline (Day 1) to Month 6 in 6MWT distance. Assuming a common standard 
deviation of 100 and a 2:1 randomization ratio to either LAI plus a multi-drug 
regimen or a multi-drug regimen alone, a sample size of 192 subjects (128 for LAI 
plus a multi-drug regimen and 64 for the multi-drug regimen) will provide at least 
90% power to detect a between-treatment difference of 50 meters in mean change 
from Baseline (Day 1) to Month 6 in 6MWT distance using a two arm t-test at the 2-
sided significance level of 0.05. 
Due to lack of durability data, it is difficult to estimate the power with a total sample 
size of 261 subjects for the comparison between treatment arms with respect to the 
proportion of subjects achieving culture conversion with durability after 3 months 
off-treatment.  Assuming the proportion of subjects achieving culture conversion 
with durability is 16% and 4% for LAI plus a multi-drug regimen and a multi-drug 
regimen respectively, and a 2:1 randomization ratio, a sample size of 261 subjects 
(174 for LAI plus a multi-drug regimen and 87 for the multi-drug regimen) will 
provide at least 83% power for Fisher’s exact test at the 2-sided significance level of 
0.05. 
Statistical Methodology 
The final analyses of the primary efficacy endpoint, the change from Baseline to 
Month 6 in 6MWT distance, and time to culture conversion by Month 6 will be 
performed when the last subject completes Month 6 and data for all subjects who 
have completed Month 6 are available. These final analyses will be performed prior 
to the completion of the study. Interim analysis of some safety data will be included. 
The primary efficacy endpoint is the proportion of subjects achieving culture 
conversion by Month 6.  The primary efficacy analysis will be performed for the 
intent-to-treat population using the Cochran-Mantel-Haenszel test stratified by 
smoking status and prior multi-drug regimen at the 2-sided significance level of 0.05. 
The null hypothesis assumes that the culture conversion by Month 6 is independent 
of treatment, and the alternative hypothesis assumes that the culture conversion by 
Month 6 is associated with treatment. 
A supportive analysis of the primary efficacy endpoint will be performed for the 
per-protocol population similarly using the Cochran-Mantel-Haenszel test stratified 
by smoking status and prior multi-drug regimen. 
The change from Baseline (Day 1) to Month 6 in 6MWT distance will be analyzed 
for the ITT population (assuming Missing-Not-at-Random [MNAR]) using a model 
Confidential

Page 26 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
under the pattern-mixture model framework.  This model assumes that subjects on 
the LAI plus a multi-drug regimen arm with missing data follow the response 
distribution of a multi-drug regimen alone arm. It involves 3 steps:     
1.
The posterior mean and covariance estimates from the SAS MI
procedure using the available non-missing data of a multi-drug
regimen alone arm will be utilized to multiply impute missing data.
2.
The endpoint will then be analysed for each complete data set with
imputed data using an analysis of covariance (ANCOVA) with
treatment arm and the randomization strata as factors, and the Baseline
6MWT distance as a covariate.
3.
The treatment LSMEAN differences will be averaged and the
associated standard errors will be summarized based on within-
imputation and between-imputation variances using the SAS
MIANALYZE procedure, to yield a final estimate of treatment
contrast with associated 95% confidence interval (CI) and p-value.
A sensitivity analysis using a mixed-effects model for repeated measures (MMRM) 
and supportive analyses will be performed. 
The changes from Baseline to Month 8 (exploratory endpoint), EOT, and 3 months 
off-treatment (exploratory endpoint) in 6MWT distance will be analyzed for the ITT 
population using the similar mixed-effects model for repeated measures (MMRM) 
with an unstructured covariance matrix implemented with SAS MIXED procedure 
over all post-randomization visits.  
Kaplan Meier estimates for the distribution of time to culture conversion will be 
constructed for treatment arms.  The treatment comparison will be made using the 
stratified log rank test for the ITT population. The estimated median time to culture 
conversion for each treatment arm will be presented. The time to culture conversion 
will also be analyzed using Cox regression model to estimate hazards ratio. 
The proportion of subjects achieving culture conversion with sustainability by the 
EOT and the proportion of subjects achieving culture conversion with durability 
after 3 months off-treatment will be analyzed for both the ITT and PP populations 
similarly using the Cochran Mantel Haenszel test stratified by smoking status and 
prior multi-drug regimen. 
The change from Baseline (Day 1) to Month 6 in SGRQ total score and the SGRQ – 
Part 2 subdomains (exploratory endpoint) will be analyzed for the ITT population 
similarly using the same MMRM method as the analysis of the change from Baseline 
to EOT in 6MWT distance. 
Confidential

Page 27 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug between Insmed Incorporated and study 
personnel. Information is not to be reproduced, abstracted or used for sharing of information for any other purpose, whatsoever, except with the 
written permission of Insmed Incorporated. 
Confidential

Page 28 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
TABLE OF CONTENTS 
SIGNATURE PAGE FOR INSMED INCORPORATED .................................................. 2 
SIGNATURE PAGE FOR THE INVESTIGATOR ........................................................... 3 
IMPORTANT CONTACTS ................................................................................................ 4 
SUMMARY OF CHANGES ............................................................................................... 5 
STUDY SYNOPSIS ........................................................................................................... 16 
LIST OF TABLES ............................................................................................................. 32 
LIST OF FIGURES........................................................................................................... 32 
LIST OF ABBREVIATIONS ............................................................................................ 33 
1 
INTRODUCTION ..................................................................................................... 35 
1.1 
BACKGROUND ............................................................................................................................... 35 
1.1.1 
Nontuberculous Mycobacterial Lung Infections ..................................................................... 35 
1.1.2 
Liposomal Amikacin for Inhalation (LAI) ............................................................................. 36 
1.1.3 
Prior Clinical Experience ...................................................................................................... 36 
1.2 
RATIONALE FOR THE STUDY ........................................................................................................... 37 
1.3 
RISK-BENEFIT ASSESSMENT ........................................................................................................... 39 
2 
STUDY OBJECTIVES.............................................................................................. 40 
2.1 
PRIMARY OBJECTIVE ...................................................................................................................... 40 
2.2 
SECONDARY OBJECTIVES................................................................................................................ 40 
2.3 
EXPLORATORY OBJECTIVES ........................................................................................................... 41 
2.4 
SAFETY OBJECTIVE ........................................................................................................................ 42 
2.5 
PHARMACOKINETIC OBJECTIVES .................................................................................................... 42 
2.5.1 
Comprehensive Pharmacokinetic Sub-Study Objectives ........................................................ 42 
3 
INVESTIGATIONAL PLAN .................................................................................... 42 
3.1 
STUDY DESIGN .............................................................................................................................. 42 
3.2 
PRIMARY ENDPOINT ...................................................................................................................... 45 
3.3 
SECONDARY ENDPOINTS ................................................................................................................ 45 
3.4 
EXPLORATORY ENDPOINTS ............................................................................................................ 45 
3.5 
SCHEDULE OF EVENTS ................................................................................................................... 46 
3.6 
DISCUSSION OF STUDY DESIGN ...................................................................................................... 52 
3.6.1 
Number of Subjects .............................................................................................................. 52 
3.6.2 
Study Duration ..................................................................................................................... 52 
Confidential

Page 29 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
3.6.3 
Premature Termination of Study Site ..................................................................................... 52 
3.6.4 
Assignment to Study Drug .................................................................................................... 53 
3.6.5 
Data Monitoring Committee .................................................................................................. 53 
4 
STUDY POPULATION............................................................................................. 53 
4.1 
INCLUSION CRITERIA ..................................................................................................................... 54 
4.2 
EXCLUSION CRITERIA .................................................................................................................... 55 
4.3 
REMOVAL OF SUBJECTS ................................................................................................................. 57 
4.4 
RE-SCREENING OF SUBJECTS .......................................................................................................... 57 
4.5 
REPLACEMENT OF SUBJECTS .......................................................................................................... 58 
4.6 
DEFINITIONS OF CONVERTER AND COMPLETER................................................................................ 58 
5 
STUDY TREATMENTS ........................................................................................... 58 
5.1 
INVESTIGATIONAL STUDY DRUG .................................................................................................... 58 
5.2 
REFERENCE STUDY DRUG .............................................................................................................. 59 
5.3 
ADMINISTRATION OF STUDY DRUG ................................................................................................ 59 
5.4 
SELECTION OF DOSES ..................................................................................................................... 60 
5.5 
SELECTION OF TIMING OF ADMINISTRATION ................................................................................... 60 
5.6 
BLINDING ...................................................................................................................................... 60 
5.7 
STUDY KIT .................................................................................................................................... 60 
5.8 
DRUG SUPPLY ............................................................................................................................... 61 
5.8.1 
Packaging ............................................................................................................................. 61 
5.8.2 
Labeling ............................................................................................................................... 61 
5.8.3 
Storage ................................................................................................................................. 61 
5.8.4 
Compliance and Drug Accountability .................................................................................... 61 
5.8.5 
Dispensing of Study Drug ..................................................................................................... 61 
5.8.6 
Disposition and Reconciliation of Study Drug ....................................................................... 62 
5.9 
CONCOMITANT MEDICATIONS ........................................................................................................ 62 
5.10 
PROHIBITED MEDICATIONS ............................................................................................................ 63 
5.11 
PRECAUTIONARY MEDICATIONS ..................................................................................................... 63 
5.12 
DISCONTINUATION OF STUDY DRUG AND/OR STUDY PARTICIPATION ................................................ 65 
5.12.1 
Procedures for Discontinuation ............................................................................................. 66 
6 
STUDY PROCEDURES ........................................................................................... 67 
6.1 
SCREENING VISIT (VISIT 1) ............................................................................................................ 67 
6.2 
BASELINE VISIT (DAY 1, VISIT 2) ................................................................................................... 68 
6.3 
VISITS AT MONTHS 1 THROUGH 6 AND 8 (VISITS 3 THROUGH 9) DURING THE RANDOMIZED,
TREATMENT PHASE ....................................................................................................................... 69 
6.4 
MONTH 10 (VISIT 10) DURING THE RANDOMIZED, TREATMENT PHASE ............................................ 71 
6.5 
MONTH 12 (VISIT 11) DURING THE RANDOMIZED, TREATMENT PHASE ............................................ 71 
Confidential

Page 30 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
6.6 
MONTH 14 (VISIT 12) DURING THE RANDOMIZED, TREATMENT PHASE ............................................ 72 
6.7 
END OF TREATMENT – UP TO MONTH 16 (VISIT 13) DURING THE RANDOMIZED, TREATMENT PHASE73 
6.8 
OFF-TREATMENT SAFETY FOLLOW-UP VISITS (VISIT 14, 15, AND 16) DURING THE OFF-TREATMENT
PHASE FOR SUBJECTS WHO COMPLETE 12 MONTHS OF TREATMENT .................................................. 74 
6.9 
END OF STUDY -12 MONTHS OFF-TREATMENT (VISIT 17) ............................................................... 75 
7 
STUDY VARIABLES AND METHODS OF ASSESSMENT .................................. 75 
7.1 
PRIMARY ENDPOINT VARIABLES .................................................................................................... 75 
7.1.1 
Sputum Collection, Transport, and Assessment ..................................................................... 75 
7.1.2 
Microbiological Assessment ................................................................................................. 76 
7.2 
SECONDARY ENDPOINT VARIABLES ............................................................................................... 77 
7.2.1 
Six-minute Walk Test ........................................................................................................... 77 
7.2.2 
Physical Examination ............................................................................................................ 77 
7.2.3 
Vital Signs ............................................................................................................................ 78 
7.2.4 
Pulmonary Function Tests ..................................................................................................... 78 
7.2.5 
12-lead Electrocardiogram .................................................................................................... 79 
7.2.6 
Adverse Events ..................................................................................................................... 79 
7.2.7 
Clinical Laboratory Evaluations ............................................................................................ 80 
7.2.8 
Concomitant Medications ..................................................................................................... 81 
7.2.9 
Audiology............................................................................................................................. 82 
7.3 
EXPLORATORY ENDPOINT VARIABLES ............................................................................................ 82 
7.3.1 
St. George’s Respiratory Questionnaire ................................................................................. 82 
7.3.2 
EQ-5D-3L ............................................................................................................................ 83 
7.3.3 
Identification of New or Different MAC Strains .................................................................... 83 
7.3.4 
Computed Tomography Scan of Chest .................................................................................. 84 
7.3.5 
All-cause Mortality ............................................................................................................... 84 
7.4 
PHARMACOKINETICS ...................................................................................................................... 85 
7.4.1 
Methodology ........................................................................................................................ 85 
7.4.2 
Sample Collection ................................................................................................................. 85 
7.4.3 
Comprehensive Pharmacokinetic Sub-Study (Japanese sites only) ......................................... 85 
7.5 
HEALTH CARE RESOURCE UTILIZATION ........................................................................................... 87 
7.6 
APPROPRIATENESS OF MEASUREMENTS .......................................................................................... 87 
8 
ADVERSE EVENTS ................................................................................................. 87 
8.1 
DEFINITION OF AN ADVERSE EVENT ............................................................................................... 87 
8.2 
DEFINITION OF A SERIOUS ADVERSE EVENT.................................................................................... 88 
8.2.1 
Assessment of Intensity......................................................................................................... 89 
8.2.2 
Assessment of Causality ....................................................................................................... 90 
8.2.3 
Assessment of Outcome ........................................................................................................ 90 
8.3 
ADVERSE EVENTS OF SPECIAL INTEREST ........................................................................................ 90 
Confidential

Page 31 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
8.4 
REPORTING REQUIREMENTS ........................................................................................................... 91 
8.4.1 
Adverse Events ..................................................................................................................... 91 
8.4.2 
Serious Adverse Events......................................................................................................... 92 
8.5 
FOLLOW-UP OF ADVERSE AND SERIOUS ADVERSE EVENTS ............................................................. 93 
8.6 
REGULATORY ASPECTS .................................................................................................................. 93 
9 
STATISTICS .............................................................................................................. 93 
9.1 
SAMPLE SIZE ................................................................................................................................. 93 
9.2 
STRATIFICATION ............................................................................................................................ 94 
9.3 
RANDOMIZATION AND BLINDING .................................................................................................... 94 
9.4 
STATISTICAL METHODOLOGY ........................................................................................................ 94 
9.5 
ANALYSIS POPULATIONS ................................................................................................................ 95 
9.5.1 
Intent-to-treat Population ...................................................................................................... 95 
9.5.2 
Per-protocol Population ........................................................................................................ 95 
9.5.3 
Safety Population .................................................................................................................. 95 
9.5.4 
Pharmacokinetic Population .................................................................................................. 95 
9.6 
EFFICACY ANALYSIS ...................................................................................................................... 95 
9.6.1 
Primary Endpoint Analysis ................................................................................................... 95 
9.6.2 
Secondary Endpoint Analyses ............................................................................................... 96 
9.6.3 
Exploratory Endpoint Analyses ............................................................................................. 98 
9.7 
SAFETY ANALYSIS ................................................................................................................... 98 
10 DATA MANAGEMENT ............................................................................................ 99 
10.1 
SOURCE DOCUMENTS..................................................................................................................... 99 
10.2 
DATA COLLECTION AND CASE REPORT FORM MONITORING ........................................................... 99 
10.3 
STUDY RECORDS RETENTION ....................................................................................................... 100 
11 
ETHICAL CONSIDERATIONS............................................................................. 100 
11.1 
GOOD CLINICAL PRACTICE........................................................................................................... 101 
11.2 
DELEGATION OF INVESTIGATOR DUTIES ........................................................................................ 101 
11.3 
PATIENT INFORMATION AND INFORMED CONSENT .......................................................................... 101 
12 ADMINISTRATIVE PROCEDURES .................................................................... 102 
12.1 
FINANCIAL DISCLOSURE BY INVESTIGATOR .................................................................................. 102 
12.2 
STUDY REGISTRATION AND RESULTS DISCLOSURE........................................................................ 102 
12.3 
STUDY FILES AND MATERIALS ..................................................................................................... 102 
12.4 
USE OF STORED SAMPLES AND DATA ........................................................................................... 103 
12.5 
DISPOSITION OF STORED SAMPLES AND DATA .............................................................................. 104 
12.6 
INITIATION OF STUDY .................................................................................................................. 104 
12.7 
PATIENT REIMBURSEMENT, LIABILITY, AND INSURANCE ............................................................... 105 
Confidential

Page 32 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
12.8 
SUBJECT IDENTIFICATION AND CONFIDENTIALITY ...................................................................... 105 
12.9 
STUDY MONITORING .................................................................................................................... 105 
12.10 STUDY PLAN AMENDMENTS ......................................................................................................... 106 
12.11 AUDITS AND INSPECTIONS ............................................................................................................ 106 
12.12 USE OF DATA AND PUBLICATIONS ................................................................................................ 107 
13 REFERENCES ........................................................................................................ 108 
14 APPENDICES ......................................................................................................... 110 
LIST OF TABLES 
Table 3-1 
Schedule of Events ....................................................................................... 47 
Table 5-1 
Composition of Liposomal Amikacin Sulfate ............................................... 59 
Table 5-2 
List of Examples of Precautionary Medications ............................................ 64 
Table 14-1 
Content of Study Drug Label...................................................................... 113 
Table 14-2 
Schedule of Events for INS-212 Comprehensive Pharmacokinetic Sub-
Study ......................................................................................................... 119 
Table 14-3 
Schedule of Events for INS-212 CT Scan Sub-Study .................................. 124 
Table 14-4 
Schedule of Events for INS-212 Japan Specific CT Scan Sub-Study .......... 129 
LIST OF FIGURES 
Figure 3-1 
Study Design................................................................................................ 44 
Confidential

Page 33 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
LIST OF ABBREVIATIONS 
Abbreviation 
Term 
6MWT 
six-minute walk test 
AE 
adverse event 
AESI 
adverse events of special interest 
AFB 
Acid-Fast Bacteria/Bacterium 
ANCOVA 
Analysis of Covariance 
ATS 
American Thoracic Society 
BR 
Bronchiectasis 
CF 
Cystic Fibrosis 
CFR 
Code of Federal Regulations 
cGMP 
current Good Manufacturing Practices 
CI 
Confidence Interval 
COPD 
Chronic Obstructive Pulmonary Disease 
CRO 
Clinical Research Organization 
CRP 
C-Reactive Protein 
CT 
Computed Tomography 
CTCAE 
Common Terminology Criteria for Adverse Events 
DMC 
Data Monitoring Committee 
DPPC 
Dipalmitoylphosphatidylcholine 
ECG 
Electrocardiogram 
eCRF 
Electronic Case Report Form 
EDC 
Electronic Data Capture 
EOS 
End of Study 
EOT 
End of Treatment 
EP 
Evaluable Population 
EQ-5D-3L 
formerly EuroQol 5D, a generic health-status classification instrument 
FDA  
Food and Drug Administration of the United States of America 
FEV1(L) 
Forced Expiratory Volume in 1 second in liters 
FEF(25-75%) 
Forced Expiratory Flow rate during mid portion of expiration 
FVC 
Forced Vital Capacity 
GCP 
Good Clinical Practice 
hCG 
human Chorionic Gonadotropin 
IB 
Investigator’s Brochure 
Confidential

Page 34 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
Abbreviation 
Term 
ICH 
International Conference on Harmonisation 
IDSA 
Infectious Diseases Society of America 
EC 
Ethics Committee 
IL-6 
Interleukin-6 
IRB  
Institutional Review Board 
ITT 
Intent-to-treat 
IV 
intravenous 
LS 
Least Square 
LAI 
Liposomal Amikacin for Inhalation 
MAC 
Mycobacterium avium complex 
MIC 
Minimum inhibitory concentration 
mm 
millimeter 
MMRM 
Mixed-effects Model for Repeated Measures 
MNAR 
Missing Not at Random 
NTM 
Nontuberculous Mycobacteria 
Pa 
Pseudomonas aeruginosa 
PI 
Principal Investigator 
PK 
Pharmacokinetics 
PP 
Per-Protocol 
QD 
Once Daily 
rhDNase 
recombinant human Deoxyribonuclease 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SGRQ 
St. George’s Respiratory Questionnaire 
SpO2 
Pulse Oximetry 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TOBI 
Tobramycin for Inhalation 
ULN 
Upper Limit of Normal 
w:w 
Weight to Weight 
Confidential

Page 35 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
1 
INTRODUCTION 
1.1 
BACKGROUND 
1.1.1 Nontuberculous Mycobacterial Lung Infections 
Nontuberculous mycobacteria (NTM) are ubiquitous in the environment.  The pulmonary 
infection caused by these organisms has features that overlap with tuberculosis, but disease 
definition can be more complex as recovery of a single isolate from the airway secretions 
does not necessarily indicate disease.  In contrast to tuberculosis, there is no convincing 
evidence of person-to-person spread (Griffith, et al.  2007; Olivier, et al.  2003). It appears 
that the prevalence of human disease attributable to these organisms over the past 2 decades 
is increasing (Khan, et al.  2007; Marras, et al.  2007; Khan et al, 2008).  Pulmonary disease 
due to NTM was traditionally reported as primarily upper lobe fibrocavitary disease 
occurring in male smokers with emphysema (Contreras, et al.  1988). More recently, certain 
disease and demographic populations seem to be particularly susceptible to nodular 
bronchiectatic pulmonary disease with predominant infection of the anterior aspect of the 
mid-lung.  In cystic fibrosis (CF), the prevalence of NTM in the lower airways is 13%, and 
increases with age (Olivier, et al.  2003).  Elderly, Caucasian women without apparent 
predisposing conditions have been reported with increasing frequency to have pulmonary 
disease associated with Mycobacterium avium complex (MAC), and one community 
pulmonary practice reported this to be a prominent cause of chronic cough with infiltrates 
(Prince, et al.  1989). 
Mycobacterium avium and Mycobacterium avium complex, a symbiotic infection of M. 
avium and M. intracellulare, are the predominant infective species in NTM pulmonary 
disease in US, Japan, European countries, and elsewhere, followed by M. abscessus and M. 
kansasii.  There is a perception that M. abscessus as a causative species is on the rise, which 
is a concern because these infections are especially difficult to treat (Leung 2013 and Olivier 
2003). In CF, the rates of NTM lung infection caused by M. abscessus often exceed those 
caused by MAC. 
Signs and symptoms of NTM pulmonary infection are variable and nonspecific.  They 
include chronic cough, sputum production, and fatigue.  Less commonly, malaise, dyspnea, 
fever, hemoptysis, and weight loss can also occur, usually with advanced NTM lung 
Confidential

Page 36 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
infection.  Evaluation is often complicated by the symptoms caused by co-existing lung 
diseases.  These conditions include chronic obstructive airway disease (COPD) associated 
with smoking, bronchiectasis, previous mycobacterial diseases, CF, and pneumoconiosis 
(Wilson, et al.  1997). 
Current treatment of NTM lung infection is primarily with multi-drug regimens developed 
for the treatment of tuberculosis.  This approach is not optimal, and the morbidity and 
mortality associated with NTM infection is significant.  A study by Andrejak et al in 
Denmark demonstrated that mortality after 5 years in those who were infected according to 
the American Thoracic Society /Infectious Diseases Society of America (ATS/IDSA) criteria 
was 40%.  In this study, M. xenopi was associated with a particularly poor prognosis 
(Andrejak, et al 2010). 
1.1.2 Liposomal Amikacin for Inhalation (LAI) 
LAI is a sterile aqueous liposomal formulation for inhalation via nebulization.  LAI is 
comprised of amikacin sulfate encapsulated in liposomes composed of 
dipalmitoylphosphatidylcholine (DPPC) and cholesterol; other inactive ingredients include 
sodium chloride, sodium hydroxide for pH adjustment and water for injection.  LAI is 
supplied in a single use 10 mL vial to deliver 590 mg amikacin to the nebulizer.  LAI is 
administered by inhalation via a PARI eFlow® nebulizer, a small machine that delivers 
medication in the form of a mist inhaled into the lungs, which is approved by the European 
Medicines Agency (EMA) for use in European Union (elsewhere it is an investigational 
medical device that is not yet commercially approved). 
1.1.3 Prior Clinical Experience 
LAI is a novel formulation of amikacin that is encapsulated in liposomes comprised of DPPC 
and cholesterol (naturally occurring lipids in the lung) to allow for effective delivery in the 
lung, leading to high concentrations of the drug at the target sites of infection, with low 
systemic levels.  Clinical studies to date to date have evaluated LAI in a total of 519 subjects, 
including 6 healthy subjects, 383 subjects with CF, 43 subjects with bronchiectasis (BR), and 
87 subjects with NTM lung disease in Canada, Europe, and the United States.  Early studies 
in the clinical development program established that LAI was effective in improving lung 
function in CF patients with chronic Pseudomonas aeruginosa (Pa) lung infection.  The 
Confidential

Page 37 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
pivotal phase 3 study that supports efficacy in the management of chronic Pa in patients with 
CF is TR02-108 in which LAI was non-inferior to tobramycin for inhalation (TOBI).  An 
open-label extension to TR02-108, the TR02-110 study, established a sustained effect of LAI 
in these subjects for up to 30 months.  These data are supported by earlier studies assessing 
LAI against placebo for short cycles of treatment (TR02-105 and TR02-106) in which LAI 
demonstrated statistical superiority over placebo.  All controlled comparator studies 
(TR02-105, 106, 108, and 110) established an additional benefit in quality of life measures 
for these subjects. 
The program also included a study in patients with NTM lung infection (TR02-112) that 
randomized and dosed 89 subjects with LAI or placebo added to a background multi-drug 
regimen.  The key secondary endpoint assessed sputum cultures and demonstrated that LAI 
was statistical superiority at the end of the double-blind period (Day 84) for achieving a 
negative sputum culture.  At Day 84, 25.0% of subjects with add-on LAI had a negative 
sputum culture compared to 6.7% of subjects with add-on placebo.  This is an important 
result in this population as subjects were refractory to therapy for a minimum of 6 months to 
more than 2 years prior to enrollment.  Furthermore, 12 subjects demonstrated sustained 
negative culture results with add-on LAI to the end of the open-label phase (Day 168) 
including the 28 days off LAI follow-up period.  The change in subject functional status was 
assessed using the 6 minute walk test and a statistically significant difference in favor of LAI 
(a mean increase from Baseline [Day 1] of 23.859 meters vs. a mean decrease of 
25.032 meters in the LAI vs. placebo arms, respectively (p = 0.0134). 
Additional results of clinical studies of LAI are summarized in the Investigator’s Brochure 
(IB). 
1.2 
RATIONALE FOR THE STUDY 
Treatment guidelines for patients with MAC lung infection in the published ATS/ IDSA 
consensus document were based primarily on small uncontrolled or non-comparative studies 
in patients with predominantly severe or refractory MAC disease (Griffith, et al.  2007).  
Overall, there remains a lack of sufficiently powered, prospective clinical trials aimed at the 
treatment of pulmonary MAC infection.  Many of the drugs used in the prolonged, 
recommended multi-drug regimens are expensive and poorly tolerated (Ballarino, et al.  
Confidential

Page 38 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
2009). It is clear from these single-site studies that there is an unmet need for more effective, 
less-toxic therapeutic options. 
Amikacin solution for parenteral administration is an established drug that is effective against 
a variety of NTM.  However, its use is limited by poor tissue penetration into lung tissue and 
the need to administer it intravenously (IV) in high enough doses that cause toxicity to 
hearing, balance, and kidney function.  In the case of bacterial infections of the lung, the 
inhalation route of administration is advantageous over the IV route in that the 
aminoglycoside is delivered directly to the effect-site with neither significant systemic 
absorption nor the associated systemic toxicities.  Disadvantages of aerosolized 
aminoglycoside solutions include rapid clearance from lung tissue, which necessitates 
frequent dosing (Geller, et al.  2002) and the length of time required to inhale sufficient 
amounts of drug.  Both factors place a high daily treatment burden on patients and may limit 
patient compliance.  Thus, LAI was developed to overcome these limitations. 
Lipid/liposome delivery systems similar to that used to deliver LAI in this study have been 
used to improve the therapeutic index of several injectable therapeutic agents.  In a liposome 
drug delivery system, a bioactive agent entrapped in a liposome is administered to the patient. 
Alternatively, drugs can be combined with lipids to form nonencapsulated lipid drug 
complexes having therapeutic advantages.  Therapeutic properties of several commercial 
products, such as anticancer compounds liposomal doxorubicin (Doxcil®) and liposomal 
daunorubicin (Daunosome®) and the antifungal lipid complex of amphotericin B (Abelcet®, 
Ambisome®), have improved dramatically after encapsulation or complexing with a lipid.  
Although these commercials products are administered IV, inhaled Ambisome is being 
evaluated for prophylactic use. 
Study TR02-112 was a randomized double-blind placebo controlled that dosed 89 subjects 
with LAI or placebo added to a background multi-drug regimen.  At Day 84, 25.0% of 
subjects with add-on LAI had a negative sputum culture compared to 6.7% of subjects with 
add-on placebo.  This is an important result in this population as subjects were refractory to 
therapy for a minimum of 6 months to more than 2 years prior to enrollment.  Furthermore, 
12 subjects demonstrated sustained negative culture results with add-on LAI to the end of the 
open-label phase (Day 168) including the 28 days off LAI follow-up period.   
Confidential

Page 39 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
The change in subject functional status was assessed using the 6 minute walk test and a 
statistically significant difference in favor of LAI (a mean increase from Baseline [Day 1] of 
23.859 meters vs. a mean decrease of 25.032 meters in the LAI vs. placebo arms, respectively 
(p = 0.0134). 
Study INS-212 will evaluate whether the signal identified in TR02-112 is further confirmed 
in a longer duration of LAI treatment in patient with NTM MAC lung infections who are 
refractory to a stable multi-drug regimen for at least 6 months.  
1.3 
RISK-BENEFIT ASSESSMENT 
The safety of LAI has been evaluated in 13 studies, 11 of which are completed and 2 are 
ongoing.  The 6 main safety studies conducted in CF and NTM included a total of 434 unique 
treated subjects who received LAI at doses ranging from 70 mg QD to 590 mg QD or TOBI 
or placebo.  In all 6 of the main safety studies, most subjects were Caucasian and the majority 
were female. 
In each of the 6 main safety studies, the majority of the subjects in all treatment groups 
experienced at least 1 treatment-emergent adverse event (TEAE), with most events related to 
the subjects’ underlying diagnosis.  Across the 6 main safety studies, the most common 
serious adverse event (SAE) in all groups was hospitalization due to pulmonary exacerbation.  
Most SAEs were not considered by the investigator to be treatment-related.  In TR02-112, in 
the double-blind phase, SAEs were reported for a greater proportion of subjects in the LAI 
arm than in the placebo arm (18.2% versus 8.9%, respectively).  The incidence of SAEs did 
not increase in the LAI arm after additional exposure to the study drug in the open-label 
phase of TR02-112 compared with the double-blind phase (14.3% vs. 18.2%, respectively). 
In preclinical studies, treatment-related lung tumors were observed at the end of 2 years of 
dosing in 2 of 120 rats. The theoretical risk of lung tumors must be weighed against the 
potential benefits of LAI for patients, and will depend on a number of factors, including 
severity of disease, comorbidities and the availability of alternative treatments. 
Additional details of clinical studies and potential AEs evidenced from preclinical studies are 
presented in the IB. 
Confidential

Page 40 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
2 
STUDY OBJECTIVES 
2.1 
PRIMARY OBJECTIVE 
The primary objective is to evaluate the efficacy of LAI (590 mg) administered QD, when 
added to a multi-drug regimen, for achieving culture conversion (3 consecutive monthly 
negative sputum cultures) by Month 6 compared to a multi-drug regimen alone. The date of 
conversion is defined by the date of the first of 3 negative cultures.  
2.2 
SECONDARY OBJECTIVES 
1. To evaluate the efficacy of LAI (590 mg) administered QD when added to a
multi-drug regimen on the six minute walk test (6MWT) at Month 6 compared to a
multi-drug regimen alone
2. To evaluate the efficacy of LAI (590 mg) QD when added to a multi-drug regimen on
the durability of treatment success 3 months after the end of total treatment course
(negative sputum culture after 3 months off treatment)
3. To evaluate the efficacy of LAI (590 mg) administered QD when added to a
multi-drug regimen for time to culture conversion compared to a multi-drug regimen
alone
4. To evaluate the efficacy of LAI (590 mg) administered QD, when added to a
multi-drug regimen, for achieving sustainability (consecutive negative sputum
cultures [with no more than 2 consecutive monthly broth positive cultures] for
12 months on treatment) compared to a multi-drug regimen alone
5. To evaluate the efficacy of LAI (590 mg) administered QD when added to a
multi-drug regimen on the 6MWT at EOT compared to a multi-drug regimen alone
6. To evaluate patient reported symptoms of NTM and change from Baseline (Day 1) in
quality of life scores on the St. George’s Respiratory Questionnaire (SGRQ) at
Month 6.
Confidential

Page 41 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
2.3 
EXPLORATORY OBJECTIVES 
The exploratory objectives are: 
1. To evaluate the change from Baseline to Month 6 on the 6MWT for converters versus
non-converters within the LAI (590 mg) administered QD added to a multi-drug
regimen arm
2. To evaluate the change from Baseline to Month 6 on the 6MWT for converters versus
non-converters for all subjects
3. To evaluate the change from Baseline to Month 6 on the 6MWT for converters versus
non-converters within the multi-drug regimen alone arm
4. To evaluate the change from Baseline to Month 6 on Body Mass Index (BMI) for
those randomized to LAI (590 mg) administered QD added to a multi-drug regimen
compared to a multi-drug regimen alone
5. To evaluate the efficacy of LAI (590 mg) administered QD when added to a
multi-drug regimen on the 6MWT at Month 8 and 3 months off-treatment compared
to a multi-drug regimen alone
6. To evaluate the proportion of subjects achieving culture conversion with durability
after 12 months off treatment (EOS) in the LAI arm compared to a multi-drug
regimen alone
7. To compare patient reported symptoms of NTM and change from Baseline (Day 1) in
quality of life scores on the SGRQ – Part 2 (Activities of Daily Living) at Month 6
8. To compare change from Baseline (Day 1) in the EQ 5D patient reported health
outcomes at Month 6 and EOT
9. To evaluate the number of subjects in each treatment arm who develop a new strain of
MAC during the study at EOS
10. To compare all-cause mortality between treatment arms 12 months after treatment
(EOS).
Confidential

Page 42 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
2.4 
SAFETY OBJECTIVE 
The safety objective is to evaluate the safety and tolerability of LAI (590 mg) QD added to a 
multi-drug regimen arm. 
2.5 
PHARMACOKINETIC OBJECTIVES 
1. To evaluate the PK of LAI via a population PK approach (Months 1, 3 and 6).
2. To evaluate the concentration of amikacin in sputum after 2 days interruption of LAI
dosing in a subset of subjects (Months 4, 5 and 6)
3. To evaluate the concentration of amikacin in sputum after 28 days off-LAI in a subset
of subjects
4. To evaluate the concentration of amikacin in sputum after 3 months off-LAI in a
subset of subjects
2.5.1 Comprehensive Pharmacokinetic Sub-Study Objectives 
1. To characterize systemic amikacin exposure, including approximate systemic
bioavailability in Japanese subjects, using a population PK model to describe the
disposition of amikacin in the serum
2. To compare population PK modeling between Japanese subjects to historical
population PK modeling for LAI
3. To evaluate the amikacin concentration in sputum
3 
INVESTIGATIONAL PLAN 
3.1 
STUDY DESIGN 
The Screening window allows time for sputum culture results, susceptibility by minimum 
inhibitory concentration (MIC) determination, and scheduling of Screening assessments. Any 
delay in obtaining microbiological results and MICs must be reported to the Sponsor 
immediately and documented within the study source documents. In the event that sputum 
culture results are not known by 8 weeks (Day -14), the Baseline (Day 1) visit should be 
scheduled as soon as possible in order to maintain the Screening window, and an extension of 
the Screening window to 14 weeks is allowed, if necessary. If sputum culture results are 
known prior to 8 weeks (Day -14), the Screening window of 10 weeks must be maintained. 
Once Screening assessments are complete and sputum culture results are known, eligible 
Confidential

Page 43 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
subjects will be randomized 2:1 to LAI administered QD plus a multi-drug regimen or a 
multi-drug regimen alone.  The primary endpoint will assess culture conversion by Month 6. 
Sputum culture results will only be available to the site after the Month 6 sputum result is 
known, in time for the Month 8 visit. At Month 8 (-28 to +7 days), after all sputum culture 
results are known, up to and including Month 6, subjects will be assessed as converters or 
non-converters.  
All converters will remain in Study INS-212 (Section 4.6). All converters who, after culture 
conversion, subsequently have MAC-positive sputum cultures in liquid broth media (agar 
negative) for 1 or 2 consecutive months only, will also remain in Study INS-212. These 
subjects will continue on their randomized treatment regimen until they complete a total of 
12 months of treatment (EOT), starting from the first of 3 negative cultures that defines 
culture conversion. These subjects will return after the EOT visit for 28 day, 3, 6 and 
12 months off-treatment follow-up visits.  The 12 months off-treatment follow-up visit will 
be the end of study (EOS) visit. No NTM treatment will be administered during the off-
treatment phase. 
At Month 8, all non-converters will be discontinued from INS-212 (Section 4.6). All subjects 
who experienced a relapse or recurrence (Section 4.6) by Month 6 will also be discontinued 
from INS-212 at their Month 8 visit. These subjects may be eligible to enter a separate 
open-label study of LAI (Study INS-312), provided all entry criteria have been met for that 
study. 
Expectorated sputum (spontaneous or induced e.g., with nebulized hypertonic saline solution 
as needed) will be collected at Day 1 and every month through Month 6, and at Months 8, 12, 
at EOT, at 28 days, 3, 6 and 12 (EOS) months off-treatment. 
All subjects will come in monthly for routine visits through Month 6, at Months 8, 10, 12, 14, 
EOT, and at 28 days, 3, 6 and 12 (EOS) months off-treatment. Home Healthcare visits may 
be available at Months 1, 2, and 5 for sites with IRB/EC approval to conduct Home 
Healthcare visits, and qualifying subjects who may have difficulty attending clinic visits. (At 
Months 10 and 14 subjects randomized to LAI will return to the clinical site for drug 
dispensation, and AE and concomitant medication assessments). Unscheduled visits will 
occur as needed should subjects’ symptoms worsen between visits.
Confidential

Page 44 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug between Insmed Incorporated and study 
personnel. Information is not to be reproduced, abstracted or used for sharing of information for any other purpose, whatsoever, except with the 
written permission of Insmed Incorporated. 
Figure 3-1 
Study Design 
Confidential

Page 45 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
3.2 
PRIMARY ENDPOINT 
The primary endpoint is the proportion of subjects achieving culture conversion 
(3 consecutive monthly negative sputum cultures) by Month 6 in the LAI arm compared to 
multi-drug regimen alone.
3.3 
SECONDARY ENDPOINTS 
Secondary efficacy endpoints are: 
1. Change in 6MWT distance at Month 6 in the LAI arm compared to multi-drug
regimen alone
2. Proportion of subjects achieving culture conversion with durability at 3 months off
treatment in the LAI arm compared to multi-drug regimen alone
3. Time to culture conversion in the LAI arm compared to multi-drug regimen alone at
Month 6
4. Proportion of subjects achieving culture conversion with sustainability at the EOT in
the LAI arm compared to multi-drug regimen alone
5. Change in 6MWT distance at EOT in the LAI arm compared to multi-drug regimen
alone
6. Change from Baseline (Day 1) at Month 6 in the SGRQ.
3.4 
EXPLORATORY ENDPOINTS 
1. Change in 6MWT distance at Month 6 for converters versus non-converters in LAI
arm
2. Change in 6MWT distance at Month 6 for converters versus non-converters for all
subjects
3. Change in 6MWT distance at Month 6 for converters versus non-converters in the
multi-drug regimen alone arm
4. Change in BMI at Month 6 in LAI arm compared to a multi-drug regimen alone
5. Change in 6MWT distance at Month 8 and 3 months off-treatment in the LAI arm
compared to multi-drug regimen alone
Confidential

Page 46 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission 
of Insmed Incorporated. 
6. Proportion of subjects achieving culture conversion with durability after 12 months
off treatment (EOS) in the LAI arm compared to a multi-drug regimen alone
7. Change from Baseline (Day 1) at Month 6 in the SGRQ – Part 2 (Activities of Daily
Living)
8. Change from Baseline (Day 1) at EOT in the EQ-5D-3L
9. Proportion of subjects who develop a new strain of MAC in the LAI arm compared to
multi-drug regimen alone
10. Radiological changes in CT scan, within a sub-set of subjects, at EOT in the LAI arm
compared to multi-drug regimen alone, where appropriate
11. Mortality at EOS
3.5 
SCHEDULE OF EVENTS 
The schedule of events is presented in Table 3-1.  Detailed procedures and assessments 
performed at each scheduled study visit are presented in Section 6.
Confidential

Page 47 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug between Insmed Incorporated and study 
personnel. Information is not to be reproduced, abstracted or used for sharing of information for any other purpose, whatsoever, except with the 
written permission of Insmed Incorporated. 
 
Table 3-1 
Schedule of Events 
INS-212 
TREATMENT PHASE 
OFF-TREATMENT PHASE 
Screening Baseline Month 
1a 
Month 
2a 
Month 
3 
Month 
4 
Month 
5a 
Month 
6 
Month 
8 
Month 
10 
Month 
12 
Month 
14 
EOT 
up to 
Month 16 
28 Day Safety 
Follow-Up 
3 Month 
Safety 
Follow-Up 
6 Month 
Safety 
Follow-
Up 
EOS  
(12 Month Safety 
Follow-Up) 
(V1) 
(V2) 
(V3) 
(V4) 
(V5) 
(V6) 
(V7) 
(V8) 
(V9) 
(V10) 
(V11) 
(V12) 
(V13) 
(V14) 
(V15) 
(V16) 
(V17) 
Visit Window 
Approxi
mately 
-98 to -70 
(10-14 
weeks)b 
Day 1  
(±3) 
(±3) 
(±3) 
(±3) 
(±3) 
(±3) 
(-28; +7) 
(±5) 
(±5) 
(±5) 
(±5) 
(±5) 
(±7)  
(±7) 
(±7)  
Informed 
consent 
X 
– 
– 
 – 
– 
 – 
– 
 – 
– 
 – 
– 
 – 
– 
– 
– 
 – 
– 
Pregnancy 
testc 
X 
X 
 X 
 X 
 X 
 X 
 X 
 X 
 X 
 – 
 X 
 – 
 X 
– 
– 
 – 
 - 
ECG 
X 
– 
– 
 – 
– 
 – 
– 
 – 
– 
 – 
– 
 – 
X 
– 
– 
 – 
– 
SGRQ 
– 
X 
 – 
– 
X 
 – 
– 
X 
X 
 – 
X 
 – 
X 
– 
X 
 – 
- 
EQ-5D-3L 
– 
X 
 – 
– 
X 
 – 
– 
X 
X 
 – 
X 
 – 
X 
– 
X 
 – 
- 
Medical 
history 
X 
 – 
– 
 – 
– 
 – 
– 
 – 
– 
 – 
– 
 – 
– 
 – 
– 
 – 
Physical 
examination 
X 
X 
X 
X 
X 
X 
 – 
X 
 – 
X 
– 
X 
 – 
X 
Vital signs 
and pulse 
oximetry 
X 
Xd 
Xd 
Xd 
Xd 
Xd 
 – 
Xd 
 – 
X 
– 
X 
 – 
X 
6 minute walk 
teste 
– 
X 
 – 
– 
 – 
X 
 – 
X 
X 
 – 
– 
 – 
X 
– 
 X 
 – 
- 
Confidential

Page 48 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug between Insmed Incorporated and study 
personnel. Information is not to be reproduced, abstracted or used for sharing of information for any other purpose, whatsoever, except with the 
written permission of Insmed Incorporated. 
 
INS-212 
TREATMENT PHASE 
OFF-TREATMENT PHASE 
Screening Baseline Month 
1a 
Month 
2a 
Month 
3 
Month 
4 
Month 
5a 
Month 
6 
Month 
8 
Month 
10 
Month 
12 
Month 
14 
EOT 
up to 
Month 16 
28 Day Safety 
Follow-Up 
3 Month 
Safety 
Follow-Up 
6 Month 
Safety 
Follow-
Up 
EOS  
(12 Month Safety 
Follow-Up) 
(V1) 
(V2) 
(V3) 
(V4) 
(V5) 
(V6) 
(V7) 
(V8) 
(V9) 
(V10) 
(V11) 
(V12) 
(V13) 
(V14) 
(V15) 
(V16) 
(V17) 
Visit Window 
Approxi
mately 
-98 to -70 
(10-14 
weeks)b 
Day 1  
(±3) 
(±3) 
(±3) 
(±3) 
(±3) 
(±3) 
(-28; +7) 
(±5) 
(±5) 
(±5) 
(±5) 
(±5) 
(±7)  
(±7) 
(±7)  
Pulmonary 
Function 
Testsf 
(FEV1[L], 
FEF(25-75%), 
FVC) 
– 
X 
 – 
– 
 – 
– 
– 
X 
 – 
– 
 – 
– 
 – 
– 
 – 
X 
 – 
Audiology 
test 
Xg 
– 
– 
X 
 – 
– 
X 
 – 
– 
X 
 – 
X 
 – 
– 
– 
– 
Concomitant 
medications 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Health Care 
Resource 
Utilization 
– 
X 
X 
X 
X 
X 
X 
X 
X 
– 
X 
– 
X 
 – 
– 
– 
– 
AE 
assessment 
– 
Xh 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Sputum 
collection for 
microbiology 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 – 
X 
 – 
X 
X 
X 
X 
X 
Chemistry 
X 
X 
X 
 – 
X 
 – 
– 
X 
X 
 – 
X 
 – 
X 
 – 
– 
 – 
– 
Hematology 
X 
X 
X 
 – 
X 
 – 
– 
X 
X 
 – 
X 
 – 
X 
 – 
– 
 – 
– 
Urinalysis 
X 
X 
X 
 – 
X 
 – 
– 
X 
X 
 – 
X 
 – 
X 
 – 
– 
 – 
– 
Confidential

Page 49 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug between Insmed Incorporated and study 
personnel. Information is not to be reproduced, abstracted or used for sharing of information for any other purpose, whatsoever, except with the 
written permission of Insmed Incorporated. 
 
INS-212 
TREATMENT PHASE 
OFF-TREATMENT PHASE 
Screening Baseline Month 
1a 
Month 
2a 
Month 
3 
Month 
4 
Month 
5a 
Month 
6 
Month 
8 
Month 
10 
Month 
12 
Month 
14 
EOT 
up to 
Month 16 
28 Day Safety 
Follow-Up 
3 Month 
Safety 
Follow-Up 
6 Month 
Safety 
Follow-
Up 
EOS  
(12 Month Safety 
Follow-Up) 
(V1) 
(V2) 
(V3) 
(V4) 
(V5) 
(V6) 
(V7) 
(V8) 
(V9) 
(V10) 
(V11) 
(V12) 
(V13) 
(V14) 
(V15) 
(V16) 
(V17) 
Visit Window 
Approxi
mately 
-98 to -70 
(10-14 
weeks)b 
Day 1  
(±3) 
(±3) 
(±3) 
(±3) 
(±3) 
(±3) 
(-28; +7) 
(±5) 
(±5) 
(±5) 
(±5) 
(±5) 
(±7)  
(±7) 
(±7)  
Serum for 
Biomarkers 
(CRP and 
IL-6) 
 – 
X 
 – 
– 
 – 
– 
 – 
X 
 – 
– 
 – 
– 
X 
 – 
– 
 – 
– 
Sub-Study: 
CT scan of 
chesti 
– 
X 
– 
– 
 – 
– 
 – 
– 
 – 
– 
 – 
– 
X 
 – 
– 
– 
– 
Sub-Study: 
CT scan of 
chest (Japan) 
See APPENDIX 5: JAPAN SPECIFIC CT SCAN SUB-STUDY 
Sub-Set: 
Population 
PK samplingj 
(blood and 
sputum) 
– 
– 
X 
 – 
X 
 – 
– 
X 
 – 
– 
 – 
– 
 – 
– 
 – 
– 
 – 
Sub-Set: 
Sputum only 
PK Collection 
 – 
X 
 – 
– 
 – 
X 
X 
X 
 – 
– 
 – 
– 
 – 
X 
X 
 – 
– 
Sub-Study: 
Comprehensi
ve PK 
samplingk 
(Japan) 
 X 
X 
 – 
X 
 – 
– 
X 
 – 
– 
 – 
– 
 – 
– 
 – 
– 
 – 
Confidential

Page 50 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug between Insmed Incorporated and study 
personnel. Information is not to be reproduced, abstracted or used for sharing of information for any other purpose, whatsoever, except with the 
written permission of Insmed Incorporated. 
 
INS-212 
TREATMENT PHASE 
OFF-TREATMENT PHASE 
Screening Baseline Month 
1a 
Month 
2a 
Month 
3 
Month 
4 
Month 
5a 
Month 
6 
Month 
8 
Month 
10 
Month 
12 
Month 
14 
EOT 
up to 
Month 16 
28 Day Safety 
Follow-Up 
3 Month 
Safety 
Follow-Up 
6 Month 
Safety 
Follow-
Up 
EOS  
(12 Month Safety 
Follow-Up) 
(V1) 
(V2) 
(V3) 
(V4) 
(V5) 
(V6) 
(V7) 
(V8) 
(V9) 
(V10) 
(V11) 
(V12) 
(V13) 
(V14) 
(V15) 
(V16) 
(V17) 
Visit Window 
Approxi
mately 
-98 to -70 
(10-14 
weeks)b 
Day 1  
(±3) 
(±3) 
(±3) 
(±3) 
(±3) 
(±3) 
(-28; +7) 
(±5) 
(±5) 
(±5) 
(±5) 
(±5) 
(±7)  
(±7) 
(±7)  
Send sputum 
collection 
containers 
home 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 – 
X 
 – 
X 
X 
X 
X 
 – 
Administer 
study drug at 
site 
– 
X 
X 
X 
X 
X 
X 
X 
X 
– 
X 
– 
– 
 – 
– 
 – 
Dispense 
study drugl 
– 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 – 
– 
 – 
– 
 – 
Collection of 
study drug 
vials 
– 
– 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 – 
– 
 – 
– 
Start consent 
process for 
INS-312 
Xm 
Confidential

Page 51 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug between Insmed Incorporated and study 
personnel. Information is not to be reproduced, abstracted or used for sharing of information for any other purpose, whatsoever, except with the 
written permission of Insmed Incorporated. 
 
Note:  At visits where study drug is administered, all patient-reported outcomes, 6MWT, Physical Exam should be performed before study drug administration. 
Note:  Culture conversion is defined to occur when the first of 3 consecutive monthly sputum cultures are MAC negative. All NTM treatment will stop when a subject has completed 
12 months of treatment starting from their first of 3 negative cultures when they were defined as a ‘converter’. 
Abbreviations:  AE, adverse event; CRP, C-reactive protein; CT, computed tomography; ECG, electrocardiogram; EOS, End of Study; EOT, End of Treatment; ED-5D-3L, EuroQol 5D; 
FEF(25-75%), forced expiratory flow at 25-75% of FVC; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; PK, pharmacokinetic; SGRQ, St. George’s Respiratory 
Questionnaire. 
a Home Healthcare visits may be available for sites with IRB/EC approval to conduct Home Healthcare visits, and for qualifying subjects who may have difficulty attending clinic 
visits. 
b The Screening window allows time for sputum culture results, minimum inhibitory concentration (MIC) determination, and scheduling of Screening assessments. Any delay in 
obtaining microbiological results and MICs must be reported to the Sponsor immediately and documented within the study source documents. In the event that sputum culture results 
are not known by 8 weeks (Day -14), the Baseline (Day 1) visit should be scheduled as soon as possible in order to maintain the Screening window, and an extension of the Screening 
window to 14 weeks is allowed, if necessary. If sputum culture results are known prior to 8 weeks (Day -14), the Screening window of 10 weeks must be maintained. 
c Serum pregnancy testing will be performed on women of child bearing potential at Screening.  A urine pregnancy will test will be performed on women of child bearing potential at 
all other visits. Women not of child bearing potential are defined as postmenopausal (i.e., amenorrheic for at least 1 year), or surgically or naturally sterile. 
d Vital signs and pulse oximetry will be assessed both before and after dosing on visits where study drug is administered.  
e The 6MWT must be conducted by a site member who is blinded to the subject’s open-label treatment assignment. 
f The PFTs will be performed at sites with access to spirometers and trained personnel to perform spirometry tests. See Section 7.2.4.  
g   The Baseline audiology examination must be performed during Screening period or on Day 1 before study drug administration. 
h At Baseline (Day 1), AEs will be assessed only after study drug administration or first dose of multi-drug regimen. Any AE that has occurred prior to the first dose must be included in 
the subject’s medical history, including any AEs that occur within the Screening period.  
i Only for subjects who agreed to participate in the CT Scan sub-study. A prior chest CT scan may be used as a subject’s Baseline (Day 1) measurement if this CT scan was obtained 
within 6 months from the subject’s Baseline (Day 1) visit. Subjects will have their follow-up chest CT scan at the EOT visit provided the last chest CT scan was not obtained within 
the prior 6 months. High resolution CT scan is preferred, if available. Please refer to APPENDIX 4 for additional details on the CT Scan sub-study.  
j Only for subjects who agreed to participate in the population PK sub-set (US and Japan only). Blood and sputum samples will be collected from 0 to 1 hours before and from 1 to 4 
hours after study drug administration (Section 7.4.1). 
k  Only for Japanese subjects from sites in Japan who agreed to participate in the comprehensive PK sub-study. Please refer to APPENDIX 5 for additional details on the comprehensive 
PK sub-study. 
l
Study drug will be dispensed to all subjects up to and including the Month 6 visit. At Month 8, subjects who are non-converters or experienced a relapse or recurrence after achieving
culture conversion will exit the study at Month 8/EOT visit (Section 3.1, Section 4.6). Subjects who remain in the study after Month 8 will receive study drug for 12 months beginning
from the first of 3 negative cultures that defines culture conversion .
m   If Study INS-312 has been IRB/EC approved, start the ICF consent process at Month 6, in order to provide sufficient time for the subject to make an informed decision 
Confidential

Page 52 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
3.6 
DISCUSSION OF STUDY DESIGN 
3.6.1 Number of Subjects 
The study is designed to enroll enough subjects to ensure at least 261 evaluable subjects reach 
Month 6.  Accounting for discontinuation, it is anticipated that up to approximately 351 
randomized subjects may be required.  An evaluable subject is one who has at least 1 sputum 
culture result at Baseline (Day 1) and for each month through Month 6. 
3.6.2 Study Duration 
This study has an anticipated recruitment period of 18-24 months, with each subject receiving 
treatment in the study for up to 16 months (excluding Screening and observational follow-up).  
Subjects will remain in the study for up to 31 months, approximately 2.5 months for Screening 
plus up to 16 months in the randomized open-label treatment phase plus 12 months in the 
off-treatment phase. 
3.6.3 Premature Termination of Study Site 
For reasonable cause, either an individual Investigator may terminate participation prematurely 
or Insmed may terminate this study prematurely.  Written notification of the termination to each 
affected investigational site is required.  Some conditions that may warrant termination include 
the following: 

discovery of an unexpected, significant, or unacceptable risk to the subjects enrolled
in the study

failure of the Investigator to enter study subjects at an acceptable rate

insufficient adherence to protocol requirements (e.g., noncompliance) by the subject
and/or the study site

decision on the part of the Sponsor to suspend or discontinue development of the drug

decision by a regulatory authority or the Sponsor to stop the study at any time, where
applicable
Confidential

Page 53 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
In the event of study discontinuation, subjects will discontinue the investigational treatments. 
Refer to Section 5.12.1 for follow-up procedures. 
The Sponsor will notify the regulatory authorities in all countries where the study is being 
conducted regarding the reason for terminating the study. 
3.6.4 Assignment to Study Drug 
Eligible subjects will be stratified at Screening according to smoking status (current smoker or 
not) and prior multi-drug regimen (on treatment or off treatment for at least 3 months) and then 
randomly assigned in a 2:1 ratio to treatment with either LAI (590 mg) QD plus multi-drug 
regimen or to multi-drug regimen alone, using an interactive web response system (IWRS).  
Treatment randomization codes will be generated using SAS®. 
3.6.5 Data Monitoring Committee 
In order to ensure the safety of subjects enrolled in INS-212, Insmed plans to implement a Data 
Monitoring Committee (DMC).  The Committee will consist of experts outside of Insmed who 
are not involved in the study conduct.  The DMC will provide a centralized review function 
independent of Insmed clinical team and all other individuals associated with the conduct of the 
study.  The DMC will be comprised of at least two physicians with pulmonary expertise who are 
not investigators in the clinical study and a statistician who is experienced in the evaluation of 
safety data.  Further details are provided in the DMC charter.  
4 
STUDY POPULATION 
To be eligible for enrollment, subjects must meet all of the following inclusion criteria and none 
of the following exclusion criteria. 
Confidential

Page 54 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
4.1 
INCLUSION CRITERIA 
To be eligible for enrollment, a prospective patient must meet all of the following criteria: 
1. be male or female, 18 years or older (20 years or older in Japan)
2. be positive for MAC on culture as defined in inclusion criterion No. 4 while being treated
with a multi-drug treatment regimen (at least 2 antibiotics) for a minimum duration of
6 consecutive months that is either ongoing or was stopped no more than 12 months
before Screening (exceptions to multi-drug treatment regimen for 6 consecutive months
include treatment with doses or frequencies below those recommended by guidelines
and/or short interruptions of therapy, both occurring due to safety/tolerability issues)
3. be diagnosed with MAC NTM lung infection with evidence of underlying lung disease
such as nodular bronchiectasis and/or fibrocavitary disease by chest radiography or chest
computed tomography. High resolution CT (HRCT) scan is preferred, if available
4. have a MAC lung infection documented by at least 2 positive cultures (MAC or mixed
infection with MAC as the dominant species), consisting of at least one obtained within
6 months prior to Screening and one positive culture at Screening (cultures to be at least 1
month apart).  Cultures may be obtained from sputum or bronchoscopy.
5. have a MAC-positive sputum at Screening
6. be willing to adhere to multi-drug treatment regimen during the course of the study
7. be able to produce approximately 3 mL of sputum or be willing to undergo an induction
that produces approximately 3 mL of sputum for mycobacteriology
8. female of child bearing potential agrees to practice an acceptable method of birth control
(e.g., true abstinence [refraining from heterosexual intercourse during the entire study],
hormonal or barrier methods, partner sterilization, or intrauterine device [IUD]) while
participating in the trial. Periodic abstinence (e.g., calendar, ovulation, symptothermal,
post-ovulation methods), declaration of abstinence for the duration of the study, and
withdrawal are not acceptable methods of contraception.
Confidential

Page 55 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
9. the patient will provide written informed consent before performing any study related
procedure
10. be willing to have serum specimens stored
11. be able to comply with study drug use, study visits, and study procedures as determined
by the investigator.
4.2 
EXCLUSION CRITERIA 
A prospective patient with any of the following conditions must be excluded from this study: 
1. patients with cystic fibrosis
2. patients whose MAC NTM infection is resistant to amikacin (as identified by MIC
susceptibility >64 µg/mL)
3. patients who are not able to perform the 6MWT
4. positive pregnancy test or lactation at Screening.  All women of child bearing potential
will be tested.  Women not of child bearing potential are defined as postmenopausal (i.e.,
amenorrheic for at least 1 year), or surgically or naturally sterile.
5. active pulmonary malignancy (primary or metastatic) or any malignancy requiring
chemotherapy or radiation therapy within 1 year before Screening or anticipated during
the study period
6. active allergic bronchopulmonary mycosis or any other condition requiring chronic
systemic corticosteroids at a dose greater than the equivalent of 10 mg/day of prednisone
within 3 months before Screening
7. active pulmonary tuberculosis requiring treatment at Screening
8. history of lung transplantation
9. initiation of chronic therapy (e.g., high dose ibuprofen, inhaled anti-inflammatory agents
including steroids, low dose maintenance steroids, rhDNase) within 28 days before Day 1
10. administration of any investigational drug within 8 weeks before Screening
Confidential

Page 56 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
11. prior exposure to LAI  (including clinical study)
12. known hypersensitivity to aminoglycosides
13. use of inhaled or systemic aminoglycosides with activity against MAC (e.g., amikacin,
kanamycin, or streptomycin) within 28 days before Day 1
14. acquired and primary immunodeficiency syndromes (e.g. HIV-positive patients
regardless of CD4 counts)
15. significant (as determined by the investigator) hearing loss, vestibular dysfunction,
neuromuscular weakness or a diagnosis of myasthenia gravis, where the potential risk of
aminoglycoside toxicity outweighs the potential benefit
16. aspartate aminotransferase or alanine aminotransferase ≥ 3 times the upper limit of
normal (ULN) or total bilirubin ≥ 2 times ULN at Screening
17. absolute neutrophil count ≤500/μL at Screening
18. serum creatinine >2 times ULN at Screening
19. current alcohol, medication or illicit drug abuse
20. any condition that, in the opinion of the Investigator, interferes with ability to safely
complete the study or adhere to study requirements.
21. persons who have been committed to an institution by virtue of an order issued either by
the judicial or the administrative authorities
22. in the opinion of the Investigator, patients who are not expected to survive the duration of
the study
23. Patients with disseminated MAC infection
Confidential

Page 57 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
4.3 
REMOVAL OF SUBJECTS 
A subject may be withdrawn from the study for any of the following reasons: 
1. the event of the subject’s death
2. the subject experiences an AE and the Investigator or the patient determines that
withdrawal from the study is appropriate
3. a major protocol deviation that interferes with the integrity of the study data for this
subject
4. the subject is noncompliant (does not comply with dosing instructions provided by the
Investigator  or does not comply with the study visit schedule) and the Investigator
determines that withdrawal of the subject is appropriate
5. the subject withdraws consent to participate in the study
6. the site is unable to contact the subject after all reasonable efforts have been exhausted
(Lost to Follow-Up)
7. any condition that, in the judgment of the Investigator, would compromise the ability of
the subject to comply with the study protocol or complete the study
8. any subject who has to have “rescue” medication will be discontinued
A subject may decide to withdraw from the study at any time, for any reason, without prejudice 
to subsequent care or treatment by the Investigator. 
Subjects who discontinue the study prematurely should be assessed in accordance with the 
end-of-treatment visit in Section 6.8 and the follow-up procedures in Section 5.12.1. 
4.4 
RE-SCREENING OF SUBJECTS 
Subjects may be re-screened once, if approved by Sponsor, if the subjects’ Screening culture is 
not positive for MAC or there is a substantial delay (longer than the Screening period) in 
obtaining the results from the microbiology labs. In the event that sputum culture results are not 
known by 8 weeks (Day -14), the Baseline (Day 1) visit should be scheduled as soon as possible 
in order to maintain the Screening window, and an extension of the Screening window to 14 
weeks is allowed, if necessary. If sputum culture results are known prior to 8 weeks (Day -14), 
Confidential

Page 58 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
the Screening window of 10 weeks must be maintained. Subject will only be allowed to be re-
screened only provided that all other entry criteria have been satisfied.  Re-screened subjects will 
be assigned a new subject number within the EDC system. All Screening assessments must be 
repeated when a subject is re-screened. 
4.5 
REPLACEMENT OF SUBJECTS 
Subjects may be replaced to ensure 261 subjects will be evaluable subjects by Month 6. 
4.6 
DEFINITIONS OF CONVERTER AND COMPLETER 
A converter is defined as a subject who has 3 consecutive monthly MAC-negative sputum 
cultures at any time within the first 6 months of the study.  
Relapse or recurrence is defined as having MAC-positive sputum cultures in liquid broth media 
(agar negative) for 3 or more consecutive months, or having 1 MAC-positive sputum culture on 
solid media (agar positive) after achieving culture conversion.  
A non-converter is defined as a subject who does not have 3 consecutive monthly MAC-negative 
sputum cultures at any time within the first 6 months of the study.  
A completer for this study will be defined as follows: 
1. A converter who successfully completes 12 months on the same treatment regimen
beginning from the first of 3 negative cultures that defined conversion and successfully
completes the 12 months off-treatment EOS follow-up visit.
2. A non-converter who successfully completes all dosing and protocol requirements up to
and including the Month 6 study visit.
5 
STUDY TREATMENTS 
5.1 
INVESTIGATIONAL STUDY DRUG 
Liposomal amikacin sulfate is encapsulated in liposomes composed of DPPC and cholesterol 
(2:1 w:w lipid ratio) formulated as a suspension at a targeted concentration equivalent to 70 mg 
Confidential

Page 59 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
amikacin/mL in 10 mL of water for injection (Error! Reference source not found.5-1).  The 
total lipid to drug ratio is 0.57 to 0.77 w:w (weight to weight). 
Table 5-1 
Composition of Liposomal Amikacin Sulfate 
Ingredient 
Quality Grade 
Mg/mL 
Amikacin base (amikacin 
sulfate) 
EP/USP 
70 
Cholesterol 
HPa 
15.7 
Dipalmitoylphosphatidylcholine 
(DPPC) 
In-house 
31.5 
Sodium chloride 
USP/EP/JP 
12 
Sodium hydroxide 
USP/EP/JP 
QS to adjust pH 
Water for injection 
USP/EP/JP 
QS 
Abbreviations:  EP, European Pharmacopeia; HP, High Purity; JP, Japanese Pharmacopeia; NF, National Formulary, USP, 
United States Pharmacopeia. 
a HP grade meets or exceeds all requirements for cholesterol USP/NF/EP. 
5.2 
REFERENCE STUDY DRUG 
None 
5.3 
ADMINISTRATION OF STUDY DRUG 
LAI is administered daily by inhaling drug product that has been aerosolized in an eFlow 
nebulizer over approximately 14 minutes.  Study drug will be administered daily by the subject 
except two days prior to a scheduled study visit when sputum is collected (refer to Section 7.1.1). 
The day of study visit, when sputum is collected, the study drug will be administered at the study 
Confidential

Page 60 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
site by study personnel.  Written directions for preparing and administrating the study drug will 
be provided to subjects. 
Dose Interruption 
If a subject experiences local respiratory events such as, but not limited to, dysphonia, 
oropharyngeal pain, and cough while taking LAI that may be distressing to the subject, short 
interruptions of LAI may be necessary and are permitted. As the frequency of these local 
respiratory events decreased with continued use in prior LAI studies, it is recommended that LAI 
is reintroduced after a short interruption of dosing when symptoms subside. Please contact the 
medical monitor to discuss.  
5.4 
SELECTION OF DOSES 
It is intended that all subjects randomized to the LAI plus multi-drug regimen will receive the 
contents of 1 vial, 590 mg of LAI, of nebulized study drug. 
Subjects who cannot tolerate 590 mg of LAI QD will be discontinued from LAI (with the 
exception of short interruptions as discussed in Section 5.3); the dose of LAI will not be changed 
during the study. 
5.5 
SELECTION OF TIMING OF ADMINISTRATION 
Study drug may be administered QD around the same time each day, any time of day, in the 
fasted or as-fed condition. 
5.6 
BLINDING 
None 
5.7 
STUDY KIT 
Subjects will receive kits containing vials of LAI, the handset/nebulizer, and controller. 
Confidential

Page 61 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
5.8 
DRUG SUPPLY 
The active ingredient, amikacin sulfate, is manufactured in accordance with cGMPs by ACS 
DOBFAR S.p.A. 
5.8.1 Packaging 
LAI is provided as a unit dose consisting of a 10 mL Type I clear borosilicate glass vial with a 
20 mm finish using a closure system consisting of a 20 mm bromobutyl stopper and a 20 mm 
aluminum flip-off tear-off combination seal. 
5.8.2 Labeling 
Vials of study drug will be labeled as shown in APPENDIX 2. 
5.8.3 Storage 
At the site, LAI must be stored at 2ºC to 8ºC (36ºF to 46ºF) in a secured place with restricted 
access.  Do not freeze. 
5.8.4 Compliance and Drug Accountability 
Drug accountability will be recorded at each study visit by count of study drug at each study 
visit. 
A subject will be considered non-compliant with study drug if treatment adherence is less than 
80% or more than 120% unless instructed by the Investigator to interrupt dosing for safety 
reasons (Section 5.3). 
5.8.5 Dispensing of Study Drug 
Study drug (LAI) will be shipped to the study site after the first subject is screened. Patients 
randomized to the LAI treatment will be dispensed adequate study drug at each visit to allow for 
daily dosing, including extra supply for potential study visit scheduling delays. 
Confidential

Page 62 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
5.8.6 Disposition and Reconciliation of Study Drug 
Drug accountability records will be maintained for all clinical supplies.  All transactions will be 
recorded on the drug accountability records including shipment receipts, study subject doses, and 
transfers to other locations within the study site.  All transactions will be recorded on a real-time 
basis. 
The pharmacy will maintain detailed documentation of the number and identification of vials 
with copies of these documents to be provided to the Sponsor at the end of the study.  All used 
and unused boxes of study drug will be maintained by the site until inventoried by the study 
monitor.  Upon completion of the drug inventory by the study monitor, used and any unused 
vials will be disposed of in accordance with instructions provided to sites and according to site 
destruction policies. Documentation of destruction should be provided to the Sponsor. 
Accountability of the PARI eFlow® nebulizer will be maintained and tracked at the site. Subjects 
must return the nebulizers to the study site at the end of treatment.  Additional instructions for 
handling the disposal or return of the devices will be provided to the sites and according to site 
destruction policies. 
5.9 
CONCOMITANT MEDICATIONS 
Throughout the duration of the study, subjects should continue on the same, multi-drug (at least 2 
antibiotics), anti-mycobacterial regimen. The regimen should be based on the 2007 ATS/IDSA 
Guidelines or respective local guidelines, and should not change during the treatment period 
except for safety concerns or if “rescue” anti-mycobacterial therapy is required.  Any subject 
who has to have “rescue” medication will be discontinued. All NTM treatment should stop at the 
EOT visit. No NTM treatment should be given during the safety follow-up period.   
Where allowed, and if approved by IRB/EC, the sponsor will provide reimbursement of the 
multi-drug anti-mycobacterial regimen for as long as the patient participates in the study and is 
adherent to all protocol requirements. These drugs may include, but are not limited to: 
azithromycin, clarithromycin, clofazimine, ethambutol, ethionamide, rifabutin, and rifampicin. 
Confidential

Page 63 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
5.10 PROHIBITED MEDICATIONS 
Subjects are prohibited from using any inhaled antibiotics and any aminoglycosides with activity 
against MAC from 28 days before Day 1, and should not initiate these drugs during the study 
period unless clinically indicated as determined by the Investigator.  If a subject requires an 
inhalational antibiotic for medical management of an acute pulmonary exacerbation secondary to 
Gram-negative bacteria during the study, then LAI should be interrupted during the course of 
that inhaled antibiotic treatment and until the acute event has resolved. Inhaled antibiotics such 
as tobramycin that do not have activity against MAC are permitted. Administration of LAI 
should begin again after the inhaled antibiotic is stopped and the acute event has resolved. 
During the course of an inhaled antibiotic treatment, the subject will remain in the study and 
complete all remaining study visits if possible. Exceptions include treatment with IV amikacin 
(or nebulized IV amikacin solution) and other aminoglycosides with activity against MAC, such 
as streptomycin or kanamycin. Such aminoglycosides for the treatment of NTM lung infection 
will be considered a “rescue” medication. If the Investigator believes that any of the 
aforementioned prohibited medications are necessary they must discuss these with the medical 
monitor and the subject will discontinue study drug and/or the study. Any questions about 
prohibited medications should be discussed with the medical monitor for the study. 
5.11 PRECAUTIONARY MEDICATIONS 
Treatment with oral or IV antibiotics (other than the subject’s stable anti-mycobacterial regimen) 
for acute pulmonary exacerbations or acute infection is allowed as determined by the 
Investigator; the reason for use must be documented in the eCRF (electronic case report form). 
Intra-muscular antibiotics that do not have activity against MAC (see prohibited medications) are 
permitted and must be documented in the eCRF. 
Chronic anti-inflammatory therapy (e.g., high-dose ibuprofen, prednisone ≤ 10 mg/day or the 
equivalent) is permitted if the regimen remains unaltered for at least 28 days preceding Day 1 
and throughout the study.  The doses should not change except for safety reasons or as needed 
for medical management of the subject. 
Although systemic exposure to amikacin is low after LAI administration, precaution should be 
taken if subjects require the following systemic medications that may have possible interactions 
Confidential

Page 64 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
with amikacin: potent diuretics (such as ethacrynic acid and furosemide), beta lactam antibiotics 
(such as penicillins and cephalosporins); bisphosphonates; platinum compounds and thiamine. 
Bronchodilator therapy is allowed. Subjects who develop bronchospasm may be pre-treated with 
a bronchodilator before study drug administration. 
Table 5-2 
List of Examples of Precautionary Medications 
Name of Drug, etc. 
Clinical Symptoms/ 
Treatment 
Mechanism/ Risk Factor(s) 
Potentially nephrotoxic 
blood substitutes such as 
Dextran 
Hydroxyethyl starch, etc. 
Since there is a risk that 
nephrotoxicity occurs or is 
aggravated, concomitant use 
should be avoided. 
When nephrotoxicity occurs, 
discontinue drug and 
implement appropriate 
treatment such as renal 
dialysis, etc. 
The mechanism of action is not 
completely clear but there are 
reports that the combination 
leads to deposits of 
aminoglycoside antibiotics in 
blood and to vacuolization of 
the proximal tubular 
epithelium. 
Loop diuretics 
Ethacrynic acid 
Furosemide 
Azosemide, etc. 
Since both drugs may cause or 
aggravate nephro- and 
ototoxicity, concomitant use 
should be avoided 
The mechanism of action is not 
completely clear but there are 
reports that the combination 
leads to increased blood 
concentration and renal 
deposits of aminoglycoside 
antibiotics 
Nephrotoxic and ototoxic 
drugs such as 
Vancomycin, Enviomycin, 
Platinum-containing anti-
cancer drugs (cisplatin, 
carboplatin, nedaplatin), 
etc. 
Since both drugs may cause or 
aggravate nephro- and 
ototoxicity, concomitant use 
should be avoided 
Both drugs are nephrotoxic/ 
ototoxic but the mechanism of 
action of the interaction is not 
known. 
Confidential

Page 65 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
Anesthetics 
Muscle relaxants 
Tubocurarine 
Pancuronium bromide 
Tolperisone 
Botulinum type A toxin 
products, etc. 
Risk of respiratory 
suppression. If respiratory 
suppression occurs, administer 
choline esterase inhibitor or 
calcium preparation, etc. as 
appropriate. 
Both drugs have a neuro- 
muscular inhibitory effect. 
Concomitant use will aggravate 
this effect. 
Nephrotoxic drugs 
Cyclosporine A 
Amphotericin B, etc. 
Risk that renal impairment 
occurs or is aggravated 
Both drugs are nephrotoxic but 
the mechanism of the 
interaction is not known. 
5.12 DISCONTINUATION OF STUDY DRUG AND/OR STUDY PARTICIPATION 
1. The Investigator may discontinue study drug and/or study participation in the interest of
subject safety.  The Investigator must identify specific AEs (laboratory abnormality,
intercurrent illness, other medical condition or situation) that result in premature
discontinuation of study drug and/or study participation in the eCRF.
2. A subject who withdraws consent to receive study drug may be followed up according to
the protocol visit schedule.  All attempts must be made to conduct an EOT visit
(Section 6.7).
3. Subjects who meet the following criteria established by Hy’s law will be discontinued
from the study:  alanine aminotransferase or aspartate aminotransferase ≥ 3 ULN AND
total bilirubin > 2 ULN.
4. Subjects who need “rescue” medication as described in Section 5.9 will be discontinued.
5. Subjects who become pregnant will be discontinued from the study and followed until the
pregnancy is concluded.
6. Administration of study drug will be discontinued to all subjects seen by an Investigator
who terminates participation in the study prematurely.
Confidential

Page 66 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
7. Administration of study drug will be discontinued to all subjects if the study is
terminated.
The Investigator must contact the medical monitor immediately before discontinuing a subject 
from study drug and/or study participation if possible, or no later than 1 business day after the 
event. When a subject is prematurely discontinued from study drug, the subject will be given the 
option to continue in the study, off study drug, until their Month 8 visit (except for subjects 
enrolled at sites in Japan. All subjects at sites in Japan who discontinue study drug will also 
discontinue study participation). When a subject is prematurely discontinued from study drug 
and/or study participation, the Investigator will clearly document the reason in the medical 
record and complete the appropriate eCRF page describing the reason for discontinuation. If the 
subject completes all study procedures (including those who discontinued study drug but remain 
in the study), up to and including the Month 6 study visit, and sputum results indicate non-
conversion or relapse/recurrence, they will be invited to participate in a separate open-label study 
of LAI (Study INS-312), provided all entry criteria have been met for that study.  Any subject 
who discontinues the study prior to the Month 6 study visit will not be eligible to participate in 
the separate open-label study of LAI (INS-312). 
In the event that a subject is withdrawn from the study treatment because of an AE, the subject 
should be followed and treated by the Investigator until the abnormal parameter or symptom is 
resolved or stabilized.  It is up to the Investigator to determine and document that the AE is either 
resolved or that it has reached a stable state, after which no further follow-up is necessary. 
If a subject fails to complete scheduled assessments in the study, the Investigator must determine 
the reasons and the circumstances as completely and accurately as possible.  “Lost to follow-up” 
should be marked only in an exceptional case when all documented attempts to reach the subject 
by the Investigator or other staff members were unsuccessful. 
5.12.1 Procedures for Discontinuation 
If a subject prematurely discontinues the study prior to the Month 12 (Visit 11) visit (excluding 
subjects enrolling in INS-312), the subject will have: 

EOT visit
Confidential

Page 67 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 

Telephone contact 28 days after the EOT visit for safety follow-up

Telephone contact at Month 12 (time point from Baseline) for safety follow-up (if not
coinciding with the 28 day after EOT telephone contact)

Telephone contact 12 months after the EOT visit for vital status and safety follow-up
If a subject prematurely discontinues the study on or after the Month 12 visit, the subject will 
have: 

EOT visit

Telephone contact 28 days after the EOT visit for safety follow-up

Telephone contact 12 months after the EOT visit for vital status and safety follow-up
If a subject prematurely discontinues the study during the off-treatment phase (after completion 
of 12 months of treatment), the subject will have: 

Telephone contact at the 12 Month Safety Follow-Up visit for vital status and safety
follow-up
Subjects who are part of the sputum PK subset who discontinue LAI at any time point will have 
to return for clinic visits 28 days and 3 months off-LAI for sputum PK and sputum culture 
collection. 
6 
STUDY PROCEDURES 
6.1 
SCREENING VISIT (VISIT 1) 
None of the following procedures or assessments can be made until the subject has provided 
informed consent as documented on the Informed Consent Form (ICF). 
After informed consent has been obtained, all of the following will be performed: 

12-lead ECG (see Section 7.2.5)

obtain medical history (this can be done anytime between Screening and Baseline and
the information will only be entered into the EDC system once a subject has been
enrolled into the study)

administer physical examination, including vital signs and pulse oximetry (see
Section 7.2.2 and Section 7.2.3)
Confidential

Page 68 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 

administer audiology test (may be administered either at the Screening or Baseline
[Day 1] visit, not both; see Section 7.2.9)

soliciting of concomitant medications (see Section 7.2.8) (this can be done anytime
between Screening and Baseline and the information will only be entered into the
EDC system once a subject has been enrolled into the study)

collect sputum specimen for microbiological assessment (see Section 7.1.1)

collect blood or urine specimens for clinical chemistry, hematology, and urinalysis
testing and, for women of child-bearing, a human chorionic gonadotropin (hCG)
pregnancy test (see Section 7.2.7)

dispense sputum collection containers (see Section 7.2.7)

subjects will collect 2 sputum samples at home during the week immediately
following the Screening visit.
6.2 
BASELINE VISIT (DAY 1, VISIT 2) 
All of the following should be performed or obtained within 70 days after Screening unless the 
results of the sputum culture analysis are delayed. In the event that sputum culture results are not 
known by 8 weeks (Day -14), the Baseline (Day 1) visit should be scheduled as soon as possible 
in order to maintain the Screening window, and an extension of the Screening window to 14 
weeks is allowed, if necessary. If sputum culture results are known prior to 8 weeks (Day -14), 
the Screening window of 10 weeks must be maintained. 

administer SGRQ before study drug administration (see Section 7.3.1)

administer EQ-5D-3L before study drug administration (see Section 7.3.2)

collect information on healthcare resource utilization

update medical history

administer physical examination, including vital signs and pulse oximetry. Only vital
signs and pulse oximetry will be assess both before and after study drug
administration(see Section 7.2.2 and Section 7.2.3)

administer 6MWT (see Section 7.2.1)
Confidential

Page 69 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 

administer the pulmonary function test prior to study drug administration (see Section
7.2.4)

administer audiology test (may be administered either at the Screening or Baseline
[Day 1] visit, not both; see Section 7.2.9)

obtain CT chest scan if part of CT Scan Sub-Study and has not been acquired within
6 months before Day 1 (see Section 7.3.4, APPENDIX 4)

obtain CT chest scan if part of Japan specific CT Scan Sub-Study and has not been
acquired within 6 months before Day 1 (see APPENDIX 5)

solicit concomitant medications (see Section 7.2.8)

assess AEs (see Section 8)

collect sputum specimen for microbiological assessment (see Section 7.1.1)

collect sputum specimen for sputum-only PK sub-set analyses (see Section 7.4.1)

collect blood or urine specimens for clinical chemistry, hematology, and urinalysis
testing and, for women of child-bearing, a urine pregnancy test (see Section 7.2.7)

collect blood (serum) specimen for biomarker assessment (CRP and IL-6) (see
Section 7.2.7)

collect blood (serum) and sputum specimens for Comprehensive PK Sub-Study
analysis in Japanese subjects only (see Section 7.4.3 and APPENDIX 3)

dispense sputum collection containers (see Section 7.2.7)

administer study drug at the study site (see Section 5.3)

dispense study drug.
6.3 
VISITS AT MONTHS 1 THROUGH 6 AND 8 (VISITS 3 THROUGH 9) DURING 
THE RANDOMIZED, TREATMENT PHASE 
All of the following should be performed or obtained at Visits 3 through 9, unless noted, within 
3 days of the scheduled visit. For Visits 3 (Month 1), 4 (Month 2), and 7 (Month 5), Home 
Confidential

Page 70 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
Healthcare visits may be available for sites with IRB/EC approval to conduct Home Healthcare 
visits, and for qualifying subjects who may have difficulty attending clinic visits: 

administer SGRQ before study drug administration at the Months 3, 6, and 8 visits
only (see Section 7.3.1)

administer EQ-5D-3L before study drug administration at the Months 3, 6, and
8 visits only (see Section 7.3.2)

collect information on healthcare resource utilization

At Months 2, 4, 6, and 8 only: administer physical examination, including vital signs
and pulse oximetry. Vital signs and pulse oximetry will be assessed both before and
after study drug administration (see Section 7.2.2 and Section 7.2.3)

administer 6MWT at the Months 4, 6 and 8 visits only (see Section 7.2.1)

administer the pulmonary function test at Month 6 only prior to study drug
administration (see Section 7.2.4)

administer audiology test at the Months 3 and 6 visits only (see Section 7.2.9)

solicit concomitant medications (see Section 7.2.8)

assess AEs (see Section 8)

collect sputum specimen for microbiological assessment (see Section 7.1.1)

collect blood and urine specimens for clinical chemistry, hematology, and urinalysis
testing at the Months 1, 3, 6, and 8 visits only and, for women of child-bearing, a
urine pregnancy test  at Months 1-6 and 8 (see Section 7.2.7)

collect blood (serum) and sputum specimen for biomarker assessment at the Month 6
visit only (CRP [c-reactive protein] and IL-6 [interleukin 6]) (see Section 7.2.7)

collect blood and sputum specimens for population PK sub-set analyses at the
Months 1, 3, and 6 visits only (see Section 7.4.1)

collect sputum specimens for sputum-only PK sub-set analyses at the Months 4, 5 and
6 visits only, 2 days interruption of LAI dosing (see Section 7.4.1)
Confidential

Page 71 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 

collect blood (serum) and sputum specimens for Comprehensive PK Sub-Study
analysis at the Month 1, 3 and 6 visits for Japanese subjects only (see Section 7.4.3
and APPENDIX 3)

(Japan only) at Month 6 obtain CT chest scan as part of Japan specific CT Scan Sub-
Study (see APPENDIX 4)

dispense sputum collection containers (see Section 7.2.7)

administer study drug at the study site (see Section 5.3)

dispense study drug

collect previously dispensed study drug vials from subject.
Beginning with Month 3 and extending throughout the study, subjects will be assessed for 
culture conversion by the central microbiology laboratory (Section 3.1).  Beginning with 
Month 4, relapse or recurrence will be assessed by the central microbiology laboratory (Section 
3.1).   
6.4 
MONTH 10 (VISIT 10) DURING THE RANDOMIZED, TREATMENT PHASE 
All of the following should be performed or obtained within 5 days of the scheduled visit: 

solicit concomitant medications (see Section 7.2.8)

assess AEs (see Section 8)

dispense study drug

collect previously dispensed study drug vials from subject.
For subjects who were randomized to the multi-drug regimen only arm, this visit may take place 
as a telephone contact as no drug dispensation will be performed. 
6.5 
MONTH 12 (VISIT 11) DURING THE RANDOMIZED, TREATMENT PHASE 
All of the following should be performed or obtained within 5 days of the scheduled visit: 
Confidential

Page 72 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 

administer SGRQ before study drug administration (see Section 7.3.1)

administer EQ-5D-3L before study drug administration (see Section 7.3.2)

collect information on healthcare resource utilization

administer physical examination, including vital signs and pulse oximetry. Only vital
signs and pulse oximetry will be assessed both before and after study drug
administration (see Section 7.2.2 and Section 7.2.3)

administer audiology test (see Section 7.2.9)

solicit concomitant medications (see Section 7.2.8)

assess AEs (see Section 8)

collect sputum specimen for microbiological assessment (see Section 7.1.1)

collect blood and urine specimens for clinical chemistry, hematology, and urinalysis
testing and, for women of child-bearing, a urine pregnancy test (see Section 7.2.7)

(Japan only) obtain CT chest scan as part of Japan specific CT Scan Sub-Study (see
APPENDIX 4)

dispense sputum collection containers (see Section 7.2.7)

administer study drug at the study site (see Section 5.3)

dispense study drug

collect previously dispensed study drug vials from subject.
6.6 
MONTH 14 (VISIT 12) DURING THE RANDOMIZED, TREATMENT PHASE 
All of the following should be performed or obtained within 5 days of the scheduled visit: 

solicit concomitant medications (see Section 7.2.8)

assess AEs (see Section 8)

dispense study drug

collect previously dispensed study drug vials from subject.
Confidential

Page 73 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
For subjects who were randomized to the multi-drug regimen only arm, this visit may take place 
as a telephone contact as no drug dispensation will be performed. 
6.7 
END OF TREATMENT – UP TO MONTH 16 (VISIT 13) DURING THE 
RANDOMIZED, TREATMENT PHASE 
All of the following should be performed or obtained within 5 days of the scheduled visit: 

obtain 12-lead ECG (see Section 7.2.5)

administer SGRQ (see Section 7.3.1)

administer EQ-5D-3L (see Section 7.3.2)

collect information on healthcare resource utilization

administer physical examination, including vital signs and pulse oximetry. (see
Section 7.2.2 and Section 7.2.3)

administer 6MWT (see Section 7.2.1)

administer audiology test (see Section 7.2.9)

obtain CT chest scan if part of CT Scan Sub-Study and no less than 6 months have
elapsed since the previous CT scan was performed (see Section 7.3.4, APPENDIX 4)

(Japan only) at Month 16, obtain CT chest scan as part of Japan specific CT Scan
Sub-Study (see APPENDIX 45)

solicit concomitant medications (see Section 7.2.8)

assess AEs (see Section 8)

collect sputum specimen for microbiological assessment (see Section 7.1.1)

collect blood and urine specimens for clinical chemistry, hematology, and urinalysis
testing and, for women of child-bearing, a urine pregnancy test (see Section 7.2.7)

collect blood (serum) specimen for biomarker assessment (CRP and IL-6) (see
Section 7.2.7)

dispense sputum collection containers (see Section 7.2.7)

collect previously dispensed study drug vials from subject
Confidential

Page 74 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
For subjects who do not convert, the last visit will occur no later than at the Month 8 visit.  For 
subjects who do convert, the last visit will be at the visit corresponding to 12 months following 
their conversion dates. All subjects who discontinue study drug early should have all procedures 
listed in the end of treatment (EOT) visit performed, with the exception of the chest CT scan.  A 
chest CT scan should only be performed if the subject is participating in the CT scan sub-study 
but only if 6 months or more have elapsed since the subject’s last CT scan has been performed. 
Please refer to APPENDIX 5 for Japan specific CT Scan Sub-Study study procedures and study 
schedule. High resolution CT scan is preferred, if available. 
6.8 
OFF-TREATMENT SAFETY FOLLOW-UP VISITS (VISIT 14, 15, AND 16) 
DURING THE OFF-TREATMENT PHASE FOR SUBJECTS WHO COMPLETE 12 
MONTHS OF TREATMENT 
Visit 14 (28 day off-treatment safety follow-up) 
For any subject who completes treatment, all of the following should be performed or obtained 
within 5 days of the 28 day safety follow-up scheduled visit: 

solicit concomitant medications (see Section 7.2.8)

assess AEs (see Section 8)

dispense sputum collection containers (see Section 7.2.7)

collect sputum specimen for microbiological assessment (see Section 7.1.1)

collect sputum specimen for sputum-only PK assessment (see Section 7.4.1)
Visits 15 and 16 (3 and 6 months off-treatment safety follow-up) 
All of the following should be performed or obtained within 7 days of the scheduled visit: 

administer SGRQ at the 3 month safety follow-up only (see Section 7.3.1)

administer EQ-5D-3L at the 3 month safety follow-up only (see Section 7.3.2)

administer physical examination, including vital signs and pulse oximetry at the 3
month safety follow-up only (see Section 7.2.2 and Section 7.2.3)
Confidential

Page 75 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 

administer 6MWT at the 3 month safety follow-up only (see Section 7.2.1)

administer the pulmonary function test at the 6 month safety follow-up only (see
Section 7.2.4)

solicit concomitant medications (see Section 7.2.8)

assess AEs (see Section 8)

dispense sputum collection containers (see Section 7.2.7)

collect sputum specimen for microbiological assessment (see Section 7.1.1)

collect sputum specimen for sputum-only PK assessment for the 3 month safety
follow-up off-LAI only (see Section 7.4.1)
6.9 
END OF STUDY -12 MONTHS OFF-TREATMENT (VISIT 17) 
All of the following should be performed or obtained within 7 days of the scheduled visit: 

administer physical examination, including vital signs and pulse oximetry (see
Section 7.2.2 and Section 7.2.3)

solicit concomitant medications (see Section 7.2.8)

assess AEs (see Section 8)

collect sputum specimen for microbiological assessment (see Section 7.1.1)
The EOS visit is scheduled to occur 12 months after EOT and is for all subjects who complete 12 
months of treatment from their first of 3 negative cultures that classified them as a converter. 
7 
STUDY VARIABLES AND METHODS OF ASSESSMENT 
7.1 
PRIMARY ENDPOINT VARIABLES 
7.1.1 Sputum Collection, Transport, and Assessment 
Pre-dose expectorated or induced sputum specimens (approximately 3 mL) are required at 
Screening, Day 1, at Months 1 through 6, at Months 8 and 12, at EOT, at the 28 day, the 3, 6, and 
12 months off-treatment visits.  To improve the probability of obtaining a good sputum 
specimen, at least 2 and preferably 3 sputum samples will be obtained from each subject at each 
Confidential

Page 76 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
assessment.  If a subject is unable to produce sputum spontaneously, one induced sputum 
specimen at the site will be acceptable.  With the exception of the Screening samples (collected 
during the week following the Screening visit), each sputum sample will be collected on 
consecutive days prior to a scheduled visit.  Subjects will refrain from administering LAI on the 
days sputum is obtained, starting 2 days prior to the scheduled visit, even if a spontaneous 
sputum cannot be obtained by the subject at home.  At the scheduled visit, once sputum is 
collected (spontaneously or by induction), the administration of LAI can recommence.  Sites are 
encouraged to notify subjects by telephone of this procedure 3 days prior to their scheduled visit.  
If a subject is unable to produce sputum independently, sputum may be induced as described in 
APPENDIX 1, if these suggestions are safe for the subject. If a subject is still unable to produce 
sputum despite reasonable efforts, and they have already met the definition of converter, this will 
be recorded as a negative culture result at that time point. 
Sterile, leak proof, non-wax, disposable plastic containers labeled with 2 subject identifiers will 
be used to collect specimens aseptically to avoid contamination.  Sputum samples should be 
refrigerated, not frozen, until shipped to the central microbiology lab within 2 days of collection 
to avoid overgrowth by contaminating normal flora.  No fixative or preservatives are to be used 
with sputum samples.  Detailed instructions for collecting, processing, and shipping sputum 
specimens will be provided in the site laboratory manual. 
Sites are strongly discouraged from performing local mycobacterium sputum cultures for the 
duration of the study, as this may introduce bias to subject assessments. Sputum may be sent to 
local laboratories to be cultured for organisms other than mycobacterium. 
7.1.2 Microbiological Assessment 
Sputum specimens will be cultured in liquid media in addition to solid media (agar).  If results 
are negative on agar, the liquid media will be held for 6 weeks before reporting as culture 
negative. 
Standard antibiotic sensitivity testing using MICs will be routinely performed on bacterial 
isolates (Clinical and Laboratory Standards Institute [CLSI] M48-A and NCCLS M24-A) 
Confidential

Page 77 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
(Forbes 2008).  All mycobacterial isolates will be banked for subsequent determination of 
amikacin susceptibility and selective molecular typing (Prammananan, et al.  1998). 
Isolates of MAC will be identified to complex, using a commercial RNA probe (AccuProbe, Gen 
Probe, Inc.) and subsequently identified to species (M. avium, M. intracellulare, MAC “X” 
group) using molecular methodology (Cousins, et al.  1996). 
7.2 
SECONDARY ENDPOINT VARIABLES 
7.2.1 Six-minute Walk Test 
7.2.1.1 Methodology 
A 6MWT of exertional capability will be performed at Baseline (Day 1) and at Months 4, 6, 8 
and at EOT and 3 months off-treatment according to ATS guidelines 
(http://ajrccm.atsjournals.org/cgi/content/full/166/1/111).  Overall fatigue and dyspnea (Borg 
scale) will be measured before and after subjects walk a prescribed course as far as they can in 
6 minutes. 
7.2.1.2 Assessment 
The 6MWT must be conducted by a site member who is blinded to the subject’s open-label 
treatment assignment. The maximum distance achieved will be recorded in the eCRF. 
7.2.2 Physical Examination 
7.2.2.1 Methodology 
A physical examination of the head (external), eyes, ears, nose and throat, lungs, cardiovascular 
system, abdomen, musculoskeletal system, skin, lymph nodes, central nervous system, and, as 
appropriate, other body systems will be performed before the administration of study drug at 
every scheduled visit except at Months 1, 3, 5, 10, 14, at 28 days and 6 months off-treatment.  
The physical examination will also include weight; the measurement of height, without shoes, 
will only be done at Screening.  All significant findings must be recorded in the eCRF as 
described below. 
Confidential

Page 78 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
7.2.2.2 Assessment 
Significant findings at Baseline (Day 1) and any changes from Baseline (Day 1) prior to first 
dose of LAI or multi-drug regimen at Day 1 must be recorded in the Medical History/Current 
Medical Conditions pages of the eCRF.  Significant findings made after the Baseline (Day 1) 
visit that meet the definition of an AE must be recorded on the Adverse Event page of the eCRF. 
7.2.3 Vital Signs 
7.2.3.1 Methodology 
Five-minute sitting blood pressure, pulse rate, body temperature, respiratory rate, and oxygen 
saturation will be recorded in the eCRF at every scheduled visit except at Months 1, 3, 5, 10, 14, 
at 28 days and 6 months off-treatment.   
At visits when the 6MWT is administered (at Baseline [Day 1], at Months 4, 6, and 8 and at EOT 
and 3 months off-treatment) vital signs will be measured before and after subjects walk a 
prescribed course as far as they can in 6 minutes.   
7.2.3.2 Assessment 
Significant findings observed at any time after the first dose of LAI or multi-drug regimen that 
meet the definition of an AE must be recorded on the Adverse Event page of the eCRF. 
7.2.4 Pulmonary Function Tests 
Pulmonary function tests (FEV1[L], FEF(25-75%), FVC) will be performed at sites with access to 
spirometers and trained personnel to perform spirometry at Baseline (Day 1), Month 6 for all 
subjects and at the 6-months off-treatment visit only for subjects completing LAI treatment. All 
subjects undergoing PFTs should be optimally treated for their underlying lung disease before 
these assessments are performed.  Additionally, for subjects randomized to the LAI plus multi-
drug regimen arm they will be performed prior to the administration of LAI. If necessary, per the 
discretion of the Investigator, subjects randomized to LAI may have pre- and post-dose PFTs 
performed to determine the degree of sub-clinical bronchospasm and airway obstruction so 
Confidential

Page 79 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
appropriate management can be commenced prior to LAI dosing. . More information will be 
provided in a separate manual provided by the Sponsor. 
7.2.4.1 Assessment 
The pulmonary function parameters of forced expiratory volume in 1 second (FEV1[L]), forced 
expiratory flow rate during mid portion of expiration (FEF(25-75%)) and forced vital capacity (FVC) 
based on local assessments will be recorded on the specific page within the eCRF. Any clinically 
significant findings observed must be recorded on the Adverse Event page of the eCRF. 
7.2.5 12-lead Electrocardiogram 
7.2.5.1 Methodology 
An ECG will be recorded at Screening and EOT. 
7.2.5.2 Assessment 
The Screening ECG will be considered as Baseline. The date and interpretation (Normal; 
Abnormal – not clinically significant; Abnormal – clinically significant) must be recorded within 
the ECG page of the eCRF.  Any abnormal – clinically significant findings at Baseline (Day 1) 
and any changes from Baseline (Day 1) prior to first dose of LAI or multi-drug regimen at Day 1 
must be recorded in the Medical History/Current Medical Conditions pages of the eCRF.  Any 
abnormal – clinically significant findings made after the Baseline (Day 1) visit that meet the 
definition of an AE must be recorded on the Adverse Event page of the eCRF. 
7.2.6 Adverse Events 
7.2.6.1 Methodology 
AEs will be identified at every contact with a subject throughout the study period beginning with 
Day 1 and after first dose of LAI or multi-drug regimen by direct observation, from assessments 
of safety parameters, and by asking open-ended, non-leading questions such as “How have you 
felt since your last visit?”  See Section 8 for definitions and a fuller description of the assessment 
Confidential

Page 80 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
and reporting requirements of AEs.  Any AE that is observed prior to first dose of LAI or multi-
drug regimen will be classified as medical history. 
7.2.6.2 Assessment 
All AEs will be recorded on the Adverse Event page of the eCRF.  Attempts will be made to 
determine the start and stop dates of the event, the intensity, causality, treatment, and outcome of 
the event. Any AE that is observed prior to first dose of LAI or multi-drug regimen must be 
recorded on the Medical History page of the eCRF. 
7.2.7 Clinical Laboratory Evaluations 
The following clinical chemistry, hematology, and urine parameters comprise the clinical 
laboratory evaluations: 
Clinical 
chemistry 
Sodium, chloride, potassium, bicarbonate (CO2), magnesium, calcium, glucose, 
phosphate, total bilirubin (with direct and indirect fractionation, if total bilirubin 
is elevated >2 ULN), alkaline phosphatase, lactate dehydrogenase (LDH), 
aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, 
total protein, creatinine, urea-nitrogen, uric acid, estimated glomerular filtration 
rate from the Cockroft-Gault method, and, at Screening only, human chorionic 
gonadotropin (hCG) pregnancy test for women of child-bearing potential 
Hematology Hemoglobin, erythrocytes, hematocrit, mean corpuscular hemoglobin (MCH), 
mean corpuscular volume (MCV), mean corpuscular hemoglobin concentration 
(MCHC), leukocytes, differential blood count of neutrophils, eosinophils, 
basophils, monocytes, lymphocytes, and platelets.  
Urinalysis 
Qualitative analysis of glucose, ketones, nitrites, protein, pH, leukocytes, blood, 
bilirubin, specific gravity; microscopic examination for cells, casts, and bacteria 
Urine pregnancy test for women of child-bearing potential.  Performed at the site 
and results will be entered into the eCRF 
Confidential

Page 81 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
Other  
Biomarkers     CRP and IL-6 
Assessments made only before the first administration of study drug are not considered safety 
parameters. 
7.2.7.1 Methodology 
Blood samples will be drawn with a minimum number of needle insertions to determine clinical 
chemistry and hematology parameters at Screening, and before administering study drug on 
Day 1, at Months 1, 3, 6, 8, and 12, and at EOT.  Lab values that meet exclusionary criteria based 
on results from the central laboratory may be repeated at the Investigator’s discretion and sent to 
the central laboratory provided that the re-evaluation is completed within the protocol defined 
Screening period and can only be repeated once.  Only those labs that need to be re-evaluated 
should be performed as an unscheduled visit, not the entire laboratory panel.  Details for 
collecting, handling, storing, and transporting blood samples will be provided in the site 
laboratory manual. 
Urine samples will be collected at the same times as blood is drawn. 
7.2.7.2 Assessment 
Clinical chemistry and hematology analyses will be performed by a central laboratory; 
qualitative urinalyses will be performed by a central laboratory, and evaluated microscopically 
for cells, casts, and bacteria.   
7.2.8 Concomitant Medications 
The dosage of all concomitant medications should be recorded on the eCRF at every contact with 
a subject throughout the study period beginning with Day 1. 
Confidential

Page 82 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
7.2.9 Audiology 
7.2.9.1 Methodology 
Audiology testing will be performed either at Screening or before administration of study drug at 
Baseline (Day 1), before study drug administration at Months 3, 6 and 12, and the end of 
treatment visit.  Frequencies of 250, 500, 1000, 2000, 4000, and 8000 Hz will be evaluated for 
each ear using air conduction.  If post-Baseline (Day 1) audiometry findings are an AE Grade 
2 or higher (according to the Common Terminology Criteria for Adverse Events [CTCAE] 
Version 4.0 guideline), an additional audiometric evaluation should be conducted at the next 
scheduled visit. 
7.2.9.2 Assessment 
Significant Baseline (Day 1) findings and all post-Baseline (Day 1) findings (including hearing 
loss of a CTCAE Grade 2 or higher) prior to first dose of LAI or multi-drug regimen on Day 1 
must be recorded on the medical history page of the eCRF.  Significant findings that meet the 
definition of an AE (including hearing loss of a CTCAE Grade 2 or higher) must be recorded on 
the AE page of the eCRF. 
7.3 
EXPLORATORY ENDPOINT VARIABLES 
7.3.1 St. George’s Respiratory Questionnaire 
7.3.1.1 Methodology 
The SGRQ is a self-administered questionnaire that has been validated in subjects with airways 
disease, specifically in subjects with BR (Jones 1991; Jones, et al.  1991; Wilson, et al.  1997). 
The SGRQ assesses health-related quality of life in subjects with chronic pulmonary disease by 
evaluating 3 health domains:  symptoms (distress caused by respiratory symptoms); activity 
(effects of disturbances to mobility and physical activity); and impacts (the effect of disease on 
factors such as employment, personal control of one’s health, and need for medication).  The 
SGRQ will be completed before administration of study drug on Day 1, at Months 3, 6, 8, and 
12, and at EOT and 3 months off-treatment. 
Confidential

Page 83 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
7.3.1.2 Assessment 
A composite total score is derived as the sum of domain scores for symptoms, activity, and 
impact, with 0 the best possible score and 100 the worst possible score.  A reduction in score of 
4 units is generally recognized as a clinically meaningful improvement in quality of life. 
7.3.2 EQ-5D-3L 
7.3.2.1 Methodology 
The EQ-5D-3L, is a preference-based, (multi-attribute) generic health-status classification 
instrument that generates a composite score reflecting the preference value associated with a 
given heath state.  The system has 5 dimensions:  mobility, self-care, usual activities, 
pain/discomfort, and anxiety/depression.  Each dimension has 3 levels:  no health problems, 
moderate health problems, and extreme health problems.  Current general health is also scored 
using a visual analog scale.  The EQ-5D-3L (Version 1.0 - 01Oct2014) will be completed before 
administration of study drug on Day 1, at Months 3, 6, 8, and 12, and at EOT and 3 months off-
treatment. 
7.3.2.2 Assessment 
The health state is reported with a 5-digit descriptor ranging from 11111, representing the best 
case, to 33333, representing the worst case. The score for each domain of the EQ-5D-3L will be 
reported in the eCRF. 
7.3.3 Identification of New or Different MAC Strains 
7.3.3.1 Methodology 
In subjects who convert (i.e., who have 3 consecutive monthly negative MAC sputum cultures) 
and who subsequently have a positive MAC sputum culture, analyses will be conducted to 
confirm whether the positive MAC culture is due to a different MAC species or strain acquired 
by the subject, or due to a relapse of the same MAC species or strain as observed at Baseline 
(Day 1). The MAC species will be identified by sequencing the gene for the 16S rRNA subunit. 
Confidential

Page 84 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
If the MAC isolates identified after conversion are a different species, it will be determined that 
the subject acquired a different MAC species, rather than having a relapse.  If the same species 
as seen at Baseline (Day 1) is observed, then DNA fingerprinting (based on a variable number of 
tandem repeat) will be conducted to identify the strain to determine whether the subject has 
acquired a different MAC strain.  
7.3.3.2 Assessment 
Different species or strains of MAC than those that are identified post Baseline (Day 1) after 
culture conversion will be recorded in source data.  
7.3.4 Computed Tomography Scan of Chest 
Chest CT scans will be evaluated as part of the chest CT Scan Sub-Study at sites that are willing 
and have been approved for the sub-study. The objective this sub-study will be to compare 
assessments of the chest CT scans, read by a trained medical professional, from Baseline (Day 1) 
to the (EOT) visit (±14 days) provided a chest CT scan was not obtained within the prior 6 
months.  High resolution CT scan is preferred, if available. Details regarding the chest CT Scan 
Sub-Study are described in APPENDIX 4. Details of the Japan specific CT Scan Sub-Study are 
described in APPENDIX 5. 
7.3.5 All-cause Mortality 
7.3.5.1 Methodology 
Study staff will make every effort to determine the vital status of subjects who do not complete 
the EOS visit. 
7.3.5.2 Assessment 
The cause of death, if available, for subjects that do not survive 12 months beyond EOT or early 
discontinue during the study will be recorded in the eCRF. 
Confidential

Page 85 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
7.4 
PHARMACOKINETICS 
7.4.1 Methodology 
Population PK Sub-Set (US and Japan Only): Blood and sputum samples will be collected to 
determine amikacin concentrations, one from 0 to 1 hour before and one from 1 to 4 hours after 
study drug administration at Months 1, 3, and 6 in at least 16 evaluable US subjects randomized 
to the LAI treatment arm at pre-selected sites.  In addition, at least 8 evaluable Japanese subjects 
randomized to the LAI treatment arm will participate in the population PK assessment.    
Sputum-Only PK Sub-Set: An additional sub-set of subjects in the LAI added to a multi-drug 
regimen arm (at least 60 subjects) will have sputum samples collected to assess residual 
amikacin concentration in sputum after interrupting/stopping LAI treatment at the various 
different time points: Baseline, Months 4, 5 and 6 (2 days interruption of LAI dosing), 28 days 
and 3 months off-treatment. 
All samples will be stored at or below –20°C before shipping to a central PK laboratory.  Details 
for collecting, handling, storing, and transporting blood and sputum samples for PK analyses will 
be provided in the site laboratory manual. 
7.4.2 Sample Collection 
All sample handling procedures, including the date and time of each sample collection will be 
documented in the eCRF. The time of placement into storage (at the end of the sample work-up), 
and the date of transfer or shipment of the samples to the responsible analyst will be collected in 
the source documents. . 
7.4.3 Comprehensive Pharmacokinetic Sub-Study (Japanese sites only) 
PK of LAI in serum and sputum will be determined at pre-defined time points for the first 6 
months in at least 8 evaluable Japanese subjects who have been randomized to the LAI plus a 
multi-drug regimen arm. The objectives will be to characterize the PK, including bioavailability, 
and systemic exposure of LAI, compare to historical population PK results, and to evaluate the 
Confidential

Page 86 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
concentration of LAI in the sputum for Japanese subjects with NTM lung disease. Refer to 
APPENDIX 3 
Confidential

Page 87 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
COMPREHENSIVE PHARMACOKINETIC SUB-STUDY for details. 
7.4.3.1 Comprehensive Pharmacokinetic Sub-Study Sample Collection 
All sample handling procedures, including the date and time of each sample collection. The time 
of placement into storage (at the end of the sample work-up), and the date of transfer or shipment 
of the samples to the responsible analyst will be collected in the source documents. 
7.5 
HEALTH CARE RESOURCE UTILIZATION 
The number of days missed from work, NTM related and non-NTM related visits to healthcare 
providers, Emergency Room (ER) visits, and hospitalizations including days in the hospital, and 
days in Intensive Care Units (ICU) will be captured at every visit except Month 10, 14, and off-
treatment visits. 
7.6 
APPROPRIATENESS OF MEASUREMENTS 
Data will be collected using standard methods, widely used and generally regarded as reliable 
accurate, and relevant. 
8 
ADVERSE EVENTS 
The Investigator is responsible for the detection and documentation of events meeting the criteria 
and definition of an AE or SAE as provided in this protocol. 
8.1 
DEFINITION OF AN ADVERSE EVENT 
Any untoward medical occurrence in a subject or clinical investigation subject administered a 
pharmaceutical product and which does not necessarily have to have a causal relationship with 
this treatment. 
An AE can therefore be any unfavorable and unintended sign (including an abnormal laboratory 
finding, for example), symptom, or disease temporally associated with the use of a medicinal 
product, whether or not considered related to the medicinal product.  
Examples of AEs include one of the following or a combination of 2 or more of these factors: 
Confidential

Page 88 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 

A new sign, symptom, illness, or syndrome

Worsening of a concomitant illness

An effect of investigational product, including comparator or concomitant medication

An effect of an invasive procedure required by the protocol

An accident or injury

Laboratory abnormality that the Investigator considers clinically relevant
Surgical procedures themselves are not AEs; they are therapeutic measures for conditions that 
require surgery.  The condition for which the surgery is required is an AE, if it occurs or is 
detected during the study period.  Surgical measures planned prior to study enrollment are 
permitted by the clinical study protocol and the condition(s) leading to these measures are not 
AEs. 
8.2 
DEFINITION OF A SERIOUS ADVERSE EVENT 
A serious adverse event (experience) or reaction is any untoward medical occurrence that at any 
dose: 

results in death,

is life-threatening,
o
NOTE:  The term "life-threatening" in the definition of "serious" refers to an
event in which the subject was at risk of death at the time of the event; it does
not refer to an event which hypothetically might have caused death if it were
more severe.

requires inpatient hospitalization or prolongation of existing hospitalization,

results in persistent or significant disability/incapacity, or

is a congenital anomaly/birth defect.
Medical and scientific judgment should be exercised in deciding whether expedited reporting is 
appropriate in other situations, such as important medical events that may not be immediately 
life-threatening or result in death or hospitalization but may jeopardize the subject or may require 
Confidential

Page 89 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
intervention to prevent one of the other outcomes listed in the definition above.  These should 
also usually be considered serious. 
Examples of such events are intensive treatment in an emergency room or at home for allergic 
bronchospasm; blood dyscrasias or convulsions that do not result in hospitalization; or 
development of drug dependency or drug abuse.  . The IB serves as the Reference Safety 
Information for the determination of expectedness of AEs. Investigators should reference the 
current IB when assessing the expectedness of adverse reactions for reporting to Health 
Authorities/IRB/Independent or Institutional Ethics Committee (EC)/Investigators. 
8.2.1 Assessment of Intensity 
Each AE will be graded according to CTCAE v4.0, as applicable.  All other laboratory and 
clinical AEs that occur in a subject will be assessed for severity and classified using the 
categories below. 

Grade 1 (Mild):  Event requires minimal or no treatment and does not interfere with
the subject’s daily activities.

Grade 2 (Moderate):  Event results in a low level of inconvenience or concern with
the therapeutic measures.  Moderate events may cause some interference with
functioning.

Grade 3 (Severe):  Event interrupts a subject’s usual daily activity and may require
systemic drug therapy or other treatment.  Severe events are usually incapacitating.

Grade 4 (Life threatening):  Any adverse drug experience that places the subject, in
the view of the Investigator, at immediate risk of death from the reaction as it
occurred (i.e., it does not include a reaction that had it occurred in a more severe
form, might have caused death).

Grade 5 (Death)
Confidential

Page 90 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
8.2.2 Assessment of Causality 
The Investigator who identifies an AE will determine the causality of each based on the temporal 
relationship to administration of study drug and clinical judgment.  The degree of certainty about 
causality will be graded using the categories below. 
Definitely Related:  A reaction that follows a reasonable temporal sequence from administration 
of study drug; that follows a known or expected response pattern to the study drug; it disappears 
or decreases on cessation or reduction in study drug dose; and/or it reappears or worsens when 
the study drug is administered. 
Probably Related:  A reaction that follows a reasonable temporal sequence from administration 
of study drug; that follows a known or expected response pattern to the study drug; and/or that 
could not be reasonably explained by other factors such as underlying disease, complications, 
concomitant drugs, or concurrent treatments. 
Possibly Related:  A reaction that follows a reasonable temporal sequence from administration 
of study drug; that follows a known or expected response pattern to the study drug, but that could 
reasonably have been produced by a number of other factors including underlying disease, 
complications, concomitant drugs, or concurrent treatments. 
Not Related:  A reaction for which sufficient data exist to indicate that the etiology is unrelated 
to the study drug. 
8.2.3 Assessment of Outcome 
The Investigator will record the outcome of the AE as either resolved or ongoing on the AE page 
of the eCRF.  AEs of unknown outcome will be considered as ongoing for purposes of AE 
reporting. 
8.3 
ADVERSE EVENTS OF SPECIAL INTEREST 
Adverse events of special interest (AESI) are those known to be attributed to parenteral 
amikacin: 
Confidential

Page 91 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 

nephrotoxicity, including elevation of serum creatinine, albuminuria, presence of red
and white cells, casts, azotemia, and oliguria

ototoxicity affecting the eighth cranial nerve resulting in hearing loss, loss of balance,
or both.

neuromuscular disorders

allergic alveolitis

bronchospasm

hemoptysis
Cough is often associated with the drug products that are nebulized.  In order to properly 
characterize AEs of cough, specific details regarding AE of cough will be reported in separate 
eCRF pages.  
It is expected that patients in this study will experience a large number of pulmonary 
exacerbation events due to their underlying lung condition(s).  Pulmonary exacerbation will be 
defined based on the Investigators best clinical judgment. Details of the type of exacerbation 
should be provided. These events should not be reported on the AE eCRF unless they meet the 
criteria for an SAE. Instead, these events should be reported in the “pulmonary exacerbation not 
SAE” page of the eCRF.   
8.4 
REPORTING REQUIREMENTS 
8.4.1 Adverse Events 
All AEs will be reported on the Adverse Events Form of the eCRF. Adverse events that occur 
between the time subject signs the informed consent form for the study and the time when 
subject receives his/her first dose of LAI or multi-drug regimen on Day 1 will be summarized as 
medical history and not as a treatment emergent AE (TEAE) unless the event meets the 
definition of an SAE as defined below. 
Confidential

Page 92 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
8.4.2 Serious Adverse Events 
All SAEs, regardless of causality, must be reported to organization delegated by the Sponsor 
(Primevigilance will handle SAE reporting for INS-212) on a Serious Adverse Event Report 
Form within 24 hours of becoming aware of the event; corrections and additions are required to 
be submitted within 24 hours.  Study-specific email, phone, and fax number for SAE reporting 
are presented in the Study Reference Manual. 
Unexpected drug-related SAEs as assessed by Sponsor or authorized person qualify for 
expedited reporting and will be reported to the IRB/EC, regulatory authorities, participating 
Investigators and, if cross reporting is required for suspected unexpected serious adverse 
reactions (SUSARs), in accordance with all applicable global laws and regulations.  A SUSAR is 
a Serious Adverse Reaction, which is suspected to be caused by the investigational medicinal 
product and which is unexpected i.e. its nature or severity is not consistent with the information 
in the relevant source documents. SAEs, including those that do not meet requirements for 
expedited reporting, and all other AEs will be reported to the regulatory agencies as appropriate 
(i.e. for the FDA these are reported in the Investigational New Drug [IND] annual report and for 
EMA these are reported in the Drug Safety Update Report ([DSUR]). 
8.4.2.1 Pregnancy 
Any pregnancy that occurs during any phase of the study must be reported to Prime Vigilance 
within 24 hours of learning of the pregnancy using a Clinical Study Pregnancy Form. 
The study treatment should be discontinued and the pregnancy should be followed to term.  The 
details of termination must also be reported, including details of birth, the presence or absence of 
birth defects, congenital abnormalities or maternal and newborn complications, or whether 
termination was spontaneous or voluntary. 
8.4.2.2 Overdose 
An overdose is defined as a dose greater than the dose level evaluated in this study as described 
in Section 5 that results in clinical signs and symptoms. In the case of an overdose of study drug, 
Confidential

Page 93 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
the Investigator should use clinical judgment in treating the overdose and contact the study 
Medical Monitor. The Investigator should refer to the relevant document(s) for detailed 
information regarding warnings, precautions, contraindications, adverse events, and other 
significant data pertaining to the study drug used in the study. Such document(s) may include, 
but not limited to, the Investigator’s brochure for LAI and approved product labeling for 
Amikacin.  
8.5 
FOLLOW-UP OF ADVERSE AND SERIOUS ADVERSE EVENTS 
All SAEs, including those ongoing at end-of-study, must be followed until resolution or 
stabilization or until otherwise explained. 
8.6 
REGULATORY ASPECTS 
The Sponsor has a legal responsibility to notify the FDA, National Competent Authorities and 
Central Ethics Committees of the European Union, and all other foreign regulatory agencies, as 
well as all sites, about the safety of the drug.  The Investigator has the responsibility to notify the 
local EC about SUSARs. 
The Investigator(s)/institution(s) will permit study-related monitoring, audits, IRB/EC review 
and regulatory inspection(s), providing direct access to source data/documents.  Copies of the 
notification to the ethics committee must be sent to the Sponsor. 
9 
STATISTICS 
9.1 
SAMPLE SIZE 
The sample size was determined for the primary comparison between the treatment arms LAI 
plus a multi-drug regimen and a multi-drug regimen alone with respect to the proportion of 
subjects achieving culture conversion by Month 6 using nQuery Advisor® 7.0.  Assuming a 
culture conversion rate by Month 6 of no less than 20% for the LAI plus a multi-drug regimen 
treatment arm, the rate by Month 6 of 5% for the multi-drug regimen alone treatment arm, and a 
2:1 randomization ratio, a sample size of 261 subjects (174 for LAI plus a multi-drug regimen 
and 87 for the multi-drug regimen) will provide at least 90% power for the continuity-corrected 
Chi-square test at the 2-sided significance level of 0.05. 
Confidential

Page 94 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
The sample size was also evaluated for the secondary endpoint of change from Baseline to 
Month 6 in 6MWT distance. Assuming a common standard deviation of 100 and a 2:1 
randomization ratio to either LAI plus a multi-drug regimen or a multi-drug regimen alone, a 
sample size of 192 subjects (128 for LAI plus a multi-drug regimen and 64 for the multi-drug 
regimen) will provide at least 90% power to detect a between-treatment difference of 50 meters 
in mean change from Baseline to Month 6 in 6MWT distance using a two arm t-test at the 2-
sided significance level of 0.05. 
Due to lack of durability data, it is difficult to estimate the power with a total sample size of 261 
subjects for the comparison between treatment arms with respect to the proportion of subjects 
achieving culture conversion with durability after 3 months off-treatment.  Assuming the 
proportion of subjects achieving culture conversion with durability is 16% and 4% for LAI plus a 
multi-drug regimen and a multi-drug regimen respectively, and a 2:1 randomization ratio, a 
sample size of 261 subjects (174 for LAI plus a multi-drug regimen and 87 for the multi-drug 
regimen) will provide at least 83% power for Fisher’s exact test at the 2-sided significance level 
of 0.05. 
9.2 
STRATIFICATION 
Subjects will be stratified by smoking status (current smoker or not) and prior multi-drug 
regimen (on treatment or off treatment for at least 3 months) at Screening. 
9.3 
RANDOMIZATION AND BLINDING 
Eligible subjects will be randomized 2:1 to open-label treatment with LAI plus a multi-drug 
regimen or a multi-drug regimen alone. 
9.4 
STATISTICAL METHODOLOGY 
A statistical analysis plan (SAP) will be developed describing details regarding all analyses, 
tables, figures, and data listings.  All analyses will be performed using SAS®.  
Confidential

Page 95 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
The final analyses of the primary efficacy endpoint, the change from Baseline to Month 6 in 
6MWT distance, and time to culture conversion by Month 6 will be performed when the last 
subject completes Month 6 and data for all subjects who have completed Month 6 are available. 
These final analyses will be performed prior to the completion of the study. Interim analysis of 
some safety data will be included. 
9.5 
ANALYSIS POPULATIONS 
9.5.1 Intent-to-treat Population 
The intent-to-treat (ITT) population is the set of all randomized subjects. 
9.5.2 Per-protocol Population 
The per-protocol (PP) population is a subset of the ITT subjects who received at least 1 dose of 
either LAI plus a multi-drug regimen or a multi-drug regimen, met the inclusion/exclusion 
criteria, and did not have major protocol violations. 
9.5.3 Safety Population 
The safety population is the set of all subjects who received at least 1 dose of either LAI plus a 
multi-drug regimen or a multi-drug regimen. 
9.5.4 Pharmacokinetic Population 
The PK population is the set of all randomized subjects who received at least 1 dose of study 
drug and provided at least 1 PK sample. 
9.6 
EFFICACY ANALYSIS 
9.6.1 Primary Endpoint Analysis 
The primary efficacy endpoint is the proportion of subjects achieving culture conversion by 
Month 6. The primary efficacy analysis will be performed for the ITT population using the 
Cochran-Mantel-Haenszel test stratified by smoking status and prior multi-drug regimen (on 
treatment or off treatment for at least 3 months) at the 2-sided significance level of 0.05.  The 
Confidential

Page 96 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
null hypothesis assumes that the culture conversion by Month 6 is independent of treatment, and 
the alternative hypothesis assumes that the culture conversion by Month 6 is associated with 
treatment.  Subjects with missing sputum culture results for which culture conversion cannot be 
evaluated (3 consecutive monthly negative sputum cultures) will be considered as 
non-converters. 
A supportive analysis of the primary efficacy endpoint will be performed for the PP populations 
similarly using the Cochran-Mantel-Haenszel test stratified by smoking status and prior multi-
drug regimen. 
9.6.2 Secondary Endpoint Analyses 
The change from Baseline (Day 1) to Month 6 in 6MWT distance will be analyzed for the ITT 
population (assuming Missing-Not-at-Random [MNAR]) using a model under the pattern-
mixture model framework.  This model assumes that subjects on the LAI plus a multi-drug 
regimen arm with missing data follow the response distribution of a multi-drug regimen alone 
arm. It involves 3 steps:   
1. The posterior mean and covariance estimates from the SAS MI procedure using the
available non-missing data of a multi-drug regimen alone arm will be utilized to multiply
impute missing data.
2. The endpoint will then be analysed for each complete data set with imputed data using an
analysis of covariance (ANCOVA) with treatment arm and the randomization strata as
factors, and the Baseline 6MWT distance as a covariate.
3. The treatment LSMEAN differences will be averaged and the associated standard errors
will be summarized based on within-imputation and between-imputation variances using
the SAS MIANALYZE procedure, to yield a final estimate of treatment contrast with
associated 95% confidence interval (CI) and p-value.
A sensitivity analysis of the change from Baseline (Day 1) to Month 6 in 6MWT distance will be 
performed using a mixed-effects model for repeated measures (MMRM) with an unstructured 
covariance matrix implemented with SAS MIXED procedure over Months 4 and 6. This model 
Confidential

Page 97 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
will include treatment, month, the treatment-by-month interaction, smoking status and prior 
multi-drug regimen (on treatment or off treatment for at least 3 months) as fixed factors, the 
Baseline (Day 1) 6MWT distance as a covariate, as well as the Baseline 6MWT distance-by-
month interaction. The Kenward-Rogers correction for denominator degrees of freedom, 
standard errors, and test statistics will be utilized. The between-treatment difference in Least 
Squares (LS) mean change from Baseline to Month 6, the corresponding 95% CI for the true 
between-treatment difference, and the p-value will be presented.   
Supportive ANCOVA analyses of the change from Baseline to Month 6 in 6MWT distance with 
treatment arm and the randomization strata as factors, and the Baseline 6MWT distance as a 
covariate will also be performed for both the ITT and the PP populations. In the ANCOVA 
analysis for the ITT population, the last-observation-carried-forward method will be used to 
handle the missing data. 
The changes from Baseline to Month 8 (exploratory endpoint), EOT, and 3 months off-treatment 
(exploratory endpoint)  in 6MWT distance will be analyzed for the ITT population using the 
similar mixed-effects model for repeated measures (MMRM) with an unstructured covariance 
matrix implemented with SAS MIXED procedure over all post-randomization visits.  
Kaplan-Meier estimates for the distribution of time to culture conversion will be constructed for 
treatment arms.  The treatment comparison will be made using the stratified log rank test for the 
ITT population. The estimated median time to culture conversion for each treatment arm will be 
presented. The time to culture conversion will also be analyzed using Cox regression model to 
estimate hazards ratio. 
The proportion of subjects achieving culture conversion with sustainability at the EOT and the 
proportion of subjects achieving culture conversion with durability after 3 months off-treatment 
will be analyzed for both the ITT and PP populations similarly using the 
Cochran-Mantel-Haenszel test stratified by smoking status and prior multi-drug regimen. 
Subjects who relapse, have “rescue” medication and/or die before reaching EOT for 
sustainability and 3 months off-treatment for durability will be considered as failure to achieving 
culture conversion. 
Confidential

Page 98 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
The change from Baseline (Day 1) to Month 6 in SGRQ total score and the SGRQ – Part 2  
subdomain (exploratory endpoint) will be analyzed for the ITT population similarly using the 
same MMRM method as the analysis of the change from Baseline to EOT in 6MWT distance. 
9.6.3 Exploratory Endpoint Analyses 
The change in 6MWT distance at Month 6 for converters compared with non-converters overall 
for ITT population, within LAI plus a multi-drug regimen, within the multi-drug regimen alone, 
the change in BMI at Month 6 for LAI plus a multi-drug regimen compared with a multi-drug 
regimen alone, and the changes in chest CT scan at EOT for LAI plus a multi-drug regimen 
compared with a multi-drug regimen alone in a sub-set of subjects will be analyzed using the 
ANCOVA models with the comparison arm (converters vs. non-converters or the treatment arm) 
and the randomization strata as factors, and the corresponding Baseline measure as a covariate. If 
a CT scan is not performed at EOT for any subject, then prior CT scan will be used in the 
analysis.  
The change from Baseline (Day 1) to Month 6 and EOT in the EQ-5D-3L patient reported health 
outcomes will be analyzed for the ITT population similarly using the same MMRM method as 
the analysis of the change from Baseline to EOT in 6MWT distance. Kaplan-Meier estimates for 
the distribution of time to death will be constructed by treatment arm.  The treatment comparison 
will be made using the stratified log rank test for the ITT population.  Incidence of new MAC 
strains will be summarized by treatment arms. 
9.7 
SAFETY ANALYSIS 
Safety data will be summarized for the Safety Population. 
Adverse events will be coded using the agreed upon version of the Medical Dictionary for 
Regulatory Activities (MedDRA).  For non-converters entering the single arm LAI study (Study 
INS-312), safety monitoring will continue as defined in that protocol.  The number and percent 
of subjects with treatment emergent AEs by system organ class and preferred term will be 
presented by treatment arm.  The severity of the AEs, the relationship to the investigational 
Confidential

Page 99 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
product, AEs causing study discontinuation, and all treatment emergent SAEs will be similarly 
presented. Fatal SAEs will also be presented separately in a similar manner. 
Vital signs (temperature, systolic and diastolic blood pressure, pulse, pulse oximetry, and 
respiratory rate) results will be descriptively summarized by treatment arm. 
Clinical laboratory test and pulmonary function results will be descriptively presented.  Shifts of 
laboratory results from Baseline (Day 1) to Month 6 and EOT will be presented by treatment 
arm. 
10 DATA MANAGEMENT 
10.1 SOURCE DOCUMENTS 
Study data will be collected on source documents.  The Principal Investigator (PI) is responsible 
for assuring that collected data are complete and accurate.  Source documentation (the point of 
initial recording of a piece of data) should support data collected on the eCRF.  Source 
documents include all recordings of observations or notations of clinical activities and all reports 
and records necessary for the evaluation and reconstruction of the clinical study. 
10.2 DATA COLLECTION AND CASE REPORT FORM MONITORING 
All data obtained for this study will be entered into a local regulation (i.e. 21 CFR Part 11 in the 
USA) compliant Data Management System provided by Insmed or its designee.  These data will 
be recorded with an Electronic Data Capture (EDC) system using eCRFs.  The Investigator will 
ensure the accuracy and completeness of the data reported to the Sponsor.  All data entry, 
modification or deletion will be recorded automatically in an electronic audit trail. 
The Investigator will provide access to his/her original records to permit a representative from 
the Sponsor to verify the proper transcription of data.  Data reported in the eCRFs should be 
consistent with and substantiated by the subject’s medical record and original source documents.  
The eCRF data will be monitored by the Sponsor or designee.  The final, completed eCRF 
Casebook for each subject must be electronically signed and dated by the PI within the EDC 
Confidential

Page 100 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
system to signify that the Investigator has reviewed the eCRF and certifies it to be complete and 
accurate. 
The Sponsor will retain the final eCRF data and audit trail.  A copy of all completed eCRFs will 
be provided to the Investigator. 
10.3 STUDY RECORDS RETENTION 
Study documents should be retained for a minimum of 2 years after the last approval of a 
marketing application in an International Conference on Harmonisation (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 should be retained for a longer period, however, if required by local 
regulations.  No records will be destroyed without the written consent of Insmed.  It is the 
responsibility of Insmed to inform the Investigator when these documents no longer need to be 
retained. 
11 ETHICAL CONSIDERATIONS 
A copy of the protocol, informed consent forms, other information to be completed by subjects, 
such as questionnaires and any proposed advertising or recruitment materials, will be submitted 
to the regulatory authority(ies) and ECs in accordance with country-specific requirements. 
All subsequent amendments to the protocol, informed consent documents, and other study 
documentation referenced above must be submitted and approved in accordance with 
country-specific requirements. 
Periodic study status reports will be submitted to the ECs in accordance with country-specific 
regulations.  Where applicable, the Investigator will be responsible for obtaining IRB/EC 
approval of the annual continuing review throughout the duration of the study. 
The PIs will notify the local IRBs/ECs of violations from the protocol and SAEs. 
Confidential

Page 101 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
Subjects will be informed that medical care will not be affected by their agreement or refusal to 
participate in this study, and that they are free to withdraw from the study at any time without 
prejudice to the clinician patient relationship. 
The study will be conducted according to the principles of the Declaration of Helsinki (Fortaleza, 
Brazil, October 2013), and the ICH E6 Guideline for Good Clinical Practice (GCP).  The 
Sponsor will ensure that the study complies with all local, federal, or country regulatory 
requirements as applicable.  Throughout the study, the Sponsor and its designee will work with 
the Investigator(s) to ensure proper study protocol implementation and adherence to regulatory 
requirements as listed in the study protocol. 
11.1 GOOD CLINICAL PRACTICE 
This study is to be conducted according to globally accepted standards of good clinical practice 
(as defined in the ICH E6 Guideline for Good Clinical Practice), in agreement with the 
Declaration of Helsinki and in keeping with local regulations. 
11.2 DELEGATION OF INVESTIGATOR DUTIES 
The Investigator should ensure that all persons assisting with the trial are adequately qualified, 
informed about the protocol, any amendments to the protocol, the study treatments, and their 
trial-related duties and functions. 
The Investigator should maintain a list of sub-Investigators and other appropriately qualified 
persons to whom he or she has delegated significant trial-related duties. 
11.3 PATIENT INFORMATION AND INFORMED CONSENT 
Before being enrolled in the clinical study, patients must consent to participate after the nature, 
scope, and possible consequences of the clinical study have been explained in a form 
understandable to them. 
An informed consent document that includes both information about the study and the consent 
form will be prepared and given to the patient.  This document will contain all the elements 
required by the ICH E6 Guideline for Good Clinical Practice and any additional elements 
Confidential

Page 102 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
required by local regulations.  The document must be in a language understandable to the patient 
and must specify who informed the patient.  Where required by local law, the person who 
informs the patient must be a physician. 
12 ADMINISTRATIVE PROCEDURES 
12.1 FINANCIAL DISCLOSURE BY INVESTIGATOR 
The disclosed financial interest of the Investigator must be collected before Screening of the first 
patient, following study completion at the Investigator site and 1 year following overall study 
completion.  The Investigator should promptly update this information if any relevant changes 
occur during this period. 
12.2 STUDY REGISTRATION AND RESULTS DISCLOSURE 
The Sponsor may provide study information for inclusion in national registries according to local 
regulatory requirements. 
Results of this study will be disclosed according to the relevant national regulatory requirements. 
12.3 STUDY FILES AND MATERIALS 
Before the start of any study related procedures, all initial documents required by ICH GCP, 
Good Pharmacoepidemiology Practice, and applicable local regulations must be available in the 
relevant files maintained by the Sponsor (or delegate) and the Investigator.  An Investigator 
Study File prepared by the Sponsor (or delegate), containing all applicable documents for use at 
the study site, will be made available to the Investigator before the start of the study.  A list of 
personnel and organizations responsible for conduct of the study as well as the list of 
Investigators at each site will be included in the Investigator Study File.  The respective files will 
be kept and updated by the Sponsor (or delegate) and the Investigator, as applicable. 
All study documentation and materials maintained in the Investigator Study File at the study site 
must be available for inspection by the Sponsor’s study monitor (or delegate) to determine that 
all required documentation is present and correct. 
Confidential

Page 103 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
The study may be audited by qualified delegates from the Sponsor or a competent regulatory 
authority (Section 12.11). 
12.4 USE OF STORED SAMPLES AND DATA 
Serum and sputum samples collected for PK analysis will be stored for a period of up to 2 years 
after the completion (termination) of the study, or longer if required by the institution 
participating in the study.  Serum samples from the IL-6 analysis will be stored at the 
aforementioned laboratory for a period of up to 2 years after the completion (termination) of the 
study, or longer if required by the institution participating in the study to see whether there may 
be indicators associated with NTM lung infections and for other exploratory analyses for an 
NTM lung infection (no genetic testing or analysis will be performed on blood samples 
collected). Mycobacterial isolates will be stored for a period of up to 2 years after the completion 
(termination) of the study, or longer if required by the institution participating in the study and 
used for future selective susceptibility testing for correlation with microbiologic and clinical 
response and for molecular typing of serial isolates to look for multiple strains within individuals 
that might influence treatment outcome.  Stored samples will be labeled with study and subject 
information and kept in a locked room with limited access.  Electronic data will be kept in 
password-protected computers at the laboratory and then transferred to the Sponsor or Clinical 
Research Organization (CRO), as applicable, for data analysis.  Samples and corresponding data 
will be tracked using the laboratory’s specimen tracking system. 
Prior Sponsor and IRB approval are required before using or sharing study samples or data in 
ways not specifically specified in the study protocol. 
Any loss or unanticipated destruction of samples (e.g., freezer malfunction) or data (e.g., loss of 
a data sheet with individually identifiable information) that violates or compromises the 
scientific integrity of study data must be reported to the Sponsor and the IRB. 
At any time, subjects may inform the Investigator that they do not wish to have their samples 
stored beyond the completion (termination) of the study.  In this case, the Investigator will 
request that all known remaining samples be destroyed and report the disposition of samples to 
the requesting subjects and the IRB. 
Confidential

Page 104 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
12.5 Disposition of Stored Samples and Data 
Access to stored samples will be limited by using a locked room.  Samples stored by the central 
laboratories will be labeled with the subject’s study identification information.  Data will be kept 
in password-protected computers at the laboratory and then transferred to the vendor for data 
analysis.  Samples and corresponding data acquired will be tracked using the laboratory’s 
specimen tracking system. 
In the future, other Investigators may wish to study these samples and/or data.  In that case, 
IRB/EC approval and Sponsor approval must be obtained before any sharing of samples and/or 
data.  Any clinical information shared about the sample would similarly require prior Sponsor 
and IRB/EC approval. 
Any loss or unanticipated destruction of samples (e.g., due to freezer malfunction) or data (e.g., 
loss of a data sheet with individually identifiable information) that results in a violation that 
compromises the scientific integrity of the data collected for the study will be reported to the 
Sponsor and the IRB/EC. 
Additionally, subjects may decide at any point not to have their samples stored for a period of up 
to 2 years beyond the duration of the study.  In this case, the PI will request the destruction of all 
known remaining samples and report what was done to both the subject and to the IRB/EC.  This 
decision will not affect the subject’s participation in this protocol. 
12.6 INITIATION OF STUDY 
Before the start of the study at each study site, the Sponsor’s study monitor (or delegate) will 
visit the study site to ensure adequacy of the facilities and to discuss responsibilities regarding 
study protocol adherence with the Investigator and other personnel involved in the study. 
The Investigator may not enroll any subject into the study before the Sponsor has received 
written approval or a favorable opinion from the EC or IRB for conducting the study and a 
formal meeting has been conducted by the Sponsor’s study monitor (or delegate) to initiate the 
study.  This meeting will include a detailed review of the study plan, and completion of the 
eCRF. 
Confidential

Page 105 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
12.7 PATIENT REIMBURSEMENT, LIABILITY, AND INSURANCE 
The civil liability of the involved parties with respect to financial loss due to personal injury and 
other damage that may arise as a result of this study being conducted are governed by the 
applicable legal requirement(s). 
The Sponsor will provide insurance to the Investigator if required by the applicable regulatory 
and legal requirement(s). 
If required by local law, subjects taking part in this study will be insured against any injury 
caused by the study in accordance with the applicable regulatory and legal requirement(s). 
12.8 SUBJECT IDENTIFICATION AND CONFIDENTIALITY 
Subject names will not be supplied to the sponsor.  A subject number will be recorded in the 
eCRF, and if the subject name appears on any other document (e.g., laboratory report), it must be 
obliterated on the copy of the document to be supplied to the sponsor.  All records will be kept 
confidential to the extent provided by federal, state, and local laws.  The subjects will be 
informed that representatives of the sponsor, IRB/EC, or regulatory authorities may inspect their 
medical records to verify the information collected, and that all personal information made 
available for inspection will be handled in strictest confidence and in accordance with local data 
protection laws. 
The Investigator will maintain a personal subject identification list (subject numbers with the 
corresponding subject names) to enable records to be identified. 
12.9 STUDY MONITORING 
Before study initiation, at a site initiation visit or at an Investigator’s meeting, a Sponsor 
representative will review the protocol, eCRF, IB, and any study-related materials with the 
Investigators and their staff.  During the study, the study Sponsor monitor or its designee will 
visit the site regularly to check the completeness of subject records, the accuracy of entries on 
the eCRFs, adherence to the protocol, adherence to ICH GCP and applicable regulatory 
requirements, the progress of enrollment, and also to ensure that study drug is being stored, 
dispensed, and accounted for according to specifications. 
Confidential

Page 106 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
The Investigator must give the monitor access to relevant hospital or clinical records to confirm 
their consistency with the eCRF entries.  No information in these records about the identity of 
the subjects will leave the study center.  The study Sponsor monitoring standards require full 
verification for the presence of informed consent, adherence to the inclusion/exclusion criteria, 
documentation of SAEs, and the recording of primary activity and safety variables.  Additional 
checks of the consistency of the source data with the eCRFs are performed according to the 
study-specific monitoring plan. 
12.10 STUDY PLAN AMENDMENTS 
Any substantial change or addition to this protocol requires a written protocol amendment that 
must be approved by the Sponsor, before implementation.  Amendments significantly affecting 
the safety of subjects, the scope of the investigation, or the scientific quality of the study, require 
additional approval by the applicable regulatory authority(ies), central ECs, and local IRBs/ECs.  
Copies of the applicable written approvals must be given to the site monitor or their designee. 
The requirements for approval should in no way prevent any immediate action from being taken 
by the Investigator or by the Sponsor in the interests of preserving the safety of all subjects 
included in the study.  If an immediate change to the protocol is felt to be necessary by the 
Investigator and is implemented by him/her for safety reasons, the study Sponsor or its agent 
should be notified and the applicable regulatory authority(ies)/central ECs/local IRBs/ECs 
should be informed within 10 working days.  Any other regional reporting requirements must be 
adhered to. 
Amendments affecting only administrative aspects of the study do not require formal protocol 
amendments or regulatory authority/central EC/local IRB/EC approval, but the regulatory 
authority(ies)/central ECs/local IRBs/ECs must be kept informed of such administrative changes 
in accordance with country-specific requirements. 
12.11 AUDITS AND INSPECTIONS 
Domestic and foreign regulatory authorities, the IRB/EC, and an auditor authorized by the 
sponsor may request access to all source documents, case report forms, and other study 
documentation for on-site audit or inspection.  Direct access to these documents must be 
Confidential

Page 107 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
guaranteed by the Investigator, who must provide support at all times for these activities.  
Medical records and other study documents may be copied during audit or inspection provided 
that subject names are obliterated on the copies to ensure confidentiality. 
If an inspection is requested by a regulatory authority, the Investigator will inform the study 
Sponsor, immediately that this request has been made. 
12.12 USE OF DATA AND PUBLICATIONS 
Any formal presentation or publication of data collected from this study will be considered as a 
joint publication by the Investigator(s) and the appropriate personnel of the study Sponsor.  
Authorship will be determined by mutual agreement.  For multi-center studies, it is mandatory 
that the first publication be based on data from all centers, analyzed as stipulated in the protocol 
by the study Sponsor and statisticians, and not by the Investigators themselves.  Investigators 
participating in multi-center studies agree not to present data gathered from a single center or a 
small group of centers before the full, initial publication, unless formally agreed to by all other 
Investigators and study Sponsor. 
The study Sponsor must receive copies of any intended communication in advance of publication 
(at least 15 working days for an abstract or oral presentation and 45 working days for a journal 
submission).  The study Sponsor will review the communications for accuracy (thus avoiding 
potential discrepancies with submissions to regulatory authorities), verify that confidential 
information is not being inadvertently divulged, and to provide any relevant supplementary 
information.  Authorship of communications arising from pooled data may include members 
from each of the contributing centers as well as the study Sponsor personnel. 
At the conclusion of the study, after the data are analyzed, the results of study will be reported in 
a clinical study report. 
Confidential

Page 108 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
13 REFERENCES 
Andréjak C, Thomsen VØ, Johansen IS, Riis A, Benfield TL, Duhaut P, Sørensen HT, Lescure 
FX, Thomsen RW. Nontuberculous pulmonary mycobacteriosis in Denmark: incidence and 
prognostic factors. Am J Respir Crit Care Med. 2010 Mar 1;181(5):514-21. 
Ballarino, G.  J., K.  N.  Olivier, R.  J.  Claypool, S.  M.  Holland, and D.  R.  Prevots. 
"Pulmonary nontuberculous mycobacterial infections:  antibiotic treatment and associated costs." 
Respir Med 103, no.  10 (2009):  1448-55.  
Contreras, M.  A., O.  T.  Cheung, D.  E.  Sanders, and R.  S.  Goldstein. "Pulmonary infection 
with nontuberculous mycobacteria." Am Rev Respir Dis 137, no.  1 (1988):  149-52.  
Cousins, D., B.  Francis, and D.  Dawson. "Multiplex PCR provides a low-cost alternative to 
DNA probe methods for rapid identification of Mycobacterium avium and Mycobacterium 
intracellulare." J Clin Microbiol 34, no.  9 (1996):  2331-3.  
Forbes, B.  A. "Laboratory Detection and Identification of Mycobacteria; Approved Guideline." 
Clinical and Laboratory Standards Institute, M48-A 28, no.  17 (2008):  1-92.  
Geller, D.  E., W.  H.  Pitlick, P.  A.  Nardella, W.  G.  Tracewell, and B.  W.  Ramsey. 
"Pharmacokinetics and bioavailability of aerosolized tobramycin in cystic fibrosis." Chest 122, 
no.  1 (2002):  219-26.  
Griffith, D.  E., T.  Aksamit, B.  A.  Brown-Elliott, A.  Catanzaro, C.  Daley, F.  Gordin, et al. "An 
official ATS/IDSA statement:  diagnosis, treatment, and prevention of nontuberculous 
mycobacterial diseases." Am J Respir Crit Care Med 175, no.  4 (2007):  367-416.  
Jones, P.  W. "Quality of life measurement for patients with diseases of the airways." Thorax 46, 
no.  9 (1991):  676-82.  
Jones, P.  W., F.  H.  Quirk, and C.  M.  Baveystock. "The St George's Respiratory 
Questionnaire." Respir Med 85 Suppl B (1991):  25-31; discussion 33-7.  
Kenward, M.  G.  and J.  H.  Roger. "Small sample inference for fixed effects from restricted 
maximum likelihood." Biometrics 53, no.  3 (1997):  983-97.  
Khan, K., J.  Wang, and T.  K.  Marras. "Nontuberculous mycobacterial sensitization in the 
United States:  national trends over three decades." Am J Respir Crit Care Med 176, no.  
3 (2007):  306-13.  
Confidential

Page 109 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
Khan A, Akhtar S, Ahmad JN, Sarkar D. Presence of a functional nitrate assimilation pathway in 
Mycobacterium smegmatis. Microb Pathog. 2008; 44: 71-7. 
Leung JM, Olivier KN. Nontuberculous mycobacteria: the changing epidemiology and treatment 
challenges in cystic fibrosis. Curr Opin Pulm Med. 2013; 19: 662-9. 
Marras, T.  K., P.  Chedore, A.  M.  Ying, and F.  Jamieson. "Isolation prevalence of pulmonary 
non-tuberculous mycobacteria in Ontario, 1997 2003." Thorax 62, no.  8 (2007):  661-6.  
Olivier, K.  N., D.  J.  Weber, R.  J.  Wallace, Jr., A.  R.  Faiz, J.  H.  Lee, Y.  Zhang, et al. 
"Nontuberculous mycobacteria.  I:  multicenter prevalence study in cystic fibrosis." Am J Respir 
Crit Care Med 167, no.  6 (2003):  828-34.  
Prammananan, T., P.  Sander, B.  A.  Brown, K.  Frischkorn, G.  O.  Onyi, Y.  Zhang, et al. "A 
single 16S ribosomal RNA substitution is responsible for resistance to amikacin and other 
2-deoxystreptamine aminoglycosides in Mycobacterium abscessus and Mycobacterium
chelonae." J Infect Dis 177, no.  6 (1998):  1573-81.
Prince, D.  S., D.  D.  Peterson, R.  M.  Steiner, J.  E.  Gottlieb, R.  Scott, H.  L.  Israel, et al. 
"Infection with Mycobacterium avium complex in patients without predisposing conditions." N 
Engl J Med 321, no.  13 (1989):  863-8.  
Wilson, C.  B., P.  W.  Jones, C.  J.  O'Leary, P.  J.  Cole, and R.  Wilson. "Validation of the St. 
George's Respiratory Questionnaire in bronchiectasis." Am J Respir Crit Care Med 156, no.  2 Pt 
1 (1997):  536-41.  
Confidential

Page 110 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
 
14 APPENDICES 
APPENDIX 1 
SPUTUM INDUCTION SUGGESTIONS 
Introduction 
Collection of good sputum samples is critical to the success of this study.  Sputum samples will 
be collected at the clinical site and also by the subject at home.  To facilitate obtaining good 
sputum samples during the study visits at the clinic, sputum induction must be performed if the 
subject is unable to expectorate approximately 3.0 ml of sputum.  
Purpose 
The purpose of this appendix is to provide suggestions to the clinical sites for obtaining a sputum 
sample by induction if the subject is unable to expectorate a sputum sample on their own or after 
chest percussion.  
Suggested Equipment 

Standard handheld nebulizer used in the clinic or the subject can be asked to bring the
nebulizer they use at home for pulmonary hygiene
o
The nebulizer should be thoroughly disinfected to ensure no cross-contamination
o
DO NOT use the subject’s PARI eFlow® nebulizer for sputum induction

Sputum specimen containers with label – sputum collection tube provided by central
laboratory

Sodium chloride solution (Saline)

Standard clinic supplies (e.g., disinfectant/germicidal/alcohol wipes, tissues, paper
towels, etc)
Procedure 
General Instructions: 

At the clinic, sputum induction should occur before administration of study drug.
Confidential

Page 111 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 

Sputum induction should occur in a private, contained room. Specific processes in place
at the clinic to prevent contamination and ensure sterilization before and after sputum
induction should be followed.

Clinic personnel should wear gloves and a mask during the entire procedure.

Only one subject should be induced at a time.

All collection containers should have a sputum collection label clearly completed with
subject identifiers, visit name, date and time.

The subject should have been instructed to not eat at least within 1 hour of sputum
induction procedures.

Explain to the subject that the purpose of this procedure is to help him/her cough up a
sputum sample and that the success of the procedure is dependent on the subject’s active
participation.
Inhalation and Collection Procedures: 

The induction procedure should start by utilizing lower concentrations of saline (e.g. 3%)
based on the Investigator’s preference.

Approximately 3-6 mL of the selected saline should be placed in the nebulizer.

The subject should be sitting up or in a semi-fowler position.

The subject may wear a nose clip during the nebulization.

The subject should breathe slowly and deeply through the nebulizer mouthpiece inhaling
the salt water mist.  Remind the subject to not breathe quickly but to have slow, deep
breaths pausing at peak inspiration to allow deposition of particles.

The nebulization time is 10 minutes.

At the end of this time, the subject should take a few deep breaths, swallow the extra
saliva in his/her mouth and try to cough up a sputum sample.

The subject should be encouraged to cough forcefully using the deep coughing method
and/or “huffing” cough method.

All sputum should be deposited in the container. The specimen container should not be
opened until the specimen is ready to be deposited. The container should be closed
immediately after depositing the sample.

The sputum sample should be approximately 3 mL - slightly below the bottom line (5
mL) on the collection container.
Confidential

Page 112 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 

If a sufficient sputum sample is not collected and the subject appears to be tolerating the
induction procedure well, the subject can complete another 10 minute nebulization
period.
o
If a second 10-minute nebulization period is required, the recommendation is to
increase the sodium chloride concentration (i.e., if 3% was used first then 7%
should be used for the subsequent nebulization; if 7% was used first then 10%
should be used for the subsequent nebulization).
o
Closely monitor the subject for tolerability issues or side effects.
o
No more than two 10-minute nebulization periods should be completed.

The sputum sample should be refrigerated until it is sent to the microbiology laboratory.
Side Effects 

The subject may experience side effects from the sputum induction procedure.  The most
common side effects include:

coughing

sore throat

wheezing

nausea

lightheadedness

headache

shortness of breath

chest tightness

Other possible side effects include hyperventilation or bronchospasm.  For
bronchospasm, ensure subject receives the necessary medical management.
Miscellaneous 

If the subject needs to expectorate during nebulization, turn off the nebulizer and allow
the subject to cough up sputum into the container.  If a sufficient specimen is not
collected, the subject should then resume the nebulization to complete the 10 minute
nebulization duration.

The subject should be encouraged to blow his/her nose as often as needed during the
induction procedure to help prevent nasal sections from becoming mixed with sputum
specimen.
Confidential

Page 113 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
APPENDIX 2 
CONTENT OF STUDY DRUG LABEL 
Table 14-1 
Content of Study Drug Label 
Number 
Label requirements 
Specific Label information 
1 
Pharmaceutical dosage form, route of administration, 
and in the case of open study, the name/identifier and 
strength/potency 
590 mg Liposomal Amikacin 
(aminoglycoside) nebulizer suspension 
for inhalation using PARI eFlow® 
nebulizer  
2 
Quantity of the dosage unit 
590 mg 
3 
Protocol number 
INS-212 
4 
Patient Identifier 
Patient specific 
5 
Human patient randomization number 
Patient specific 
6 
Lot number 
Patient specific 
7 
Re-assay/expiration date 
Patient specific 
8 
Caution statement 
For clinical trial use only. 
9 
Storage conditions 
Store between 2-8 ˚C.  Do not freeze. 
Protect from heat. 
10 
Sponsor identification, name, address and phone number 
GLOBAL CLINICAL AND 
REGULATORY AFFAIRS 
Insmed Incorporated 
10 Finderne Avenue 
Bridgewater, NJ 08807 
11 
Direction for use 
This product should only be used after 
appropriate training.  Shake well. 
12 
Statement: “Keep out of sight and reach of children” 
Keep out of sight and reach of children. 
Confidential

Confidential

Page 115 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated.
 
SIGNATURE PAGE FOR THE INVESTIGATOR 
Protocol Number 
INS-212 
I have read the INS-212 Comprehensive Pharmacokinetic Sub-Study protocol and agree that it 
contains all necessary details for carrying out this sub-study.  I will conduct the sub-study as 
outlined herein and will complete the sub-study within the time designated, in accordance with 
all stipulations of the sub-study protocol and in accordance with Good Clinical Practices, local 
regulatory requirements, and the Declaration of Helsinki. 
I will provide copies of the INS-212 Comprehensive Pharmacokinetic Sub-Study protocol and all 
pertinent information to all individuals responsible to me who assist in the conduct of this sub-
study.  I will discuss this material with them to ensure that they are fully informed regarding the 
study drug and the conduct of the sub-study. 
I will use only the informed consent approved by the Institutional Review Board/Independent 
Ethics Committee (IRB/EC) and will fulfill all responsibilities for submitting pertinent 
information to the IRB/EC responsible for this sub-study. 
I agree that the Sponsor, Insmed Incorporated, or its representatives shall have access to any 
source documents from which case report form information may have been generated. 
I further agree not to originate or use the name of Insmed Incorporated, or study drug code in any 
publicity, news release, or other public announcement, written or oral, whether to the public, 
press, or otherwise, relating to this sub-study protocol, to any amendment to the sub-study 
protocol, or to the performance of this sub-study, without the prior written consent of Insmed 
Incorporated. 
Name of Approver 
Type or print name of signer. 
Signature of Approver ___________________________________________ 
Date: mm/dd/yyyy  
Confidential

Page 116 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
Introduction 
LAI is a novel formulation of amikacin that is encapsulated in liposomes comprised of DPPC 
and cholesterol (naturally occurring lipids in the lung) to allow for effective delivery in the lung, 
leading to high concentrations of the drug at the target sites of infection, with low systemic 
levels.  In clinical study TR02-112 LAI in addition to standard background therapy was 
statistical superiority at the end of the double-blind period (Day 84) for achieving a negative 
sputum culture compared to those who received placebo in addition to standard background 
therapy.  Population PK modeling in the TR02-112 study revealed that systemic bioavailability 
of LAI is sufficiently low resulting in minimal systemic exposure relative to an IV administration 
of amikacin. The median estimated AUC in the subjects included in this analysis was 
approximately 13 times lower than the mean daily AUC observed in a published study of 
subjects with CF who received amikacin IV 30 mg/kg once daily. In general, the AUC24 at 
steady-state was slightly higher than that observed on Day 1. However, the difference was small 
(percent difference in the median values is 19.0%) indicating that very little accumulation of 
amikacin occurs with repeat dosing up to approximately 6 months. 
Study INS-212 will evaluate whether the signal identified in TR02-112 is further confirmed in a 
longer duration of LAI treatment in patient with NTM MAC lung infections who are refractory 
to a stable multi-drug regimen for at least 6 months.  This Comprehensive PK sub-study is being 
conducted at Japanese sites in Japan only and will only include subjects of Japanese descent.  
This sub-study will characterize the system exposure of amikacin after inhalation of LAI and 
evaluate the concentration of LAI in the sputum for these Japanese subjects.  This will be 
compared to historical data from non-Japanese subjects in lieu of a Phase I bridging study and in 
agreement with PMDA regulators.  
Confidential

Page 117 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
Sub-Study Objectives 
1. To characterize systemic amikacin exposure, including approximate systemic
bioavailability in Japanese subjects, using a population PK model to describe the
disposition of amikacin in the serum
2. To compare population PK modeling between Japanese subjects to historical population
PK modeling for LAI
3. To evaluate the amikacin concentration in sputum
Sub-Study Design 
At Baseline (Day 1), Japanese subjects at Japanese sites who are randomized to the LAI plus 
multi-drug regimen arm and signed the Comprehensive PK Sub-Study informed consent will be 
able to participate. PK blood and sputum samples will be collected from PK subjects at Baseline 
(Day 1) and at Months 1, 3, and 6. Details on sample collection timepoints are listed in the Sub-
Study Procedure section below. The Comprehensive PK Sub-Study will enroll subjects until 8 
subjects complete all required assessments and have evaluable data. .  
Sub-Study Endpoints 
1. Characterize systemic amikacin exposure, including approximate systemic bioavailability
in Japanese subjects
2. Compare Japanese subjects to historical population using PK modeling
3. Evaluate the amikacin concentration in sputum
Sub-Study Population 
Confidential

Page 118 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
Only Japanese sites will participate in this sub-study once they have IRB/EC approval for the 
main INS-212 study and for this sub-study.  All subjects must meet eligibility criteria for the 
main INS-212 study, must give written informed consent for that study, and must also give 
written informed consent for this sub-study. Eight evaluable subjects are expected to participate 
in the Comprehensive PK sub-study. There are no separate inclusion or exclusion criteria for this 
sub-study besides the requirement for written informed consent.  
Sub-Study Procedures 
Either at Screening or  at Baseline (Day 1), subjects will be asked to provide informed consent 
for this sub-study.  Blood and sputum samples will be collected to determine amikacin 
concentrations. The Schedule of Events for the Comprehensive PK Sub-Study is provided in 
Table 14-2.   
PK sputum sample collection timepoints 
On Day 1, two to three (2-3) sputum samples will be collected at the following timepoints: 0 to 1 
hour prior to study drug administration and at 8 (optional) and 24 hours after study drug 
administration. At Months 1, 3, and 6, PK sputum will be collected 0 to 1 hour prior to study 
drug administration and 1 to 4 hours after study drug administration. Day 1 and Month 3 PK 
sputum samples must be collected in conjunction with the 8 PK blood draws on the same day 
and time (within 30 minutes of blood being collected) as indicated below. 
PK blood sample collection timepoints 
On Day 1 and at Month 3, subjects will have 8 PK blood sample collections at the following 
timepoints: 0 to 1 hour prior to study drug administration, and at 1, 2, 4, 6, 8, 12, and 24 hours 
after study drug administration (±5 minutes at each time point is allowed).  At Months 1 and 6, 
PK blood samples will be collected 0 to 1 hour prior to study drug administration and 1 to 4 
hours after study drug administration.   
Confidential

Page 119 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
All samples will be stored at or below –20°C before shipping to a central PK laboratory.  Details 
for collecting, handling, storing, and transporting blood and sputum samples for PK analyses will 
be provided in the site laboratory manual. 
Table 14-2  
Schedule of Events for INS-212 Comprehensive Pharmacokinetic Sub-Study 
INS-212 Comprehensive Pharmacokinetic Sub-Study 
Baseline 
Month 1 
Month 3 
Month 6 
(V2) 
(V3) 
(V5) 
(V8) 
Visit Window 
Day 1  
(±3 days) 
(±3 days) 
(±3 days) 
Informed Consenta 
X 
– 
– 
– 
PK Blood Samplingb 
pre-dose: 
0-1 hr
pre-dose: 
0-1 hr
pre-dose: 
0-1 hr
pre-dose: 
0-1 hr
post dose:  
1, 2, 4, 6, 8, 12, 24 hrs 
post dose: 
1-4 hrs
post dose: 
1, 2, 4, 6, 8, 12, 24 hrs 
post dose: 
1-4 hrs
PK Sputum Sampling 
pre-dose: 
0-1 hr
pre-dose: 
0-1 hr
pre-dose: 
0-1 hr
pre-dose: 
0-1 hr
post dose:  
8 (optional), 24 hrs 
post dose: 
1-4 hrs
post dose: 
1-4 hrs
post dose: 
1-4 hrs
Administer Study 
Drug at Site 
X 
X 
X 
X 
a  The subject will be asked to provide informed consent for this sub-study at either Screening or at Baseline (Day 1). Informed consent must be obtained prior to 
any procedures for this sub-study can be performed. 
b  blood samples have a window of (±5 minutes at each time point)  
Confidential

Confidential

Page 121 of 129 
SIGNATURE PAGE FOR THE INVESTIGATOR 
Protocol Number 
INS-212 
I have read the INS-212 CT Scan Sub-Study protocol and agree that it contains all necessary 
details for carrying out this sub-study. I will conduct the sub-study as outlined herein and will 
complete the sub-study within the time designated, in accordance with all stipulations of the sub- 
study protocol and in accordance with Good Clinical Practices, local regulatory requirements, 
and the Declaration of Helsinki. 
I will provide copies of the INS-212 CT Scan Sub-Study protocol and all pertinent information 
to all individuals responsible to me who assist in the conduct of this sub-study. I will discuss this 
material with them to ensure that they are fully informed regarding the study drug and the 
conduct of the sub-study. 
I will use only the informed consent approved by the Institutional Review Boardllndependent 
Ethics Committee (IRBIEC) and will fulfill all responsibilities for submitting pertinent 
information to the IRBIEC responsible for this sub-study. 
I agree that the Sponsor, Insmed Incorporated, or its representatives shall have access to any 
source documents from which case report form information may have been generated. 
I further agree not to originate or use the name of Insmed Incorporated, or study drug code in any 
publicity, news release, or other public announcement, written or oral, whether to the public, 
press, or otherwise, relating to this sub-study protocol, to any amendment to the sub-study 
protocol, or to the performance of this sub-study, without the prior written consent ofInsmed 
Incorporated. 
I.\'l;"l\\~ 
Name of Approver 
 
'j 
Type or print name of signer. 
Signature of Approver --
- 
~~'__I'~~ 
(, 
Date: mmlddlyyyy 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely/or the purpose 0/ communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of in/ormation for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
Confidential

Page 122 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
Introduction 
LAI is a novel formulation of amikacin that is encapsulated in liposomes comprised of DPPC 
and cholesterol (naturally occurring lipids in the lung) to allow for effective delivery in the lung, 
leading to high concentrations of the drug at the target sites of infection, with low systemic 
levels.  In clinical study TR02-112 LAI in addition to standard background therapy was 
statistical superiority at the end of the double-blind period (Day 84) for achieving a negative 
sputum culture compared to those who received placebo in addition to standard background 
therapy.   
Study INS-212 will evaluate whether there are any radiographical changes that occur in subjects 
who have achieved culture conversion and continued on treatment.  
Sub-Study Objective 
1. To compare assessments of radiographs, read by a trained medical professional, from
Baseline (Day 1) in CT scans at EOT in a subset of subjects within each treatment arm
Sub-Study Design 
Eligible subjects must be enrolled into the INS-212 study.  At randomization (Day 1), any 
subject who has signed the informed consent for this chest CT Scan Sub-Study will participate; 
there is no maximum number of subjects that can participate. At the latest, the informed consent 
and the subject’s Baseline chest CT scan must be collected no later than 2 weeks after the 
subject’s first dose of LAI or multi-drug regimen in the INS-212 study. A prior chest CT scan 
may be used as a subject’s Baseline measure if this CT scan was obtained within 6 months from 
the subjects Day 1 study visit. All subjects in this chest CT Scan Sub-Study will have their 
follow-up chest CT scan on the (EOT) visit (±14 days) provided the last chest CT scan was not 
obtained within the prior 6 months. High resolution CT scan is preferred, if available. 
Sub-Study Endpoint 
Confidential

Page 123 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
1. Radiological changes in CT scan, within a sub-set of subjects, at EOT in the LAI arm
compared to multi-drug regimen alone, where appropriate
Sub-Study Population 
Only sites that have agreed to and have the ability to perform the chest CT scans will participate 
in this sub-study once they have IRB/EC approval for the main INS-212 and for this chest CT 
Sub-Study.  Subjects must provide written informed consent for both the main INS-212 study 
and  for this sub-study. It is expected that at least 60 subjects will participate in this CT Scan 
Sub-Study. 
Sub-Study Procedures 
On Day 1 (±14 days) subjects will be asked to provide informed consent for this sub-study. Once 
the informed consent has been signed the subject should have a chest CT scan performed (a prior 
CT scan that was obtained within 6 months prior to signing the informed consent may be used 
for Baseline).  A CT scan should not be performed during Screening for this CT-Scan Sub-Study. 
It will be performed at Baseline (Day 1) once the subject is randomized.  A second chest CT scan 
will performed when a subject has completed treatment (EOT ±14 days), which includes any 
subject that prematurely discontinues study drug provided that more than 6 months have elapsed 
since their last CT scan. High resolution CT scan is preferred, if available. 
All chest CT scans will be read locally and a description of findings for each scan will be entered 
into the eCRF page. An overall assessment of improved, worsening, or no change from previous 
scan will be reported for all scans after the subject’s Baseline scan.  All chest CT scans must be 
made available to the Sponsor to be stored as study source documentation. 
Confidential

Page 124 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
Table 14-3  
Schedule of Events for INS-212 CT Scan Sub-Study 
INS-212 CT Scan Sub-Study 
Baseline 
EOT 
(V2) 
Visit Window 
(-6 months to +14 Days)  
(±14 days) 
Informed Consenta 
X 
– 
CT Scan of Chest 
X 
X 
a  informed consent for this sub-study must take place after the subject has been enrolled and randomized into the INS-212 study.  This will be a separate informed 
consent from the INS-212 main study. 
b   Computed tomography of the chest at Baseline (Day 1) is performed only for those subjects whom have signed the CT Scan Sub-Study informed consent if not 
completed within 6 months before the first dose of LAI or multi-drug regimen at the Baseline (Day 1) visit.  EOT scan is required if no less than  6 months 
have elapsed since the previous CT scan was performed. 
Confidential

Confidential

Page 126 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
SIGNATURE PAGE FOR THE INVESTIGATOR 
Protocol Number 
INS-212 
I have read the INS-212 Japan Specific CT Scan Sub-Study protocol and agree that it contains all 
necessary details for carrying out this sub-study.  I will conduct the sub-study as outlined herein 
and will complete the sub-study within the time designated, in accordance with all stipulations of 
the sub-study protocol and in accordance with Good Clinical Practices, local regulatory 
requirements, and the Declaration of Helsinki. 
I will provide copies of the INS-212 Japan Specific CT Scan Sub-Study protocol and all 
pertinent information to all individuals responsible to me who assist in the conduct of this sub-
study.  I will discuss this material with them to ensure that they are fully informed regarding the 
study drug and the conduct of the sub-study. 
I will use only the informed consent approved by the Institutional Review Board/Independent 
Ethics Committee (IRB/EC) and will fulfill all responsibilities for submitting pertinent 
information to the IRB/EC responsible for this sub-study. 
I agree that the Sponsor, Insmed Incorporated, or its representatives shall have access to any 
source documents from which case report form information may have been generated. 
I further agree not to originate or use the name of Insmed Incorporated, or study drug code in any 
publicity, news release, or other public announcement, written or oral, whether to the public, 
press, or otherwise, relating to this sub-study protocol, to any amendment to the sub-study 
protocol, or to the performance of this sub-study, without the prior written consent of Insmed 
Incorporated. 
Name of Approver 
Type or print name of signer. 
Signature of Approver ___________________________________________ 
Date: mm/dd/yyyy  
Introduction 
Confidential

Page 127 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
LAI is a novel formulation of amikacin that is encapsulated in liposomes comprised of DPPC 
and cholesterol (naturally occurring lipids in the lung) to allow for effective delivery in the lung, 
leading to high concentrations of the drug at the target sites of infection, with low systemic 
levels.  In clinical study TR02-112 LAI in addition to standard background therapy was 
statistical superiority at the end of the double-blind period (Day 84) for achieving a negative 
sputum culture compared to those who received placebo in addition to standard background 
therapy.   
Study INS-212 will evaluate whether there are any radiographical changes that occur in subjects 
who have achieved MAC culture conversion and continued on treatment.  
Sub-Study Objectives 
1. To compare assessments of radiographs, read by a trained medical professional, from
Baseline (Day 1) in CT scans at EOT in Japanese subjects from sites in Japan
2. To assess the safety of LAI by CT scans (at 6 month intervals) in subjects from sites in
Japan
Sub-Study Design 
Eligible subjects must be enrolled into INS-212: A Randomized, Open-Label, Multicenter Study 
of Liposomal Amikacin for Inhalation (LAI) in Adult Patients with Nontuberculous 
Mycobacterial (NTM) Lung Infections Caused by Mycobacterium avium complex (MAC) That 
are Refractory to Treatment.  The informed consent for this Japan specific CT Scan Sub-Study is 
included in the informed consent for the main study.  All Japanese subjects in Japan will 
participate in this sub-study. There is no maximum number of subjects that can participate.  The 
subject’s Baseline chest CT scan must be collected no later than 2 weeks after the subject’s first 
dose of LAI or multi-drug regimen in the INS-212 study. A prior chest CT scan may be used as a 
subject’s Baseline measure if this CT scan was obtained within 6 months from the subject’s 
Baseline (Day) 1 study visit in the INS-212 study. All subjects will have CT scans at their 
Months 6, 12, and EOT visits, and at 18 and 24 months after EOT. 
Confidential

Page 128 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
Sub-Study Endpoint 
1. Radiological changes in CT scan at EOT in the LAI arm compared to multi-drug regimen
alone, where appropriate
2. Six-month interval safety assessment for subjects enrolled at sites in Japan
Sub-Study Population
All Japanese subjects at all study sites in Japan will participate in this sub-study once they have 
IRB/EC approval. The informed consent for this Japan specific CT Scan Sub-Study is included 
in the informed consent for the main study.  All Japanese subjects in Japan will participate in this 
substudy. There are no separate inclusion or exclusion criteria for this sub-study. 
Sub-Study Procedures 
The subject should have a chest CT scan performed (a prior CT scan that was obtained within 6 
months prior to Day 1 may be used for Baseline).  The first chest CT scan should be performed 
at Day 1 or up to 14 day after first dose of LAI or multi-drug regimen. Additional CT scans will 
be obtained at their Months 6, 12, EOT months (if at least 6 months have elapsed since the 
previous CT scan), and at 18 and 24 months after EOT. 
All chest CT scans will be read locally and a description of findings for each scan will be entered 
into the eCRF page. An overall assessment of improved, worsening, or no change from previous 
scan will be reported for all scans after the subject’s Baseline scan.  All chest CT scans must be 
made available to the Sponsor to be stored as study source documentation. 
Confidential

Page 129 of 129 
Protocol Amendment #3 version: 22 February 2016 
This protocol is solely for the purpose of communicating information about the investigational drug 
between Insmed Incorporated and study personnel. Information is not to be reproduced, abstracted or 
used for sharing of information for any other purpose, whatsoever, except with the written permission of 
Insmed Incorporated. 
Table 14-4  
Schedule of Events for INS-212 Japan Specific CT Scan Sub-Study 
INS-212 Japan Specific CT Scan Sub-Study 
Screening 
Baseline 
(Day 1) 
Month 6 
Month 12 
EOT 
Month 18 
Month 24 
(V1) 
(V2) 
(V8) 
(V11) 
(V13) 
– 
– 
Visit 
Window 
(-6 months to 
+14 Days) 
(±3 days) 
(±3 days) 
(±14 days) 
(±14 days) 
(±14 days) 
Informed 
Consenta 
X 
- 
– 
– 
– 
– 
– 
CT Scan of 
Chest 
Xb 
X 
X 
Xb 
X 
X 
a  In Japan, all subjects will participant in the CT scan sub-study. Informed consent for this sub-study is included in the informed consent of INS-212 main study.   
b   A prior chest CT scan may be used as a subject’s Baseline (Day 1) measurement if this CT scan was obtained within 6 months from the subject’s Baseline (Day 
1) visit. Subjects will have their follow-up chest CT scan at the EOT visit provided the last chest CT scan was not obtained within the prior 6 months. High 
resolution CT scan is preferred, if available. 
Confidential